Psychological distress and attitudes of emergency personnel towards suicide attempters

Emergency personnel attitudes towards suicide attempters are important because they have a key role in the management of these patients. We examined the association between staff members' psychological distress and the attitudes towards suicide attempters. We also compared the attitudes towards suicide attempters among emergency personnel between a general and a psychiatric hospital. The Understanding Suicidal Patients (USP) Questionnaire and the 12-item version of General Health Questionnaire were given to all staff in the emergency rooms of a general hospital and a psychiatric hospital (n=151). There was a general tendency among emergency room staff to view attempted suicide patients positively and sympathetically. However, there were clear differences in staff attitudes between the two hospitals: those working in the general hospital expressed more negative attitudes than those in the psychiatric hospital. No evidence emerged of association between staff members' psychological distress and negative attitudes towards suicide attempters. There was no association between psychological distress and negative attitudes towards suicide attempters.     

Work stress has negative effects on the attitudes of emergency personnel towards patients who attempt suicide

Many previous studies indicate that the attitudes of the staff towards patients who attempt suicide are often negative. Nevertheless, the attitudes of the staff working in different areas of an emergency department have not been studied. The purpose of this study was to explain the attitudes of emergency personnel (n = 184) towards patients who attempt suicide in the different stages of treatment in a general hospital by comparing the attitudes of the staff in the emergency room (n = 64), emergency ward (n = 47) and intensive care unit (n = 73). There were clear differences in attitudes of staff in the various units. The attitudes were most negative among emergency room staff, where all attempters are first treated. The intensive care staff, who treat the most serious cases, shared the most positive attitudes. It seems that specialized treatment of suicide attempters makes it possible to treat these patients in a more professional way in a general hospital.     

Patients' evaluation of their psychiatric consultation after attempted suicide

Few studies have previously investigated patients' evaluation of their psychiatric consultation after attempted suicide. The aim of the present study was to examine the patients' view of their psychiatric consultation after a suicide attempt. Of a systematic sample of 114 suicide attempters in Helsinki, 73 subjects were referred to psychiatric consultation at an emergency room or department, and 53 of these evaluated the consultation received. Half of these suicide attempters considered their psychiatric consultation had occurred too soon after the attempt. Those whose prior attitude toward the consultation was indifferent had higher Hopelessness Scale (HS) and Beck Depression Inventory (BDI) scores than those who were positive. Psychiatric assessment should not take place before the patient has recovered from toxic effects caused by any overdose attempt. Suicide attempters with severe depression and hopelessness are likely to be those most indifferent to the prospect of psychiatric consultation. The presence of severe depression or hopelessness should not deter active evaluation and treatment.     

The association of suicide attempts and comorbid depression and substance abuse in psychiatric consultation patients

Substance abuse has been associated with attempted suicide and suicide. Few studies have examined the prevalence and associations of combined depression and substance abuse in suicide attempters. A chart review study of 1136 adult general hospital patients referred for psychiatric consultation between 1995 and 1998 was conducted to assess this further. Among 371 cases with self-harm, 311 (84%) attempted suicide. Suicide attempters were younger and diagnosed more often with comorbid substance abuse than patients without self-harm. Depressive disorders were found in 59% and substance abuse disorders in 46%. Comorbid depression and substance abuse was the most frequent category in suicide attempters, i.e., in 37%. Self-reported suicide intent was associated with increasing age, male gender, and comorbid depression and substance abuse. The suicide rate in suicide attempters was 322 per 100,000 patient-years, and 131 per 100,000 in consultation patients without self-harm. It is concluded that comorbid depression and substance abuse is associated with attempted suicide in psychiatric consultation patients. Suicide attempters should be thoroughly assessed for substance abuse. The increased suicide rate in psychiatric consultation patients with and without suicide attempts warrants further research.     

Determinants of psychiatric hospitalization after attempted suicide

OBJECTIVE: This study investigated the characteristics of suicide attempters referred to psychiatric hospitals and the factors affecting such referral. METHOD: All 1198 consecutive suicide attempters treated in general hospital emergency rooms in Helsinki during a 12-month period were identified. Data on all health care contacts 1 year before the index attempt and on referrals to psychiatric hospitals after the attempt were gathered. RESULTS: We found that a quarter of patients were referred to psychiatric hospitals as inpatients after index suicide attempts. Factors predicting referral to psychiatric hospitals, compared to nonreferral, were older age, psychotic disorder, mood disorder, lack of alcohol consumption preceding the attempt, somatic illness, suicide attempt on a weekday, previous psychiatric treatment, psychiatric consultation and the hospital treating the suicide attempt. CONCLUSION: Although the clinical characteristics of patients attempting suicide are a major determinant of whether they are subsequently referred to psychiatric hospitals, the treatment practices of emergency room hospitals also influence treatment decisions.     

Attempted suicide and psychiatric consultation.

This study investigated the differences in clinical characteristics between suicide attempters referred or not referred to psychiatric consultation after a suicide attempt and factors affecting such referral to psychiatric aftercare after attempted suicide. All 1198 consecutive suicide attempters treated in hospital emergency rooms in Helsinki during a 12-month period were identified. Data were gathered on any psychiatric consultation after the attempt and on all health care contacts 1 year before and after the index attempt. We found that half of the suicide attempters who were not referred to psychiatric consultation were without any aftercare recommendation and treatment contact soon after their attempt. Factors predicting referral to psychiatric consultation were age, psychotic disorder, lack of substance use disorder and, most strongly, the hospital where the suicide attempt was treated. Although the characteristics of a patient attempting suicide do play a role in determining whether a psychiatric consultation will take place or not, the most important factor is the consultation practices of the particular hospital. This in turn influences the probability of adequate aftercare.     

A follow-up study of adolescent attempted suicide in Israel

OBJECTIVES: (1) To compare the outcome of adolescent subjects who have made a suicide attempt with the outcome of matched controls, using their psychological and psychometric screening tests for military service at age 16.5 years. Their subsequent performance during military service between ages 18 and 21 was also evaluated. (2) To compare the prognosis of those attempters who received intensive psychiatric inpatient evaluation in a general hospital with the prognosis of those who received emergency room treatment only. METHOD: The computerized military records of 216 adolescents, who had been treated between 1987 and 1988 for attempted suicide in a general hospital emergency room, prior to their induction into the army, were evaluated. They were rated on the following tests: cognitive/educational performance and psychosocial adaptation, psychiatric and psychological health diagnoses, and performance during their military service between 1989 and 1992. RESULTS: Although the female attempters had slightly more problems in the military than the controls, their overall prognosis was surprisingly good. The male suicide attempters did very poorly in their subsequent military service. There was no long-term advantage in having had a psychiatric evaluation performed in a hospital over a brief emergency room evaluation. Most differences between attempters and controls were in service performance, rather than in cognitive and psychometric tests. CONCLUSIONS: There may be marked differences between the sexes in the significance of attempted suicide and in the indications for intervention. The policy of mandatory general hospitalization for suicide attempters may need reevaluation.     

Survival analysis of suicide risk after attempted suicide

Survival analysis of suicide risk by sex and age after attempted suicide was studied in a cohort of 1573 suicide attempters referred to the psychiatric emergency room at the Karolinska Hospital from 1981 to 1988. The time course of suicide risk and the overall prognosis after attempted suicide and, in particular, the possible usefulness of sex and age as risk factors for the prediction of suicide risk after attempted suicide was analyzed. Nearly two thirds of the sample were women and most of the suicide attempters were young (in their twenties and thirties), and the median age was 35 years. The overall mortality after a 5-year mean observation period after attempted suicide was 11%, and the suicide mortality was 6 %. The suicide risk after attempted suicide among men (8.3%) was nearly twice the female suicide risk (4.3%). Age as a possible suicide risk factor was analyzed for each sex separately by median split subgrouping. It was concluded that both older and younger male suicide attempters are at high risk of suicide (7% and 10% respectively), and older women are at higher risk than younger (6%, vs 2%). The suicide risk is particularly high during the first year after the suicide attempt. The high suicide risk group of young adult male suicide attempters is one of the main feasible targets of psychiatric intervention research programs on suicidal behavior. Suicide among young men is a major cause of years of life lost.     

Selection of patients who attempted suicide for psychiatric consultation.

A total of 1018 self-poisoned patients were treated during one year (1983) at the emergency room of Helsinki University Central Hospital for 1207 suicide attempts; 46% were left without psychiatric consultation. Women were consulted more frequently than men. Patients with previous psychiatric treatment were referred more often for psychiatric consultation. The use of alcohol was more frequently present in suicide attempts that did not lead to psychiatric consultation. Somatic seriousness was also less severe in this group. It was assumed that those left without consultation were not in mortal danger. There were no differences in the suicide mortality of these 2 groups during a 5-year follow-up.     

Attitudes of clinicians in emergency room towards suicide

Objective. The present study brings to focus common attitudes of clinicians working in the emergency room. Methods. A questionnaire was used to assess the attitudes of clinicians working in the emergency room. The data were subjected to factor analysis. Results. These clinicians show attitudes of avoidance, rejection, hostility, anxiety and fear, and inadequacy. They also considered the act of suicide as manipulative and unlawful. Conclusion. Due to various internal as well as external factors these medical professionals have negative attitudes towards suicide attempters, with a resultant low quality of care. Dealing with one's own anxieties over suicide and death, along with having good evaluation skills and a multidisciplinary approach to handle such cases, could save many more lives.     

Is assessing for borderline personality disorder useful in the referral after a suicide attempt?

BACKGROUND: Management of suicide attempters accounts for 10% of the psychiatric activity in the emergency room. In this population, the prevalence of borderline personality disorder (BPD) is high (10 - 55%). These patients present poorer psychosocial outcome and more frequent suicide attempts repetitions. However, the utility of the assessment of BPD in the referral to a specific treatment plan has not been yet studied. OBJECTIVE: To examine the association between the assessment of a diagnosis of BPD after a suicide attempt and the referral from the emergency room to a specific treatment plan. HYPOTHESIS: Suicide attempters with BPD, according to clinicians diagnosis, differ in terms of severity from those without more risk factors of suicide attempt repetitions and poorer psychosocial functioning, and in psychiatric referral from the emergency room. METHOD: Our case-control study took place during 10 months in the Geneva general hospital. We continuously enrolled patients admitted to the emergency room for deliberate self poisoning and separated them into two groups (BPD and control) according to the clinician's diagnosis. Data from medical records were systemically and anonymously gathered. We compared BPD patients' socio-demographic and clinical characteristics, as well as psychiatric referral, with the control group. RESULTS: Of the 478 subjects admitted to the emergency room for deliberate self-poisoning, 99 (22.6%) were diagnosed BPD by clinicians. Compared to controls, they were more frequently female (OR=3.9) and living alone (OR=3.8) and more often resorted to psychiatric care (OR=2.9), notably to emergency care (OR=3.8). Past history of suicide attempt was also more frequent (OR=1.9) as was the use of neuroleptics in the attempt (OR=2.7). No difference was detected in terms of psychiatric referral after emergency room care. CONCLUSION: Even if borderline personality disorder in suicide attempters is associated with more severity criteria, it is not associated with a referral to a specific treatment plan.     

Quality of Psychosocial Care of Suicide Attempters at General Hospitals in Norway—A Longitudinal Nationwide Study

The objective of this study was to identify predictors of a high level of quality of care for suicide attempters at general hospital emergency departments in Norway. Structured interviews with key informants covering the quality of care of patients admitted following attempted suicide were conducted in 1999 and 2006 at 87% of all general hospitals. Hospitals having implemented a chain of care program for suicide attempters in 1999 maintained significantly higher levels on quality of care indicators 7 years later. Predictors of a high quality of care level were training of staff in management and care of suicide attempters and to have written guidelines for the care.     

Outcome of attempted suicide and psychiatric consultation: risk factors and suicide mortality during a five-year follow-up.

A total of 1018 self-poisoned patients were treated during the year 1983 in the emergency room of Helsinki University Central Hospital. By the end of a 5-year follow-up period, 3.2% of these had committed suicide, making annual suicide mortality 589 per 100,000. During the first year after the index attempt, suicide mortality was 1768 per 100,000, a 50-fold risk compared with that of the total population in Helsinki. Risk factors were being male of advancing age, having mental disorders, previous suicide attempts, a nonimpulsive index suicide attempt, moderate to very serious lethality and severe intention to die during the index suicide attempt. When the lethality was assessed as being very serious or intention to die as certain, 21% later committed suicide. The relative risk for those left without psychiatric consultation was 0.6 when the lethality was mild and 1.6 when it was severe. Results indirectly indicate that psychiatric consultation seemed to have a positive effect on the outcome of these attempted suicides.     

Suicide attempts and personality disorder

OBJECTIVE: The purpose of the present study was to compare clinical characteristics of suicide attempters with or without personality disorders. METHOD: A systematic sample (n = 114) of patients from consecutive cases of attempted suicide referred to general hospitals in Helsinki was interviewed and diagnosed according to DSM-III-R. Forty-six subjects with DSM-III-R personality disorders were identified and divided into clusters A (n = 4), B (n = 34) and C (n = 8). These subjects were compared with 65 suicide attempters without personality disorders in terms of clinical characteristics and treatment received. RESULTS: Suicide attempters with personality disorders more often had a history of previous suicide attempts and lifetime psychiatric treatment than comparison subjects. However, suicide attempts did not differ in terms of suicide intent, hopelessness, lethality or impulsiveness between subjects with or without personality disorders. CONCLUSION: Although suicidal behaviour is a more persistent feature among those with personality disorders, their clinical characteristics at the time of a suicide attempt may not differ from those without personality disorders.     

Comorbid substance use reduces the health care contacts of suicide attempters with schizophrenia spectrum or mood disorders

Utilization of health care services has been found to differ between psychiatric disorders. However, the pattern of health care contacts among suicide attempters with mental disorders is not known. This study systematically investigated the pattern of health care contacts among suicide attempters with schizophrenia spectrum versus mood disorders with or without comorbid substance use disorders both before and after attempted suicide. All consecutive medically treated suicide attempters in Helsinki from January 15, 1997, to January 14, 1998, were identified (n = 1,198). Data were gathered on all their health care contacts within the 12 months before and after the index attempt. Whereas the clear majority of all suicide attempters with schizophrenia spectrum or mood disorders had a treatment contact during the 30 days following the attempt, half of those with pure substance use disorders were without any contact with health care. Comorbid substance use made treatment less likely after attempted suicide among both psychiatric disorder groups; those with schizophrenia spectrum and comorbid substance use disorders were seven times more often left without aftercare recommendation than those without substance use comorbidity. Comorbid substance use disorders among suicide attempters with schizophrenia spectrum disorders decrease the likelihood of active aftercare, despite high suicide risk.     

Self-Injury Implicit Association Test: Comparison of Suicide Attempters and Non-attempters

Given the weaknesses of self-report measures, there has been an increased interest in alternative methods of suicide risk assessment, primarily the implicit measures of suicide risk. This study aimed to determine differences in implicit identification with self-injury and implicit attitude towards self-injury between attempters and non-attempters using the self-injury implicit association test (SI-IAT). The SI-IAT is a computer test designed to measure the implicit associations about self-injury. Participants were 100 forensic and civil inpatients at three psychiatric hospitals. A history of attempted suicide was very common in this sample. All participants completed the SI-IAT. Attempters and non-attempters did not significantly differ with respect to implicit identification with self-injury and implicit attitude towards self-injury. Implications are presented for assessment of suicide risk and future research.     

Psychiatric consultations and therapy recommendations following a suicide attempt in a general hospital and their associations with selected parameters in a 1-year period

Objective. Our study aims to determine the frequency and distribution of suicide attempts according to the patients’ characteristics and type of suicide attempt as well as the method of treatment proposed by the consultation–liaison service in a general hospital. Methods. This retrospective naturalistic study covers a 1-year period (2012), during which 51 suicide attempters were hospitalised in the Charité Berlin, Campus Benjamin Franklin, Germany. The following data were analysed: method of suicide, account of prior psychiatric history and medication, as well as the acute psychiatric diagnosis and treatment – including pharmacotherapy. Results. Most of the patients were diagnosed with a psychiatric illness. Major depressive disorder was the most frequent diagnosis in consultation. Treatment recommendations more often entailed further psychiatric treatment than medication. In the cases where medication was indeed given, benzodiazepines were the most frequently prescribed. Conclusions. Most of the suicide attempters needed further therapy in psychiatric hospitals. A specialised pharmacotherapy (antidepressants, mood stabilisers) was rarely recommended by the psychiatric consultation service. The psychiatric consultation and therapy recommendations are important in guiding future acute treatment procedures.     

A proposed model of the development of suicidal ideations

BackgroundSuicidal ideations may precede suicide attempts. They are of particular concern in psychiatric populations because psychopathology is a major risk factor for suicide. The factors affecting the development of suicide ideations may differ among psychiatric patients with and without a previous suicide attempt and individuals without a psychiatric diagnosis.ObjectivesThe aim of this study is to develop a model of suicide ideation in psychiatric patients and the general population.MethodThe study included 196 participants: 92 psychiatric patients with a previous suicide attempt (“attempters”); 47 psychiatric patients who had never attempted suicide (“non-attempters”); and 57 healthy control subjects. Data were collected on socio-demographic parameters, clinical history, and details of the suicide attempts. Participants completed a battery of psychological instruments assessing aggression–impulsivity, mental pain (including depression and hopelessness) and communication difficulties, in addition to negative life events. Findings were correlated with suicidal ideation by group.ResultsThe correlations of the different variables with suicidal ideation differed between suicide attempters and non-attempters; therefore, the model was analyzed separately for each group. The study yielded three major findings: negative life events had a significant effect on both anger-in and impulsivity in non-attempters but not in attempters; hopelessness moderately contributed to suicidal ideations in attempters but not in non-attempters; loneliness contributed significantly to depression in non-attempters but was less distressing in attempters.ConclusionThe mechanism underlying suicidal ideation appears to differ between psychiatric patients who have previously attempted suicide and those who have not, supporting a dual model of suicidal ideation. Although this is only a preliminary study, these findings are important for furthering our understanding of the process of transition of suicidal thoughts to completion of suicide. These results need further replication with a larger cohort of subjects.     

Shame-proneness in attempted suicide patients

ABSTRACT: BACKGROUND: It has been suggested that shame may be an important feature in suicidal behaviors. The disposition to react with shame, "shame-proneness", has previously not been investigated in groups of attempted suicide patients. We examined shame-proneness in two groups of attempted suicide patients, one group of non-suicidal patients and one group of healthy controls. We hypothesized that the attempted suicide patients would be more shame-prone than non-suicidal patients and healthy controls. METHOD: The Test of Self-Conscious Affect (TOSCA), which is the most used measure of shame-proneness, was completed by attempted suicide patients (n = 175: 105 women and 3 men with borderline personality disorder [BPD], 45 women and 22 men without BPD), non-suicidal psychiatric patients (n = 162), and healthy controls (n = 161). The participants were convenience samples, with patients from three clinical research projects and healthy controls from a fourth research project. The relationship between shame-proneness and attempted suicide was studied with group comparisons and multiple regressions. Men and women were analyzed separately. RESULTS: Women were generally more shame-prone than men of the same participant group. Female suicide attempters with BPD were significantly more shame-prone than both female suicide attempters without BPD and female non-suicidal patients and controls. Male suicide attempters without BPD were significantly less shame-prone than non-suicidal male patients. In multiple regressions, shame-proneness was predicted by level of depression and BPD (but not by attempted suicide) in female patients, and level of depression and non-suicidality in male patients. CONCLUSION: Contrary to our hypothesis and related previous research, there was no general relationship between shame-proneness and attempted suicide. Shame-proneness was differentially related to attempted suicide in different groups of suicide attempters, with significantly high shame-proneness among female suicide attempters with BPD and a negative relationship between shame-proneness and attempted suicide among male patients. More research on state and trait shame in different groups of suicidal individuals seems clinically relevant.     

Attempted suicide. Do we understand the patients' reasons?

This explorative study compared the patients', doctors', and nurses' views regarding their attribution of reasons for attempting suicide and the patients' emotional state immediately preceding their suicide attempts. A sample of 30 out of 94 consecutive patients seen in the emergency room of University Hospital were examined shortly after they had attempted suicide. Immediately after the routine clinical interview, conducted by a psychiatric resident and a nurse, patients filled in a questionnaire giving 14 possible reasons for attempting suicide as well as 8 feelings characterizing the emotional state preceding the suicide attempt. In the meantime, and without prior discussion of the case, the resident and the nurse independently completed the same questionnaire. In addition, sociodemographic and clinical data were obtained. Intrapersonal reasons such as to get relief from a terrible state of mind or from an unbearable situation were most frequently chosen by patients, nurses, and doctors alike. The most striking difference was found for "loss of control": this item was chosen significantly more often by patients than by nurses and doctors. Accordingly, patients reported significantly more often feelings of anxiety/panic and emptiness (mental vacuum), whereas feelings of despair and powerlessness/hopelessness were mentioned most frequently by nurses and doctors. Mental health professionals should bear in mind that many suicide attempters experience feelings of anxiety/panic prior to their suicidal act, and that a majority report having lost control over themselves, thus indicating a state of emotional crisis.