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.     

Attitudes of general hospital emergency room personnel towards attempted suicide patients

The aim of this study was to compare the attitudes of emergency room staff towards patients who have attempted suicide between two general hospitals, one with psychiatric consultation available and the other without. The Understanding Suicidal Patients (USP) Questionnaire was given to all staff in the emergency rooms of Jorvi Hospital (in the city of Espoo, with routine psychiatric consultation) and Malmi Hospital (in the city of Helsinki, without routine psychiatric consultation) (n=115). There were clear differences in staff attitudes between the hospitals. Female gender, older age and working in Malmi Hospital without routine psychiatric consultation were associated with more positive attitudes towards attempted suicide patients. Surprisingly, only working in Jorvi Hospital was associated with more negative attitudes. Differences in attitudes towards suicide attempters between personnel working in the different hospitals were found. Further investigation is needed to find the ideal psychiatric consultation arrangement for suicide attempters in good cooperation with emergency room staff.     

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.     

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.     

Elderly suicide attempters with depression are often diagnosed only after the attempt

OBJECTIVE: No previous study has comprehensively investigated the pattern of health care contacts among elderly subjects attempting suicide. The present study compared elderly suicide attempters with younger attempters, before and after attempted suicide, in terms of health care contacts, clinical diagnoses of mental disorders, and characteristics predicting lack of treatment contact after the index attempt. METHODS: All consecutive 1198 suicide attempters treated in hospital emergency rooms in Helsinki, Finland, from 15.1.1997 to 14.1.1998 were identified and divided into two age groups: (1) elderly suicide attempters aged 60 years or more (n = 81) and (2) suicide attempters aged under 60 years (n = 1117). RESULTS: During the final 12 months before the attempt, the majority of elderly suicide attempters had a contact with primary health care, but their mood disorders were likely to have remained undiagnosed before the index attempt. In primary health care, only 4% had been diagnosed with a mood disorder before the attempt, but 57% after (p < 0.001). After the suicide attempt, most elderly suicide attempters were referred for aftercare, two thirds having contact with psychiatric care. CONCLUSIONS: For purposes of preventing suicidal behaviour, screening for depression, plus further education on recognition, diagnosis and treatment of mood disorders among the elderly in primary health care setting are needed.     

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.     

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.     

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.     

Health care contacts before and after attempted suicide

Objective The prevalence and timing of contact with health care predicting and after a suicide attempt are not well known. This study systematically investigated the pattern of all health care contacts both before and after attempted suicide. Methods All consecutive 1,198 suicide attempters treated in hospital emergency rooms in Helsinki during a 12-month period were identified. Data were gathered on all health care contacts 1 year before and after the index attempt. Results The vast majority of the suicide attempters had contact with health care during the 12 months before and after the index attempt. However, half were without a treatment contact during the final 30 days before the index attempt and one-third in the 30 days following the attempt. Suicide attempters who were not referred to aftercare, did not suffer from a previously recognised major mental disorder, were male, or made non-violent attempts were less likely to be receiving treatment after the attempt. Conclusion Although most suicide attempters have contact with health care within the year before and after the parasuicide, far fewer actually have a treatment contact at the time of the attempt. Accepted: 20 September 2001     

Chronic alcohol problems among suicide attempters--post-mortem findings of a 14-year follow-up

This study set out to describe the clinical characteristics of a subgroup of suicide attempters with clear post-mortem evidence of long-term alcohol misuse, and to investigate the risk factors predicting chronic alcohol misuse/dependence using survival analysis. Data were collected over 14 years on all unselected deliberate self-poisoning patients (n=1018) treated in the emergency unit of Helsinki University Central Hospital. Of the 222 (22.7%) who had died by the end of the follow-up period, 85 (38.5%) showed clear post-mortem evidence of long-term alcohol misuse. Seventy-four per cent of misusers were men. The risk factors for chronic alcohol misuse/dependence among deceased suicide attempters were: male sex, numerous previous suicide attempts, non-impulsive suicide attempts, certain intention to die and subjective motive of the index attempt other than "wish to die". The findings emphasize that more attention should be focused on evaluating alcohol use and the risk of alcohol dependence in suicide attempters encountered in the emergency room of general hospitals.     

Psychosocial profile of suicide ideators, attempters and completers in India

The study aims to determine the psychological profile of suicide ideators, attempters and completers in a tertiary care teaching hospital. A total of 260 suicidal ideators, 58 attempters and 55 completers were studied. The majority of ideators, attempters and completers were 26-35 years of age, males (except attempters who were predominantly females), married, literate up to high school, employed (ideators) or housewives (attempters and completers). The suicide ideators, attempters and completers who had a past history of attempt were 6.9%, 24.1% and 18.2% respectively. Family history of attempted suicide or completed suicide was also common among patients suffering from depression. In suicidal ideators, mixed anxiety and depressive disorder was the most common psychiatric diagnosis followed by major depression and schizophrenia. Among suicide attempters, adjustment disorder with depression was the most common diagnosis. The most common method of suicide attempt was organophosphorus compound intake whereas in suicide completers, the most common method in use was hanging. The patients with suicidal ideation or attempt need careful evaluation, early intervention and long term 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.     

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.     

Treatment for adolescents following a suicide attempt: results of a pilot trial

OBJECTIVE: To compare the efficacy of a skills-based treatment protocol to a supportive relationship therapy for adolescents after a suicide attempt. METHOD: Thirty-nine adolescents (12-17 years old) and parents who presented to a general pediatric emergency department or inpatient unit of a child psychiatric hospital after a suicide attempt were randomized to either a skills-based or a supportive relationship treatment condition. Follow-up assessments were conducted at intake and 3 and 6 months post-attempt. RESULTS: In contrast to the low rates of treatment received by adolescent suicide attempters in the community, approximately 60% of this sample completed the entire treatment protocol. Significant decreases in suicidal ideation and depressed mood at 3- and 6-month follow-ups were obtained, but there were no differences between treatment groups. There were six reattempts in the follow-up period. CONCLUSIONS: When adolescents who attempt suicide are maintained in treatment, significant improvements in functioning can be realized for the majority of patients.     

Registration, psychiatric evaluation and adherence to psychiatric treatment after suicide attempt

Persons who are treated at hospital after attempted suicide comprise a high-risk group for suicide. The proposal for a National Programme for Prevention of Suicide and Suicide Attempt in Denmark recommends that all persons who attempt suicide should be offered treatment and that treatment should be implemented, using a supportive and guiding principle. The aim of the present study is to investigate whether patients receive psychiatric evaluation after a suicide attempt, and whether they receive the psychiatric treatment to which they are referred. In the Copenhagen Hospital Corporation in four emergency rooms and six intensive care units, we investigated all referrals in the period 1 February 2001 to 1 May 2001 with Contact Code 4 (self-harm) and selected diagnostic codes likely to be used in cases of self-poisoning, strangulation, drowning and wrist-cutting. We found that only 37% of the contacts to the emergency room were correctly coded with Reason for Contact Code 4 in Nomesco's classification of external causes of injuries. A psychiatric evaluation was planned for almost all patients, but 18% of the patients never reached the evaluation that had been planned to take place in a psychiatric emergency. Only few patients were not referred to any treatment at all, but among the patients referred to psychiatric treatment, only those admitted involuntarily received treatment in 100% of the planned cases. For outpatient treatment in the suicide prevention clinic, the percentage that attended planned treatment within the first week after the suicide attempt was especially low (57%). It is recommended that the quality of Reason for Contact Coding be improved, that patients who have attempted suicide be approached assertively, and that the supportive and guiding principle be used in securing them treatment.     

Deliberate self-poisoning: treatment follow-up of repeaters and nonrepeaters.

Since 1986 psychiatrists and social workers of the Lund Suicide Research Center have investigated subjects admitted to the medical intensive care unit after a suicide attempt. Fifty-nine of 79 deliberate self-poisoners were interviewed 12 months after a suicide attempt. Twenty-one had previously been interviewed 6 months after the index suicide attempt. We obtained minor information on 8 subjects. Two patients had committed suicide. Sixteen subjects (27%) of those who were interviewed showed repeated suicidal behavior (repeaters) during the 1-year follow-up, and their psychiatric diagnoses at the index attempt were most commonly alcohol abuse and dysthymia (DSM-III, Axis I). Compared with nonrepeaters, repeaters had more often made previous suicide attempts, their index attempt was less serious and they were more often in psychiatric treatment at index. At follow-up, repeaters more often than nonrepeaters expressed the need for professional mental health support. Two-thirds of the patients were in treatment at follow-up. About half had remained in continuous treatment and most in psychiatric care for more than 1 year. Repeated self-poisoning occurred despite ongoing treatment. In view of the fact that numerous suicide attempters obviously remain in treatment for several years, we suggest further development and evaluation of long-term treatment strategies.     

History of family suicide behaviors and negative problem solving in multiple suicide attempters.

This study examined the relationship between family history of suicide, negative problem solving orientation and suicide attempt status (multiple suicide attempters versus single suicide attempters). Suicide attempters with a family history of suicide were more likely to have multiple suicide attempts when compared to suicide attempters who did not have a family history of suicide. This relationship was consistent with a model in which the relationship between family history and suicide attempt status is mediated by negative problem solving. Results of this study are discussed as they pertain to the theory and treatment of suicide attempters.     

History of multiple suicide attempts as a behavioral marker of severe psychopathology

OBJECTIVE: Individuals with a differing number of past suicide attempts are generally considered a homogeneous group, despite emerging evidence to the contrary. The current study aimed to test the hypothesis that multiple suicide attempters would exhibit a more severe clinical profile than single suicide attempters. METHOD: A series of self-report batteries and clinical interviews was administered to 39 single attempters and 114 multiple attempters who came to an urban hospital emergency room after a suicide attempt. The participants were predominantly poor and nonwhite. RESULTS: Multiple suicide attempters versus single attempters exhibited a greater degree of deleterious background characteristics (e.g., a history of childhood emotional abuse, a history of family suicide), increased psychopathology (e.g., depression, substance abuse), higher levels of suicidality (e.g., ideation), and poorer interpersonal functioning. Profile differences existed even after control for borderline personality disorder. CONCLUSIONS: Results indicate that multiple attempters display more severe psychopathology, suicidality, and interpersonal difficulties and are more likely to have histories of deleterious background characteristics than single attempters. Moreover, these differences cannot be explained by the diagnosis of borderline personality disorder. Results suggest that the identification of attempt status is a simple, yet powerful, means of gauging levels of risk and psychopathology.     

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.     

Changes in institutional psychiatric care and suicidal behaviour: a follow-up study of inpatient suicide attempters in Bærum, Norway

Background

During the past decades, extensive reformatory changes in institutional psychiatric care have been implemented in Norway.

Aims

The objective of the present study was to investigate whether these changes have resulted in shortened length of psychiatric hospital stays for suicide attempters. Further, to examine if length of hospital stay and time period in which the patients received treatment were related to the risk of a repeated suicide attempt and/or committing suicide.

Methods

All cases of suicide attempters hospitalised between 1984 and 2006 in the municipality of Bærum, a suburb outside Oslo, were examined. The period of observation was further subdivided in two time intervals on the basis of the de-institutionalisation of psychiatric care, which started to plateau in 1996.

Results

Among 1,574 patients consecutively admitted to the local general hospital after a suicide attempt, 330 were admitted to inpatient psychiatric care. Patients admitted in the period 1996–2006 had significantly shorter hospital stays than patients in the preceding period 1984–1995 (Log Rank P < 0.001). Neither the time period of treatment variable nor the length of hospital stay variable was significantly associated with the risk of a repeated suicide attempt or suicide.

Conclusions

Psychiatric de-institutionalisation appears as not having affected suicide attempt repetition. It is possible that reduced length of hospital stay has been compensated by improved mental health care in general and extended outpatient services in particular.