Estimated Average Treatment Effect of Psychiatric Hospitalization in Patients With Suicidal Behaviors: A Precision Treatment Analysis

Abstract

Importance: Psychiatric hospitalization is the standard of care for patients presenting to an emergency department (ED) or urgent care (UC) with high suicide risk. However, the effect of hospitalization in reducing subsequent suicidal behaviors is poorly understood and likely heterogeneous.

Objectives: To estimate the association of psychiatric hospitalization with subsequent suicidal behaviors using observational data and develop a preliminary predictive analytics individualized treatment rule accounting for heterogeneity in this association across patients.

Design, setting, and participants: A machine learning analysis of retrospective data was conducted. All veterans presenting with suicidal ideation (SI) or suicide attempt (SA) from January 1, 2010, to December 31, 2015, were included. Data were analyzed from September 1, 2022, to March 10, 2023. Subgroups were defined by primary psychiatric diagnosis (nonaffective psychosis, bipolar disorder, major depressive disorder, and other) and suicidality (SI only, SA in past 2-7 days, and SA in past day). Models were trained in 70.0% of the training samples and tested in the remaining 30.0%.

Exposures: Psychiatric hospitalization vs nonhospitalization.

Main outcomes and measures: Fatal and nonfatal SAs within 12 months of ED/UC visits were identified in administrative records and the National Death Index. Baseline covariates were drawn from electronic health records and geospatial databases.

Results: Of 196 610 visits (90.3% men; median [IQR] age, 53 [41-59] years), 71.5% resulted in hospitalization. The 12-month SA risk was 11.9% with hospitalization and 12.0% with nonhospitalization (difference, -0.1%; 95% CI, -0.4% to 0.2%). In patients with SI only or SA in the past 2 to 7 days, most hospitalization was not associated with subsequent SAs. For patients with SA in the past day, hospitalization was associated with risk reductions ranging from -6.9% to -9.6% across diagnoses. Accounting for heterogeneity, hospitalization was associated with reduced risk of subsequent SAs in 28.1% of the patients and increased risk in 24.0%. An individualized treatment rule based on these associations may reduce SAs by 16.0% and hospitalizations by 13.0% compared with current rates.

Conclusions and relevance: The findings of this study suggest that psychiatric hospitalization is associated with reduced average SA risk in the immediate aftermath of an SA but not after other recent SAs or SI only. Substantial heterogeneity exists in these associations across patients. An individualized treatment rule accounting for this heterogeneity could both reduce SAs and avert hospitalizations.

Figure 1.. Propensity Score–Weighted Estimated Average Treatment Effect of Psychiatric Hospitalization

The “other” category indicates any other International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification mental or substance use disorder. MDD indicates major depressive disorder. Error bars indicate 95% CIs.

Figure 2.. Estimated Effect of Psychiatric Hospitalization by Level of Predicted Benefit From Hospitalization

Circles indicate the predicted 1-year risk of suicide attempt in the absence of psychiatric hospitalization, and lines indicate the direction and magnitude of change in that risk associated with hospitalization. Lines with an arrowhead indicate a statistically significant change. The “other” category indicates any other International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification mental or substance use disorder. MDD indicates major depressive disorder.