How to reduce suicides on the psychiatric ward

Mia St. John
Mia St. John spends time at Runnymeade Park in Winnetka where she used to find her son Julian St. John, who used to be homeless due to his schizophrenia. He was admitted to a psychiatric facility for his safety, but he killed himself there. Mia has made it her life’s goal to improve psychiatric care.
(Liz Moughon / Los Angeles Times)

Over the last decade, more than 50 people have died by suicide while admitted to psychiatric facilities in California. The figure paints a bleak picture of the options available for people in the midst of a mental health crisis.

So for families whose loved ones are suffering from suicidal thoughts, is there hope? Can hospitals actually stop people from dying by suicide?

The short answer, experts say, is yes.

Suicide rates have risen in nearly every state in America over the last 20 years. Nationwide, suicide is an epidemic, now the second-leading cause of death among people ages 10 to 35.

Psychiatric hospitals are often seen as a last resort for people who are suicidal. But a Times analysis found that over the last decade, nearly 100 people died while admitted to these facilities in California, mostly due to suicide. A study released last year found that nationwide 49 to 65 people die by suicide annually while in the hospital.


But there is wide variation in suicide rates from hospital to hospital, suggesting some places are keeping patients safer than others. One of the high-performing systems, the Department of Veterans Affairs, offers some clues as to what might work.

In 2007, VA hospitals nationwide adopted a 134-question checklist designed to reduce suicide risks for patients.

Staff members must ensure that pillows and mattresses are free of vinyl or plastic, which could be used for strangulation; that there are no privacy curtains, which can be used for hanging; that all exits and entrances to the building are within the line of sight of the nurses’ station, so patients are easily monitored.

Since the checklist was implemented, suicides in mental health units have decreased dramatically. The suicide rate fell from 4.2 suicides per 100,000 admissions to 0.74 suicides per 100,000 admissions, according to a 2016 paper.

And it has stayed down, researchers found.

“The trend suggests that the rate of suicide continues to decline since implementation of the checklist,” the paper found.

But outside the VA system, there’s been little progress, experts say.

The Joint Commission, a nonprofit that accredits most of the nation’s psychiatric hospitals, has been trying to reduce suicide rates nationwide for the last decade, to no avail, , said Dr. David Baker, the agency’s executive vice president for healthcare quality evaluation.


Part of the problem is that reliable data weren’t available on the number of suicides in hospitals and how they were taking place. The agency commissioned a study that found that among the roughly 50 suicides per year in hospitals nationwide, 70% were via hanging. Half were in the bathroom and a third in the bedroom, the study found.

In response to the findings, an expert panel made recommendations on how to limit these deaths, including the best way to monitor suicidal patients.

Mia St. John
Mia St. John meditates at her home in Palm Springs. Her adult son Julian St. John was admitted to a psychiatric facility for his safety but later killed himself there.
(Liz Moughon / Los Angeles Times)

At many hospitals, patients deemed suicidal are put on 15-minute watch, but that isn’t very effective because it doesn’t take long to complete suicide, experts say.

“It’s certainly not the best way to monitor for suicidal ideation,” said Dr. Tyler Jones, clinical associate psychiatry professor at Oregon Health and Science University. “The opportunity can happen pretty quickly.”

The better, though more resource-intensive, option is one-to-one observation, in which a staff member is within arm’s-reach of a patient at all times.

No single agency keeps tabs on the number of deaths at psychiatric facilities in California, or elsewhere in the nation. The Times submitted more than 100 public record requests to obtain the information.

Dec. 1, 2019

This year, the Joint Commission released new national standards effective July 1 aimed at reducing suicide rates. The requirements mandate widespread suicide screening among psychiatric patients as well as minimizing any anchor points, door hinges or hooks that can be used for hanging.

“I think some people come away thinking that hospitals have not been paying attention to this and I think part of that is due to the lack of clarity,” Baker said. “I think it’s much more clear what they should be doing now.”

For some patients, the hospital can provide a needed respite from their suicidal thoughts — and potentially save their lives, experts say.

When someone wants to die by suicide, they are typically focused on one mode, whether it be jumping off a bridge or overdosing, said Johns Hopkins University psychiatry professor Dr. Paul Nestadt. Without that option, the desire to complete suicide drops dramatically.

Mia St. John at her gym in Palm Springs
Mia St. John, who used to be a professional boxer, works out at her gym in Palm Springs, where she keeps the artwork of her son, Julian St. John, who suffered from schizophrenia, and killed himself at a psychiatric facility. “Two weeks after he died, I ran to the Department of Health Services begging them to give me a program to save my life,” she says. She now teaches boxing to at-risk youth a few times a week both in Palm Springs and Los Angeles.
(Liz Moughon / Los Angeles Times)

In a 1978 study, researchers followed 515 people who attempted to jump off the Golden Gate Bridge in San Francisco but survived. The study found that only 5% of them eventually died by suicide.

The research points to the importance of reducing suicide risk at places where people often kill themselves, such as installing a suicide net under the Golden Gate Bridge. When convenient means of dying are taken away, people become much less likely to attempt suicide, Nestadt said.

“There are people who just keep trying and die, but they are the minority,” Nestadt said. “That contextualizes the role of the hospital ... the hospital is there to keep someone from having access to that gun or that bridge or that train so they can be treated and the feeling can pass.”