ORIGINAL ARTICLE
https://doi.org/10.47811/bhj.199
Suicidal ideation among patients admitted to the psychiatry department at the national
Tashi Dorji1,2, Kencho Zangmo1, Bikram Chhetri2
1Department of Nursing, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
2Department of Psychiatry, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
Corresponding author:
Tashi Dorji
tashid@jdwnrh.gov.bt
ABSTRACT
Introduction: Suicidal ideation is often the first sign that a person is beginning to think seriously about ending one’s life. Understanding its prevalence and associated factors among psychiatric inpatients is essential for improving care and suicide prevention efforts, given the higher risk of suicide in this population. The objective of this retrospective study was to determine the rate of suicidal ideation and associated factors among patients admitted to the psychiatric ward at the national referral hospital in Bhutan. Method: Data were collected from the Ask Suicide-Screening Questionnaires and the initial nursing assessment form that were maintained for all patients (n= 529) admitted to the psychiatry department in 2023. Descriptive statistics were used to describe the rate of suicidal ideation among the patients. Chi-square test was done to determine the association between suicidal ideation and selected factors. Results: This study showed that 44.1% of the psychiatric in-patients had suicidal ideation. There were statistically significant associations between suicidal ideation and age, sex, employment status, primary diagnosis, past attempts and stressors with p-value of <0.001. There was also an association between suicidal ideation and level of education (p <0.05) while factors such as marital status and coping mechanisms did not show any association with the suicidal ideation. Conclusion: The high burden of suicidal ideation among psychiatric inpatients underscores the need for routine suicide risk assessments and targeted interventions. Strengthening mental health services and integrating suicide prevention strategies into inpatient care is critical for reducing suicide risk in Bhutan.
Keywords: Inpatients; Psychiatry; Suicide; Suicidal Ideation.
INTRODUCTION
Suicidal ideation refers to thinking about, considering or planning suicide. It ranges from momentary thoughts about death to detailed plans with a strong intent to die1. Understanding this spectrum of suicidal ideation is critical, as it reflects varying degrees of risk and urgency; often progressing from a general wish to die to an active and specific plan1-3. Although suicide is a major public health issue, its true prevalence may be underestimated due to stigma, legal implications, and inadequate surveillance systems4. Negative societal attitudes toward suicide act as barriers to openness and service use, complicating efforts to accurately quantify suicide-related outcomes5.
The World Health Organization (WHO) identifies suicide as one of the leading causes of death worldwide, accounting for 70,3000 deaths each year6. Reducing suicide mortality is a key WHO priority and aligns with the Sustainable Development Goals. The Southeast Asian Region is particularly affected, contributing to 39% of global suicides7. Studies report suicidal ideation rates of 34.8% to 43% among psychiatric inpatients, closely associated with mental health disorders such as depression, bipolar disorder, substance use disorder, schizophrenia, and anxiety disorders8,9. The presence of these comorbid conditions both increases vulnerability to suicidal thoughts and complicates early identification and clinical management of individuals at risk. Severe mental disorders serve both as significant risk factors for suicide and important targets for preventive measures10.
In Bhutan, it has been reported that for every 4.5 suicide deaths, one suicide attempt is recorded11. The country has an annual suicide growth rate of 9.4 percent12. Despite these figures, the lack of in-depth analysis and the sensitivity around accessing case files makes it challenging to study this issue comprehensively. The National Institute of Mental Health (NIMH) highlights that early detection is critical in preventing suicide, and many individuals who die by suicide have recently seen a healthcare provider13. Given the markedly higher risk of suicide among psychiatric inpatients, accurately identifying those at imminent risk remains a challenge, although timely recognition offers a valuable opportunity for intervention14-16. Therefore, this retrospective analysis aims to describe the prevalence and associated factors of suicidal ideation among psychiatric inpatients at the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH).
METHODS
Study design and setting
This retrospective descriptive study was conducted at the Department of Psychiatry at the JDWNRH in Thimphu, Bhutan, in 2023. The Psychiatry Department at JDWNRH, Bhutan’s only specialized mental health center, has a 20‑bed inpatient capacity and provides outpatient and inpatient psychiatric services. Care is delivered by a multidisciplinary team including psychiatrists, counselors, nurses, occupational and speech therapists, and support staff. As of 2023, the team comprised 4 psychiatrists, 4 clinical counselors, 3 psychiatry nurses, 6 general nursing/midwifery staff, 2 occupational therapists, 2 speech and language therapist, 1 health assistant, 4 peer counselors, and 1 pharmacy technician17. The psychiatry department initiated a comprehensive suicidal ideation screening process in 2022, aligning with Bhutan’s first suicidal prevention plan. As part of this initiative, all patients admitted to the psychiatry ward are screened for suicidal ideation using the 4-item Ask Suicide-Screening Questionnaire (ASQ).
Study participants
Inclusion Criteria
Patients of all ages and both sexes who were admitted to the psychiatry ward in 2023, had undergone routine suicide screening, and had complete nursing assessment data available were included in the study.
Exclusion Criteria
Patients with incomplete or missing screening/assessment data.
Sample size calculation and sampling method
This study utilized data from routine suicide screening and the initial nursing assessments of all patients admitted to the psychiatry ward during 2023. All individuals who met the inclusion criteria were included as study participants using consecutive sampling.
Study variables
The study variables included sociodemographic characteristics such as age, sex, highest level of education, and current employment status. Clinical variables included primary psychiatric diagnoses during the time of admission. Variables related to suicidal behavior included the presence of suicidal ideation at admission, any history of previous suicide attempts, and the number of past attempts.
Study tool
The Ask Suicide-Screening Questionnaires (ASQ) is a brief, validated tool developed by the NIMH to screen for suicidal ideation. It includes four yes/no questions on recent suicidal thoughts and lifetime attempts, with an optional fifth question to assess current risk. The freely available, user-friendly tool allows rapid identification and stratification of individuals at risk and has been validated in outpatient and inpatient settings globally15.
The initial nursing assessment form provides a systematic evaluation of all patients at admission. It is a standardized form approved by the hospital’s Quality Assurance Division of JDWNRH. The psychological component includes assessment of mood, recent stressors, coping mechanisms, support systems, and substance use history.
Data management
The data on the ASQ and initial nursing assessment forms were accessed from the medical record section of the hospital by the investigators. The data from the ASQ and initial nursing assessment forms were then entered into an excel sheet by the investigators. The collected data was checked for completeness and double entered into Epidata (version 3.1, EpiData Association, Odense, Denmark) software with double data entry to minimize errors. Data analysis was conducted using STATA (version 14.1 licensed to KGUMSB). Descriptive statistics were used to describe patients’ characteristics. Chi-square test was used to determine the association between the independent variables and suicidal ideation, with p-value <0.05% considered statistically significant.
Ethical considerations
Ethical clearance was obtained from the Institutional Review Board, Khesar Gyalpo University of Medical Sciences of Bhutan (Ref. No. IRB/Waiver-Exempt/PN24-037/154). A waiver for informed written consent was also granted since this study was retrospective, utilizing the existing clinical records only. Moreover, there was no direct involvement or contact with the participants, and it posed none to minimal risk to the participants. Administrative clearance for the study was sought from both the Ministry of Health and the study site. All collected data were kept confidential and under no circumstances, identifying characteristics of the participants were included in the study.
RESULTS
Among the 529 patients admitted to the psychiatric department in 2023, there were more men (59.9%) than women (40.1%) as shown in Table 1. Over half of the patients (54.8%) were young adults aged 25 to 44 years and there were 4.5% of them aged 60 years and older. More than one-third (39.3%) of the patients were dependents, 32.9% were employed, 12.7% were students, and 11.3% were farmers.
Table 1. Sociodemographic characteristics of the patients admitted to the psychiatry department of JDWNRH in 2023 (n=529)
|
Characteristics |
n (%) |
|
Age groups |
|
|
Children & Adolescents |
51 (9.6) |
|
Youths |
79 (14.9) |
|
Younger adults |
290 (54.8) |
|
Middle age adults |
85 (16.1) |
|
Older adults |
24 (4.5) |
|
Gender |
|
|
Male |
317 (59.9) |
|
Female |
212 (40.1) |
|
Highest level of education |
|
|
No formal education |
131 (24.8) |
|
Primary |
68 (12.9) |
|
Secondary |
250 (47.3) |
|
Tertiary and above |
80 (15.1) |
|
Current employment status |
|
|
Employed |
174 (32.9) |
|
Dependent |
207 (39.1) |
|
Farmer |
60 (11.3) |
|
Student |
67 (12.7) |
|
Others* |
21 (4.0) |
* Others include nuns, gomchens, anays
Suicidal ideation
Assessment using the ASQ showed that 44.1% of psychiatric inpatients had suicidal ideation at admission, of whom 18.4% reported active ideation (Table 2). As shown in Table 3, among those with suicidal ideation, 41.0% reported previous suicide attempts. The number of past attempts ranged from one to four, with most having attempted once (32.1%). Among those without suicidal ideation at admission, one had attempted suicide in the past.
Analysis of suicidal ideation and past suicide attempts across different admission diagnoses showed higher rates among patients with depression (79.4%) and trauma and stress-related disorders (78.9%). As shown in Table 4, the rates of past suicide attempts are also higher in these two groups of patients (53.9% and 47.4% respectively).
Nearly 38% of the admitted patients reported having stressors at the time of admission.
Table 2. Types of suicidal ideations and past attempts among patients admitted to psychiatric ward at JDWNRH in 2023 (n=529)
|
Suicidal ideation at admission |
Ideation type |
Past attempts |
||
|
|
Active f (%) |
Passive f (%) |
Yes f (%) |
No f (%) |
|
Yes (n=233) |
43(18.5) |
190 (81.6) |
96(41.0) |
138 (58.9) |
|
No (n=296) |
00 |
00 |
1 (0.3) |
294 (99.6) |
|
Total (N=529) |
43 (8.1) |
190(35.9) |
97(18.3) |
432 (81.7) |
Table 3. Description of past suicide attempts amongst the patients admitted to the psychiatry ward at JDWNRH in 2023 (n = 529)
|
Suicidal ideation at admission |
Number of past suicide attempts |
|||
|
|
1 |
2 |
3 |
4 |
|
Yes |
75 |
17 |
2 |
2 |
|
No |
1 |
0 |
0 |
0 |
Table 4. Frequency of suicidal ideation and previous suicide attempts according to the diagnosis on admission among patients admitted to the psychiatry ward at JDWNRH, 2023 (n=529)
|
Diagnosis on admission |
Suicidal ideation at admission n(%) |
Past attempts of suicide n(%) |
|
Alcohol use disorder |
70 (32.7) |
14 (6.5) |
|
Depression |
50 (79.4) |
34 (53.9) |
|
Bipolar affective disorder |
16 (29.6) |
7 (12.9) |
|
Substance use disorders |
25 (50.0) |
9 (18.0) |
|
Schizophrenia and other psychotic disorders |
10 (21.7) |
5 (10.9) |
|
Trauma and stress related disorders |
30 (78.9) |
18 (47.4) |
|
Anxiety disorders |
14 (58.3) |
4 (16.7) |
|
Dissociative conversion disorders |
6 (46.2) |
3 (23.1) |
|
Epilepsy |
7 (53.8) |
0 |
|
Others |
6 (37.5) |
3 (21.4) |
Factors associated with suicidal ideation
The Chi-square analysis demonstrated a strong association between suicidal ideation and age, sex, employment status, primary diagnosis, presence of stressors, and past attempts, all with p-values <0.001. A weaker but statistically significant association was also observed between suicidal ideation and level of education (p-value <0.05). (Table 5).
Table 5. Association between suicidal ideation and sociodemographic factors amongst patients admitted to the psychiatry ward at JDWNRH in 2023 (n=529)
|
Study variable |
Suicidal ideation |
Chi square value |
P value |
||
|
Yes |
No |
Total |
|||
|
n (%) |
n (%) |
n (%) |
|||
|
Age |
|
|
|
28.3 |
<0.001 |
|
Children and adolescents |
36 (15.4) |
15 (5.1) |
51 (9.6) |
||
|
Youth |
45 (19.2) |
34(11.5) |
79 (15) |
||
|
Younger adults |
119 (50.9) |
171 (57.9) |
290 (54.8) |
||
|
Middle age adults |
27 (11.5) |
58 (19.7) |
85 (16.1) |
||
|
Older adults |
7 (3) |
17 (5.8) |
24 (4.5) |
||
|
Sex |
|
|
|
|
|
|
Male |
117 (50) |
200 (67.8) |
317 (59.9) |
17.2 |
<0.001 |
|
Female |
117 (50) |
95 (32.2) |
212 (40.1) |
|
|
|
Marital status |
|
|
|
|
|
|
Married |
90 (38.5) |
145 (49.1) |
235 (44.4) |
7.4 |
>0.05 |
|
Single |
104 (44.4) |
100 (33.9) |
204 (38.6) |
|
|
|
Divorced |
38 (16.2) |
46 (15.6) |
84 (15.9) |
|
|
|
Widowed/Widower |
2 (0.9) |
4 (1.4) |
6 (1.1) |
|
|
|
Highest level of education attained |
|
|
|
|
|
|
No formal education |
46 (19.7) |
85 (28.7) |
131 (24.7) |
8.9 |
<0.05 |
|
Primary |
26 (11.2) |
42 (14.2) |
68 (12.8) |
|
|
|
Secondary |
126 (54.1) |
124 (41.9) |
250 (47.4) |
|
|
|
Tertiary and above |
35 (15) |
45 (15.2) |
80 (15.1) |
|
|
|
Employment status |
|
|
|
|
|
|
Employed |
77 (32.9) |
97 (32.9) |
174 (32.9) |
31.1 |
<0.001 |
|
Dependent |
78 (33.3) |
129 (43.7) |
207 (39.1) |
|
|
|
Farmer |
22 (9.4) |
38 (12.9) |
60 (11.3) |
|
|
|
Student |
50 (21.4) |
17 (5.8) |
67 (12.7) |
|
|
|
Others |
7 (3) |
14 (4.7) |
21 (4) |
|
|
|
Primary diagnosis during admission |
|
|
|||
|
Alcohol use disorder |
70 (30) |
144 (48.8) |
214 (40.5) |
|
|
|
Depression |
50 (21.4) |
13 (4.4) |
63 (12) |
78.8 |
<0.001 |
|
Bipolar affective disorder |
16 (6.8) |
38 (12.9) |
54 (10.2) |
|
|
|
Substance use disorder |
25 (10.7) |
25 (8.5) |
50 (9.5) |
|
|
|
Schizophrenia and other psychotic disorders |
10 (4.3) |
36 (12.2) |
46 (8.7) |
|
|
|
Trauma and stress related disorders |
|
|
|
|
|
|
Anxiety disorders |
30 (12.8) |
8 (2.7) |
38 (7.2) |
|
|
|
Dissociative conversion disorders |
14 (5.9) |
10 (3.4) |
24 (4.5) |
|
|
|
Epilepsy |
6 (2.6) |
7 (2.4) |
13 (2.4) |
|
|
|
Others |
7 (2.9) |
6 (2) |
13 (2.4) |
|
|
|
|
6 (2.6) |
8 (2.7) |
14 (2.6) |
|
|
|
Stressors |
|
|
|
|
|
|
Social |
51 (21.8) |
29 (9.8) |
80 (15.1) |
41.5 |
<0.001 |
|
Academic |
18 (7.7) |
6 (2) |
24 (4.5) |
|
|
|
Occupation |
10 (4.3) |
13 (4.4) |
23 (4.3) |
|
|
|
Psychological |
15 (6.4) |
7 (2.4) |
22 (4.2) |
|
|
|
Physical |
9 (3.9) |
9 (3.1) |
18 (3.4) |
|
|
|
Financial |
5 (2.1) |
7 (2.4) |
12 (2.3) |
|
|
|
Major life event |
12 (5.1) |
8 (2.7) |
20 (3.8) |
|
|
|
Not expressed |
114 (48.7) |
216 (73.2) |
330 (62.4) |
|
|
|
Past attempt |
|
|
|
|
|
|
Yes |
96 (41.1) |
1 (0.3) |
97 (18.3) |
144.2 |
<0.001 |
|
No |
138 (58.9) |
294 (99.7) |
432 (81.7) |
|
|
DISCUSSION
This study revealed that 44.1% of patients admitted to the psychiatry ward had suicidal ideation at the time of admission. Among them, 18.4% reported active suicidal ideation while 81.5% had passive suicidal ideation. Psychiatric inpatients are known to be at a higher risk of suicide, with an estimated rate of 147 suicides per 100,000 patient-years, which is nearly 13 times higher than the WHO’s annual global age-standardized suicide rate of 11.4 per 100,00018,19. The prevalence rate in our study is consistent with previous findings, as Chammas et al. (2022) reported rates ranging from 30 % to 50 % among psychiatric inpatients in Europe, North America, and Asia, and Furnes et al. (2021) found a prevalence of 51.9 % among acute psychiatric inpatients in Norway8,9. In contrast, a study among Chinese psychiatric inpatients reported a significantly lower prevalence rate of 12.3%, though this was higher than the rate of suicidal ideation observed in the general Chinese population20. Despite the well-established higher risk of suicide among psychiatric inpatients, the challenge is in identifying those patients who are most likely to die by suicide19.
More importantly, the 18.4% of patients who reported active suicidal ideations require close supervision and timely intervention during hospitalization. This could include regular reassessment of their suicidal ideation. A past suicidal attempt remains one of the strongest predictors of future suicide2. The current study showed that 18.3% of psychiatric inpatients reported at least one previous suicide attempt. Awareness of both the presence of current suicidal ideations and the history and frequency of past suicidal attempts can enable mental health professionals to more accurately stratify suicidal risk among psychiatric inpatients and tailor appropriate management. The ASQ is a user-friendly, rapid screening tool that enables efficient stratification of individuals at risk for suicidal ideation in busy clinical settings. It has been widely implemented in emergency, inpatient, and outpatient services in the United States, with subsequent translation and validation in Asian settings, including Nepal and Pakistan 15, 21, 22.
In terms of the diagnosis and suicidal ideation, depression, and trauma and stress-related disorder had the highest suicidal ideation at 79.4% and 78.9%, respectively. Following this, patients with anxiety disorder, epilepsy, dissociative conversion disorder, alcohol use disorder, and substance use disorder had the higher risk. The high rates of suicidal ideations across the various diagnostic spectrum indicate that suicidality cuts across a wide range of psychiatric and neurological diagnoses. These findings reinforce the importance of suicide risk assessment irrespective of the primary diagnosis at admission.
Comparison of diagnosis and past attempts revealed that depression, trauma and stress-related disorder, and dissociative conversion disorder had the higher suicidal risk. Depressive disorders are strongly associated with increased suicidal ideation. A large meta‑analysis of patients with major depressive disorder found that about 37.7 % experienced suicidal ideation, demonstrating that suicidal thoughts are common in depressive conditions, especially in inpatients23. Comparative data also show that individuals with depressive disorders have significantly higher odds of suicidal ideation than those without depressive disorders, reinforcing depression as a potent risk factor for suicidality24. In terms of the clinical predictor of suicidal ideation, a systematic review and meta-analysis found “hopelessness” as the clinical predictor25. Trauma and stress related disorder constitutes another significant proportion of patients with suicidal ideations and past attempts. Individuals experiencing stressful life events are more vulnerable to suicidal ideation and behaviors26. In our study, 37.6% (199) of patients had some stressors at the time of admission. Most of these stressors were social in nature, including relationship conflicts, while others were related to psychological strain, occupational and academic pressures, physical health, financial challenges, and other major life events. Traumatic life events and post-traumatic stress disorder (PTSD) have been reported as the major risk factor for suicidal ideation27,28. In a sample of acute-care psychiatric inpatients, greater severity of PTSD symptoms was associated with higher suicidal ideation27. In our study, patients with depression and trauma/stress‑related disorders had a heightened prevalence of suicidal ideation. This underscores the need for the routine assessment of depressive symptoms and life stressors and related disorders during initial evaluation, and for timely management of depression and associated stressors, as such measures may help mitigate suicide risk and improve patient outcomes.
Alcohol use disorder and substance use disorders were also associated with considerable levels of suicidal ideation and prior attempts in this study. Conner and colleagues reported that approximately half of individuals with alcohol dependence had a history of suicidal ideation28. It is interesting to note that patients with alcohol use disorder and substance use disorder also had high rates of suicidal ideation from the present study. This may be due to over representation of our data as alcohol use disorder is the commonest cause of psychiatric hospitalization in our hospital. The other reason may be due to co-occurring undetected depression and other psychiatric disorders among patients with alcohol and substance use disorders. It was reported that the prevalence of depression among patients with alcohol use disorder in Bhutan is 38%29.
In this study, suicidal ideation amongst psychiatric inpatients was significantly associated with age, sex, employment status, primary diagnosis, past attempts and stressors (p <0.001). Furthermore, the level of education was also associated with suicidal ideation (p<0.05). These findings are broadly consistent with other studies reporting similar associations between demographic characteristics, clinical diagnosis, stressors and suicidal ideations9,30. Systematic review and meta-analysis literature further support these associations, identifying previous suicide attempts, depressive symptoms, family history of suicide, and current suicidal ideation as moderate predictors of inpatient suicide31. Conversely, factors associated with suicide in the general population, such as male sex, substance use, and unemployment, were not significantly associated with inpatient suicide30. In a study conducted in Kathmandu, Nepal, there was no statistically significant association between suicidal ideation and variables such as sex, marital status, and type of family, whereas a study in Northern Ethiopia conducted amongst patients with mental disorders, identified family history of mental illness or suicide, previous suicide attempts, major depressive disorders, and psychiatric comorbidities as significant risk factors32,33. These differences in the findings likely reflect the differences in study design, settings, cultural contexts and study variables. Nevertheless, the consistent identification of certain clinical and social risk factors underscores the need for extra vigilance and targeted management strategies for these high-risk subgroups within the psychiatric inpatient population.
The first step in effective suicide prevention is comprehensive and repeated suicide risk assessment. Given the dynamic nature of suicidal ideations and the varying levels of risk across individuals, reassessments at multiple points during care are necessary. Evidence indicates that the first few days during and after hospitalization, and the first days and weeks after discharge represent the highest-risk periods34. This requires the formulation of effective strategies, targeted psychoeducation and planned follow-ups to reduce suicide risk in this vulnerable population.
Limitations
The study was retrospective in design and utilized secondary data which restricted analysis to the routinely documented clinical information. This limited the ability to explore certain variables like family history of suicide, family history of mental health illnesses and degree of social support.
CONCLUSION
Nearly half (44.1%) of the psychiatric inpatients had suicidal ideations on admission, emphasizing the need for regular suicide risk assessments within inpatient settings. The significant associations identified between suicidal ideation and factors such as clinical diagnosis, psychosocial stressors and certain demographic characteristics highlight areas for targeted interventions during the time of hospitalization. Enhancing the capacity of mental health services to address these risk factors within inpatient care is essential for reducing suicide risk.
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AUTHOR CONTRIBUTIONS: Following authors have made substantial contributions to the manuscript as under: TD: Conceptualization, design, literature review, data collection, writing, editing, review KZ: Conceptualization, design, data analysis, writing, review BC: Conceptualization, design, literature review, editing, review Authors agree to be accountable for all respects of the work in ensuring that questions related to the accuracy and integrity of any part of the work are appropriately investigated and resolved.
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CONFLICT OF INTEREST None
GRANT SUPPORT AND FINANCIAL DISCLOSURE None
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