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Suicide Rate Is Highest Just After Psychiatric Hospitalization

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If psychiatric hospitalization is so effective, why is the suicide rate highest immediately after release from the hospital?

A massive study (1,185,727 patient-years) published in January (“Higher-risk periods for suicide among VA patients receiving depression treatment: Prioritizing suicide prevention efforts,” M. Valenstein et al., Journal of Affective Disorders, Volume 112, Issues 1-3, January 2009, Pages 50-58) on a military veteran population being treated for depression found that suicide rates were dramatically elevated immediately following a psychiatric hospitalization.

The base suicide rate of the population was found to be 114 per 100,000 person-years. Clearly, the depressed VA patients are at a much higher suicide risk than the general population of the United States, for which the suicide rate is estimated at only 16.7 per 100,000 person-years. But the suicide rate for these depressed veterans shot up to 568 per 100,000 person-years during the 12 weeks following a psychiatric hospitalization – five times the already high base rate for the non-hospitalized depressed veterans, and 34 times that of the overall American suicide rate.

But if hospitalization were actually effective in “treating” suicidality, wouldn’t we expect the suicide rate to be quite low after a hospitalization?

One problem with this line of thinking is that we might expect only the most seriously suicidal patients to be hospitalized at all. One hypothesis is that hospitalization is effective in reducing suicidality, and that the suicide rate of hospitalized depressed veterans would have been much higher if they hadn’t been hospitalized. No study I am aware of attempts to compare the suicide rates of patients who meet criteria for hospitalization, but who are randomly assigned to be or not to be hospitalized. Given the widespread faith in hospitalization as a suicide treatment mechanism, to conduct such a study would probably be considered a breach of professional ethics toward the non-hospitalized group.

However, in the absence of data from such a study, I think the alternative hypothesis needs to be considered: that hospitalization is so horrible, demeaning, and above all ineffective, that it does nothing to prevent suicides and may actually increase one’s resolve in that direction. Far from showing caring and compassion, forced psychiatric hospitalization demonstrates to the patient that he is a prisoner. For a prisoner, there is a clear method of escape. Yes, there are people who claim to have benefited from involuntary psychiatric hospitalization, just as there are people who claim to have benefited from childhood beatings and from those wilderness camps they send bad kids to. But there are also people who have suffered involuntary hospitalization and found it to be a life-changing, demeaning experience. In fact, I think we must be suspect of the “glad it happened” group. The psychological defense mechanism of denial, the discomfort of cognitive dissonance, contribute to people interpreting past events with unwarranted optimism. As long as you can convince yourself that the involuntary hospitalization was good for you, you don’t have to admit to yourself what an insult to your dignity was done to you.

Sadly, the authors of the study are using the results to recommend yet more coercive practices. What is really needed is more intensive “treatment” following a hospitalization, they say – or a “firm connection to outpatient services,” in the Orwellian words of the study’s authors.

For those whose link to the study is gated, here’s a Washington Post summary of the study: “With Depression, Vets Face Higher Suicide Risk.”

Update: Commenter Jessa continues the discussion on coercion at her site, Made with Awesome.

Update: Zarathustra responds to my arguments here.

Update: Jim adds to the discussion here and here.

Written by Sister Y

January 12, 2009 at 10:09 pm

Oregon’s Law

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Oregon’s Death With Dignity Act succeeds in many ways. The Act respects patient autonomy, from its definition of “capable” to mean that

in the opinion of a court or in the opinion of the patient’s attending physician or consulting physician, psychiatrist or psychologist, a patient has the ability to make and communicate health care decisions to health care providers, including communication through persons familiar with the patient’s manner of communicating if those persons are available.

to the way it allows patients to decide for themselves whether to notify family members and when – even if – to self-administer the lethal prescription, once requested. (Some people who request suicide assistance don’t use it until months or years after it has been provided.)

Oregon’s law is wrong, however, in limiting access to death to those with terminal illnesses. Although this flawed version is certainly the only version of the law that would have had a chance of being enacted, the fact remains that it is wrong.

First, restricting access to comfortable means of death to those with a terminal illness is actually demeaning to people with terminal illnesses. The idea that human dignity somehow requires that one be able to walk and talk and control one’s bodily functions is demeaning and wrong, as Felicia Ackerman (see Readings) and disability advocates point out. A terminally ill person must decide for him or herself whether to request suicide assistance; it is not the right decision for everyone. But what possible justification could there be for limiting this right to terminally ill people, except that their lives are somehow less valuable than those lives that will (probably) continue on for many years? The designation “Death With Dignity Act,” of course, hints at the demeaning implication of the limit: some deaths are dignified, other are not. The state will decide for you whether you are undignified enough to be allowed to die peacefully. (The Oregon law does not allow assisted suicide to be provided to non-terminally-ill disabled or merely old people, but the implications of the restriction to terminally ill people are clear enough.)

Second, the Oregon law’s restriction against suicide assistance to non-terminally-ill people is wrong because suicide is an important right for everyone, not merely the terminally ill. In fact, if anything, the right is more important for those who are not terminally ill, because their time of suffering will most likely be much longer than those who will die soon naturally. And, as pointed out by Velleman, terminally ill people are much more likely to be harmed by having the option to die than healthy people are, because they are more likely to be dependent on the care of others and therefore to feel themselves to be a burden. A more sensible restriction might be to allow suicide assistance only to non-terminally-ill people! I am not, of course, in favor of this restriction, but it makes more philosophical sense than Oregon’s law, which makes political sense, if anything.

Meanwhile, Switzerland recently extended suicide rights to those with incurable mental illnesses. Jacob Appel, writing in the Hasting Center Report, explains the basic ethical issues:

Another set of objections are from those who support a basic right to assisted suicide in certain situations, such as those of terminal disease, but do not wish to extend it to cases of severe and incurable mental illness. This resistance may be inevitable, considering the increased emphasis that contemporary psychiatry places on suicide prevention, but the principles favoring legal assisted suicide lead logically to the extension of these rights to some mentally ill patients.

At the core of the argument supporting assisted suicide are the twin goals of maximizing individual autonomy and minimizing human suffering. Patients, advocates believe, should be able to control the decision of when to end their own lives, and they should be able to avoid unwanted distress, both physical and psychological. While these two principles might explain why a victim of amyotrophic lateral sclerosis or cancer would choose assisted suicide, they apply equally well in many cases of purely psychological disease: a victim of repeated bouts of severe depression, particularly in cases where treatment has consistently proven ineffective, rationally might prefer dignified death over future suffering. [Hastings Cent Rep. 2007;37(3):21-23. Via Medscape. Emphasis mine.]

Written by Sister Y

June 24, 2008 at 3:40 am