Involuntary psychiatric care (IPC) can be a vital intervention for individuals who are severely unwell and do not (or cannot) consent to care (Wang & Colucci, 2017). Its provision is a challenging area for psychiatry given its associations with a number of harms including coercive practices (as previously blogged about by Jessica Griffiths and Una Foye), high economic costs, decreased patient satisfaction, and crucially post-discharge suicide (Corderoy et al., 2024). History of psychiatric admission as a key risk factor for suicide is well documented, with approximately a third of suicide decedents observed to be in contact with psychiatric services within the four weeks prior to their death (Bergqvist et al., 2022).
Despite this, and the notion that IPC patients are likely more acutely ill and in greater need of resources than voluntarily admitted patients, our current understanding of suicide risk following IPC discharge remains limited, with the few extant studies reporting contrasting findings. This can be partly explained by methodological limitations of these studies including their small sample sizes, singular but variable follow-up periods, use of proxies beyond suicide (i.e. ideation and attempts), and lack of comparison to other clinical populations.
Grossmann et al. (2026) set out to address this gap by conducting the first population-based study of IPC patients following hospital discharge that sought to comprehensively characterise their absolute risk both across time and distinct subgroups, and to estimate their relative suicide risk compared to other clinically-relevant populations.
Little is known about suicide risk following involuntary psychiatric care.
Methods
The authors used linked nationwide registry data to identify all IPC inpatients in Sweden from January 1st 2010 to December 31st 2020. These individuals were followed up from the date of discharge from IPC until the outcome (suicide) or censorship (death by other cause; migration; end of follow-up). Where patients had multiple IPC episodes, only one episode was selected randomly. Three groups (all psychiatric inpatients, all psychiatric outpatients, and the general population) were also identified from the registry data for the comparison of risk estimates.
The authors reported summary statistics on a range of sociodemographic and clinical characteristics of IPC patients. They also presented age- and sex-stratified suicide counts as well as cumulative survival curves stratified by psychiatric diagnoses.
Poisson regressions were conducted to (1) calculate suicide incidence rates (IRs) per 100,000 person-years for the entire study sample and stratified by sex and five-year age strata, and (2) calculate crude and adjusted suicide incidence rate ratios (IRRs) for IPC patients compared to the three comparison groups. These analyses were conducted for both the duration of follow-up and for distinct follow-up periods (one month, three months, one year, and five years following discharge) to ascertain how suicide risk varied across time.
Results
The study identified 72,275 IPC patients with a total of 134,514 IPC episodes. Of these, 2,104 (2.9%) died by suicide over a median follow-up period of 4.4 years. Regarding sociodemographic characteristics, IPC patients were more likely to die by suicide if they were young or middle-aged adults, male, single, and received sickness or injury benefits prior to IPC.
With regard to clinical characteristics, IPC patients who died by suicide were more likely to have a diagnosis of substance use disorders, anxiety disorders, depressive disorders, and personality disorders, but not psychotic and schizophrenia-spectrum disorders. This was supported by cumulative survival analyses which showed that risk of suicide was greatest in IPC patients with personality disorders and again the lowest in those with organic psychotic and schizophrenia-spectrum disorders (see Figure 1). History of past admission due to intentional self-harm and past-year history of IPC were also more common among suicide decedents.
Figure 1: Cumulative survival from suicide after hospital discharge after involuntary psychiatric care, stratified by psychiatric diagnostic categories.
Over the entire follow-up period, the absolute risk of suicide was 631 (95%CI: 605 to 659) suicides per 100,000 person-years. This risk was greatest in the first month following discharge at 2,941 (95%CI: 2,538 to 3,407) suicides per 100,000 person-years, subsequently decreasing to 2,086 (95%CI: 1,881 to 2,312) at three months, 1,321 (95%CI: 1,237-1,413) at one year, and 738 (95%CI: 705-773) at five years. This nonetheless represents a substantially elevated risk across the entire follow-up period. With regard to sex differences, the absolute risk of suicide across the entire period was greater in males (714 [95%CI: 674 to 755]) than in females (530 [95%CI: 495 to 566]), but these differences were largely not evident in specific age groups with overlapping confidence intervals.
Relative risk analyses revealed that suicide risk in IPC patients was higher compared to that observed in the three comparison groups at all time points besides psychiatric inpatients in the first month post-discharge. As shown in Table 1, this persisted even after adjusting for sex, age at discharge, and year of follow-up start (as well as readmission status in a secondary analysis).
Of note, the suicide risk of IPC patients was almost 200 times that of the general population in the first month following discharge, and whilst this risk declined in the longer-term, it remained substantially elevated at approximately 50-fold at five years. Compared to both psychiatric inpatients and outpatients, the relative risk gradually increased across follow-up times.
Table 1: Adjusted suicide incidence rate in IPC patients compared to different comparison groups
| Adjusted IRR (95% CI) of IPC patients vs. comparison | |||
| Time period | Psychiatric inpatients | Psychiatric outpatients | General population |
| One month | 1.04 (0.88 to 1.23) | 3.78 (3.18 to 4.49) | 184.75 (147.87 to 230.83) |
| Three months | 1.18 (1.05 to 1.32) | 3.86 (3.42 to 4.36) | 145.31 (125.63 to 168.08) |
| One year | 1.40 (1.30 to 1.51) | 4.31 (3.98 to 4.65) | 94.49 (86.77 to 102.90) |
| Five years | 1.55 (1.47 to 1.63) | 4.43 (4.20 to 4.68) | 51.04 (48.39 to 53.83) |
Conclusions
This large cohort study identified that individuals discharged from IPC are at an elevated risk of suicide compared to other clinical populations, and that this risk is disproportionally higher in certain sociodemographic and diagnostic subgroups. Whilst suicide risk was greatest in the first month following IPC discharge and decreased thereafter, an excess risk remained even after five years; indicative of a need for longer-term monitoring.
The authors say that their findings:
warrant further investigation as they could inform clinicians and policymakers regarding potential risk stratification, monitoring, and care.
A number of socioeconomic and clinical factors are associated with increased suicide risk following discharge from involuntary admissions.
Strengths and limitations
Key strengths of this study include:
- A large real-world sample – the authors suggest it is the largest study to date of its kind
- Long-term follow-up that allowed for detailed subgroup analyses across a range of sociodemographic and clinical characteristics
- The use of nationwide registry data with a low likelihood of selection and recall bias given minimal missing data
- The use of several follow-up periods to assess temporality unlike previous studies
- The inclusion of several clinically-relevant comparison groups
- Clear and thorough reporting of methodology.
Regarding limitations, the observational design of the study does not allow for questions of causality to be addressed, though this study does provide a comprehensive description of suicide in this high-risk population, which can be investigated further through causal inference frameworks (e.g., Ødegård et al., 2026).
The use of registry data precluded the consideration of more fine-grained information such as symptom severity, therapeutic relationship, quality of and access to follow-up care, and other patient experiences, all of which may be potential confounders of the association between IPC and suicide risk.
Further, the lack of racial and ethnic statistics in Swedish registry data limit the intersectional assessment of suicide risk across certain ethnic groups which are overrepresented and face inequalities in IPC (as Ian Cummins has previously blogged about).
The authors conducted a thorough analysis, but were limited in their choice of confounders by the constraints of registry data.
Implications for practice
Suicide rates of IPC patients appear to vary depending on age, sex, socioeconomic status, and diagnostic categories. This risk remained elevated for many years post-discharge, indicating the need for longer-term monitoring and follow-up care. The existence of these distinct risk subgroups suggests that risk stratification and tailored interventions may be helpful for the IPC population. This is at odds with existing UK guidelines that do not recommend the use of risk assessment tools to predict future suicide or to determine treatment and/or discharge decisions (NICE, 2022).
Risk stratification in suicide remains difficult given low positive predictive values and the “low-risk paradox” (where most suicide decedents in psychiatric care are deemed to be at no or low risk of suicide) (Carter et al., 2017). This may be overcome by shifting towards probability-based estimates that can act as an adjunct for more personalised and informative decision-making at the individual level (Seyedsalehi & Fazel, 2024), for example by indicating when suicide-specific interventions may be warranted before discharge.
Surprisingly, IPC patients with psychotic and schizophrenia-spectrum disorders were at the lowest risk of suicide compared to all other diagnostic subgroups. This has similarly been observed in a previous study where suicide rates in the first few months following psychiatric discharge were lowest in individuals with schizophrenia and greatest in individuals with affective or anxiety stress disorders (Madsen et al., 2020). This may be indicative of more structured and intensive provision of follow-up care for patients with psychotic disorders – and a relative lack in other disorder subgroups, where patients may be without support for extended periods of time.
Conversely those with a personality disorder diagnosis were found to be at greatest risk of suicide following involuntary hospitalisation, which is in line with wider evidence of greatly increased mortality among inpatients with this diagnosis, as blogged by Kirsten Lawson. In order to better support these individuals, it remains important to further investigate and target risk factors for suicide in this population (McClelland et al., 2023) as well as those related to their care and treatment given the often negative experiences of IPC for people who receive that diagnosis (Stapleton & Wright, 2017). As the authors suggest, “identifying individuals most at risk is an essential first step in directing resources and efforts for suicide prevention.”
Given that quicker follow-ups following discharge are associated with lower suicide risk (Che et al. 2023), this finding highlights the need for clinicians and policy makers to focus follow-up resources and reconsider referral pathways for individuals empirically at need. While this is a difficult task in the context of scarce resources with competing demands, exacerbated by disparities in funding across mental health conditions which ought to be addressed (Woelbert et al., 2019), this study suggests a need to revisit the evidence which underpins clinical guidelines.
Risk differences between distinct subgroups suggest that meaningful risk stratification may be viable in this high-risk population.
Statement of interests
Yanakan Logeswaran has no conflicts of interests. No AI was used in the writing of this blog post.
Edited by
Simon Bradstreet.
Links
Primary paper
Grossmann L, Johansson F, Fazel S. et al (2026) Suicide after involuntary psychiatric care: a nationwide cohort study in Sweden. The Lancet Regional Health – Europe, 60.
Other references
Bergqvist E, Probert-Lindström S, Fröding E. et al (2022) Health care utilisation two years prior to suicide in Sweden: a retrospective explorative study based on medical records. BMC Health Services Research, 22(1), 664.
Carter G , Milner A , McGill K. et al (2017). Predicting suicidal behaviours using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales. The British Journal of Psychiatry, 210(6), 387–395.
Che S E, Gwon Y G & Kim K H (2023) Follow-up timing after discharge and suicide risk among patients hospitalized with psychiatric illness. JAMA Network Open, 6(10), e2336767.
Corderoy A, Kisely S, Zirnsak T & Ryan C J (2024) The benefits and harms of inpatient involuntary psychiatric treatment: a scoping review. Psychiatry, Psychology and Law, 32(5), 734-781.
Madsen T, Erlangsen A, Hjorthøj C & Nordentoft M (2020) High suicide rates during psychiatric inpatient stay and shortly after discharge. Acta Psychiatrica Scandinavica, 142(5), 355-365.
McClelland H, Cleare S & O’Connor R C (2023) Suicide risk in personality disorders: a systematic review. Current Psychiatry Reports, 25(9), 405-417.
NICE (2022) Self-harm: assessment, management and preventing recurrence. NICE guideline [NG225], 07 Sep 2022.
Ødegård K B, Myhre M Ø, Klungsøyr O. et al (2026) Discharge from mental health service admissions as a short-term causal risk factor for suicide: A case-crossover study. Journal of Psychiatric Research, 194, 174-180.
Seyedsalehi A & Fazel S (2024) Suicide risk assessment tools and prediction models: new evidence, methodological innovations, outdated criticisms. BMJ Mental Health, 27(1), e300990.
Stapleton A & Wright N (2017) The experiences of people with borderline personality disorder admitted to acute psychiatric inpatient wards: a meta-synthesis. Journal of Mental Health, 28(4), 443-457.
Wang D W L & Colucci E (2017) Should compulsory admission to hospital be part of suicide prevention strategies? BJPsych Bulletin, 41(3), 169–171.
Woelbert E, Kirtley A, Balmer N & Dix S (2019) How much is spent on mental health research: developing a system for categorising grant funding in the UK. The Lancet Psychiatry, 6(5), 445-452.
