Most of those who completed suicide were considered to be low risk. Discharged patients who completed suicide were 3.7 times more likely to have had their care reduced at their most recent outpatient appointment (Appleby et al., 1999a). A higher suicide rate was found to be associated with the loss of contact with the primary mental health professional (King et al., 2001). Other risk factors for suicide in recently discharged patients include living alone, hopelessness, relationship difficulties, loss of a job, a history of self harm, and a diagnosis of depression (King et al., 2001; McKenzie and Wurr, 2001). Patients who maintained care in the community (King et al., 2001) or maintained pharmacotherapy (Modestin et al., 1992) had lower suicide rates. These results suggest that discharged psychiatric patients are at higher risk of suicide for many reasons, but by maintaining some continuity of care and increasing adherence to treatment plans, some of the deaths may be prevented.

Although the risk of death by suicide appears low in medically hospitalized patients, estimated at 1.8 per 100,000 (Hung et al., 2000), the period immediately following hospitalization may be one of increased risk for these patients, as well. Dhossche and colleagues (2001) found that 73 percent (8 of 11) recently discharged medical patients who suicided were diagnosed with depression and/or substance abuse, whereas only 33 percent (11 of 33) of those who had not suicided had these diagnoses.

Angela, age 14, was treated in the emergency room after ingesting a “handful” of prescription pills in front of her mother and younger sister. This she did in retribution for being reprimanded and hit by her mother for staying out late. In the intake interview, she denied current suicidal ideation and stated that she was “glad” that her mother was worried. Once medically cleared, she was given an appointment with the outpatient psychiatry clinic for 9 days later, an appointment that was never kept. The nurse who attempted to contact the family by phone to follow up learned that the phone number given at intake had been disconnected for over 2 months (Berman & Jobes, Adolescent Suicide: Assessment and Intervention, 1991:164).

Treatment Adherence

Individuals who do not adhere to their treatment regimens, including medication and therapy, are at greater risk for suicide. The period following hospitalization is a time of increased likelihood that individuals will stop taking their medications (Appleby, 2000). As described in a recent



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