Mortality Risk and Related Adverse Outcomes Following Discharge from Inpatient Psychiatric Care

Being admitted to inpatient psychiatric care most often constitutes a medical emergency, reflecting both a person's deteriorating state of mind and the inability of local resources to provide adequate care in the community. Whilst hospitalisation may assist in the resolution of acute symptoms, it is often insufficient to repair deep social strains, and therefore returning to life in the community may be a particularly challenging and risky transition that poses a major threat to patient safety. Published studies have reported absolute and relative risk estimates for all-cause mortality and for specific causes of death, stratified according to diagnostic category, substance misuse comorbidity and sociodemographic factors, with suicide being the most frequently investigated cause-specific mortality outcome. Compared to other people diagnosed with mental illnesses and the rest of the population, discharged persons have greatly elevated risks for suicide and other deaths from external causes such as unintentional overdoses, as well as risk-related natural causes such as gastrointestinal and hepatic diseases. Risk of dying, and especially so by suicide, is most acutely raised during the period immediately after and within 3 months of discharge. Whilst it is possible to examine risk at the population level, should the relevant data be available, assessing risk for an individual patient is inherently flawed due to the potential for ecological fallacy when applying population-level probabilities to a single patient at a given time point. Consequently, it is difficult for clinicians to decide when it is safe to discharge a patient. More granular research findings are needed in relation to the antecedents of elevated risk post-discharge, and the pathways of discharged patients in relation to the health services and other public agencies that they have contact with and the treatment and support that they receive post-discharge, and the potential modifying influence of these inputs from services on risk of adverse outcome. More evidence is also needed in relation to a broader range of endpoints other than cause-specific mortality, including non-fatal self-harm, serious accidental injury, and perpetration of and victimisation by interpersonal violence. Finally, a wider spread of research evidence is required from a broader spread of countries to develop a more international evidence base for the topic.

We would especially welcome submissions of manuscripts that report findings from population-based epidemiological studies, as these are more likely to be conducted in large cohorts that are adequately powered for examination of rare cause-specific mortality risks. However, we also appreciate that such studies may also lack detailed contextual information and that key explanatory variables and covariates may be unavailable to investigators who examine large routinely collected data sources. Therefore we also welcome submission of manuscripts that report robust and insightful findings from smaller scale studies that have entailed collection of richer clinical information or interviews with patients, carers, staff and other stakeholders. Finally, we would also welcome submissions of manuscripts that report on economic evaluations within this topic area.