Exacerbated by hospitalisation?
A Swedish study that compared mortality in patients with personality disorder who had been hospitalised, with patients who had only received outpatient treatment, found a somewhat higher prevalence of unnatural death among the hospitalised patients, but the mortality rate was also considerably higher for those who had only received outpatient treatment. The probable explanation is that the group that was admitted as inpatients was more ill (selection bias) and it cannot therefore be concluded that inpatient treatment increases the suicide risk (2, 3).
Very few studies show that patients who are in fact acutely suicidal become worse by being hospitalised until the situation has stabilised
Some mental healthcare professionals believe that hospitalisation may increase the risk of suicidal behaviour. Removing patients from the usual demands associated with coping with life, particularly dealing with situations that elicit strong emotions, might result in patients failing to learn how to deal with these emotions, and second, might cause suicidal behaviour to be reinforced (12). A study of female patients with borderline personality disorder who received outpatient treatment found that those who had previously been hospitalised attended the acute psychiatric service more frequently than those who had not been hospitalised. Those who attended the acute psychiatric service during treatment were also those who had the most suicide attempts in the first year after treatment (12).
One reason why hospitalisation of patients with borderline personality disorder has generally been discouraged is based on claims that after only a few days' stay in an inpatient institution, their symptoms may be exacerbated or they may become involved in negative interaction with staff and fellow patients (8, 13). An increase in threats of suicide, self-harming or suicidal behaviour is feared, which in turn may result in prolonged hospitalisation or provoke a premature discharge or other negative reactions from the hospital staff (2, 3).
We are critical of these claims in relation to acute suicide crises. Very few studies show that patients who are in fact acutely suicidal become worse by being hospitalised until the situation has stabilised. For the majority of patients with borderline personality disorder, the acute risk of suicide is short-lived, even though the risk may be significantly heightened in the long term. If the patient has active plans and has no control over his/her suicidal impulses, they are in such great need and danger that therapists must implement measures to prevent suicide. If this can happen outside the inpatient institution, that is well and good, but in many cases hospitalisation is necessary until the patient has regained sufficient control.
Any potential hospitalisation should have the objective of supporting long-term, ongoing psychotherapy where this is established, or of establishing such a service. It is unlikely that patients in a state of chaotic despair who are in imminent danger of taking their own lives are in a position to learn better life-coping skills.
If it is thought that patients at risk of suicide will be made worse by being admitted to a psychiatric ward, it ought to be investigated whether this is actually the case and what needs to be done – in other words, what factors are harmful for the patients.