Written: July 19, 2019
It has been known for some time that patients are at particular risk of suicide in the days and weeks after discharge from psychiatric hospital, and new research from Manchester University highlights some deeply concerning statistics: (https://www.theguardian.com/society/2018/oct/02/newly-discharged-mental-health-patients-at-much-higher-risk-of-death)
Clearly the support given to patients in the days and weeks after discharge is vitally important. In reality, the aftercare may consist only of a single visit from the crisis team the day after leaving hospital. After that, there may be no further crisis team visits.
New clients coming to our Suicide Crisis Centre are telling us that they are only receiving this 24 hour follow-up, instead of the 48 hour follow-up which used to be available. But even 48-hour follow-up seems very little. As a result, they are using our crisis services for support. They remain under our care for as long as they need to. If they need to be with us for several weeks, then that is what we provide.
I can only imagine that staff shortages are the reason why there is so little follow-up. Worryingly, the 24-hour follow-up may only require the crisis team to “see that the patient is alive”. On some occasions the patient has been told that they just need them to answer the door and the team does not need to stay after that. All this does is show that the patient is alive at that moment.
Indeed, I experienced this myself after discharge from psychiatric hospital. The crisis team arrived the next day and I answered the door. I said that I didn’t feel that I wanted to talk to them that day. They said that was okay, they “just needed to see me”. They did not ask how I was feeling, nor any questions about my risk or if I was having any suicidal thoughts.
The Manchester report flags up the fact that patients may be returning to “the same or similar circumstances to the point at which they were so ill that they needed to be admitted to an inpatient unit.” They may return home and feel nothing has changed: the factors which led to their suicidal crisis may still remain.
On top of that, there is the potentially destabilising effect of being discharged. You may have been living in what feels like a protected environment, where staff are on hand 24 hours a day. You may have felt supported, not just by staff: patients are often extremely supportive of each other. In my experience, a community forms within each ward. Patients look out for other patients. They care about each other, and are concerned for each other. If you are returning to a place where you live alone, the contrast can be very marked.
I recall the first time I went outside the psychiatric hospital during my last inpatient stay in 2016. It was a planned visit to the shops, accompanied by staff. I was shocked by the level of noise from traffic and people, and by the number of people on the streets. It all felt overwhelming and frightening. I felt extremely vulnerable. I had very quickly started to lose the ability to cope with everyday life. As I walked along the road, I also had a strong sense of being separate and disconnected from the rest of the world, as though I no longer belonged. In some ways, my stay in psychiatric hospital, although supportive, had made me more vulnerable once back out in the community.
When I eventually discharged myself and left the hospital for good, I thought I was ready to return home. It is so hard to predict how you will feel in those circumstances, though. I had strong suicidal thoughts that night as the shock of returning to the community hit me with full force.
A “trial night” at home before the actual discharge can be a good idea for some patients and indeed, I wish I had had this. It allows the patient to see how it feels to spend a night at home, knowing they can return to hospital the next day – and that they can return that same night if they feel distressed.
It is incomprehensible to me that 24 hour follow up or even 48 hour follow up is considered “enough” after the intensive care experience of a psychiatric hospital. We know from the clients who come to us that the intensive care they need afterwards in the community must last far longer than that.
By Joy Hibbins: previously published in Mental Health Today: https://www.mentalhealthtoday.co.uk/blog/patients-newly-discharged-from-psychiatric-hospital-are-at-higher-risk-of-suicide-so-why-do-they-receive-so-little-aftercare
Joy runs a Suicide Crisis Centre in Gloucestershire. For information: http://www.suicidecrisis.co.uk
National sources of support: In the UK, the Samaritans can be contacted by calling 116 123.