Long-Term Suicide Risk in Forensic Psychiatric Patients

Based on the article Long-Term Suicide Risk in Forensic Psychiatric Patients by Clarke, M., Davies, S., Clive, H. & Duggan, C. (2011) in Archives of Suicide Research, 15: 1, 16 — 28

It is often said that psychiatric patients are a greater risk to themselves than others; while this may be true for general samples, the risk that patient treated in Forensic Psychiatric Units present to themselves, rather than to others, which by the nature of the sample is high, had not been a focus for study. Clarke et al. (2011) investigated the long-term suicide risk in forensic psychiatric patients. They performed a retrospective study, which considered the mortality outcomes of a cohort of 595 former patients of a medium secure unit in Leicester, England. Patients were admitted during the 20-year period between 1983 and 2003. The study found an increased risk of mortality in former forensic patients, from all causes, and particularly from suicide.

The relative risk of mortality, between former forensic psychiatric patients and the general population, was measured according to a calculated Standardised Mortality Rate (SMR). The way in which the SMR was calculated conformed to previous studies considering the same, and involved comparing the rate of observed deaths with the rate of expected deaths.

The SMR for death from natural causes was 300, indicating a mortality rate 3 times greater than that expected in the general population. For unnatural deaths the SMR was calculated as 1,898, indicating a mortality rate from unnatural deaths that is almost 19 times greater than that expected in the general population. This finding confirmed the results of previous studies, which also found an increased risk of mortality from all causes. The mortality rate from suicide in former forensic psychiatric patients is considerably higher than the general population; indeed, this study found a risk of suicide over 32 times greater in former patients than that expected in the general population.

A factor strongly associated with increased risk of mortality is the patients reason for admission to long-term psychiatric care, what was known during the 20 year period that medical records were obtained as the legal classification (that the patients clinical diagnosis was unavailable was a limitation of the study). The mortality rate of patients admitted under a legal classification of Mental Illness (broadly psychotic illness, predominantly schizophrenia) was 6 times greater than that of the general population; under Psychopathic Disorder, 4.5 times greater than that of the general population.

Increased risk of suicide was correlated with factors such as family history of suicide, four or more previous admissions, and treatment with ECG. The patients’ age was related to the risk of suicide, with patients aged below 40 at greater risk than those aged over 40. Former forensic psychiatric patients aged 30-35 were found to be more likely to die of suicide than any other cause. The most common method of suicide in this cohort of forensic psychiatric patients was by hanging. The location of the suicide – four were considered, MSU, community, prison, other hospital – was not significant.

This study was carried out with 595 former forensic psychiatric patients’ medical records, which were obtained freely, without consent of patients or their family, under Section 60 of the Health and Social Care Act 2001. This Act opens the door to researchers who may consider a similar analysis with a different cohort of patients. The authors of this study posit that follow-up care, received by patients after discharge, is likely to be the major factor influencing long-term mortality outcomes. They call for forensic psychiatrists to consider the adoption of risk assessment systems to measure the risk of suicide, and for such systems to become part of routine forensic practice.

It is concluded that this population´s risks of mortality are high, particularly from suicide. Forensic psychiatric patients have a number of risk factors including long-term psychiatric disorders, high rates of substance misuse, and social exclusion. The authors recommended that clinical care should be focused on interventions to reduce suicide rates, i.e. interventions should concentrate on the risk that forensic psychiatric patients pose to themselves. Should this approach be adopted in routine forensic practice, such interventions would complement existing interventions that have concentrated on the risk these patients pose to others.


Clarke, Martin , Davies, Steffan , Hollin, Clive and Duggan, Conor (2011) ‘Long-Term Suicide Risk in Forensic Psychiatric Patients’, Archives of Suicide Research, 15: 1, 16 — 28

DOI: 10.1080/13811118.2011.539951

URL: http://dx.doi.org/10.1080/13811118.2011.539951