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.     

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.     

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.     

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     

Suicide risk in female suicide attempters not responding to a follow-up study

The 95 patients not responding to a follow-up study of 227 female suicide attempters differed from the responders in that fewer of them were undergoing psychiatric treatment at the time of the suicide attempt and fewer were referred for psychiatric outpatient aftercare following the suicide attempt. Yet, the subsequent occurrence of suicide was no higher in the group of nonresponders than in the group of responders. This study again underlines the difficulty of predicting recurrent suicidal behavior, even in a high-risk group of suicide attempters.     

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.     

Treatment received by alcohol-dependent suicide attempters

The purpose of this study was to examine the clinical features of alcohol-dependent suicide attempters and the treatment they received before and after the index attempt. A total of 47 subjects with current DSM-III-R alcohol dependence were identified from a systematic sample of 114 suicide attempters in Helsinki. All of them were comprehensively interviewed after the attempt, and the treatment they had received was established from psychiatric and other health-care records and follow-up interviews. Most had a history of psychiatric (83%) or substance abuse (83%) treatment. During the final month before the attempt, half of the subjects (51%) had been treated by health care services; 11% had received disulfiram-treatment and 6% had received psychotherapy. Subjects complied with recommended aftercare more often when they had been actively referred. After 1 month, 64% were being treated by health care services. However, only 14% were receiving disulfiram-treatment and 9% were receiving psychotherapy. These findings suggest that the quality and activity of treatment offered to suicide attempters with alcohol dependence should be improved.     

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.     

Predicting aftercare in psychiatric emergencies

Background Aftercare dispositions in psychiatric emergencies have often been limited to the classic armamentarium of admission vs nonadmission. It is unknown to what extent there are differences in predicting follow-up after psychiatric emergency room (PER) visits when focusing on a broader scope of aftercare possibilities. Material and methods This observational study describes and predicts aftercare dispositions after a psychiatric emergency referral: admission, onsite short-term crisis-intervention program (CIP), refusal of any aftercare, and outpatient aftercare. From March 2000 until March 2002, PER patients (N=3,719) of the university hospital were monitored regarding sociodemographic and clinical characteristics, and use of health services. Results Forty-four percent were admitted, 38% were referred to outpatient treatment, 9% refused any aftercare, and the remainder was referred to the CIP. Psychotic patients were most likely to be admitted [odds ratios (ORs) between 5.98 and 6.52], followed by patients with suicidal symptoms (OR=2.25) and those who reported outpatient service utilization (OR=1.43). Young patients (OR=3.36) or those with anxiety disorders (OR=2.03) were most likely to be referred for outpatient aftercare. Patients diagnosed with a personality disorder were at highest risk of refusing any aftercare (OR=1.81). Conclusion Despite the existence of a short-term onsite CIP, the majority of the patients were admitted after PER referral. We assume that the existence of this program decreased the number of patients who otherwise would refuse all aftercare. More research is needed in order to explain aftercare dispositions more appropriately.     

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.     

Mental illness and social integration among suicide attempters in Copenhagen

In order to describe a population of suicide attempters in an affluent suburb of Copenhagen, 100 patients were interviewed, randomly chosen from a group of 246 patients referred to psychiatric consultation after a suicide attempt. The group consisted of 71 women and 29 men. Single status, abuse, and previous suicide attempts occurred frequently as did suicide among first-degree relatives. The most frequent reason for a suicide attempt was conflict with partners. In comparison with the normal population in the same catchment area, the patients were alone and felt lonely, but no difference was found in the group's relation to the labor market. After a four-year follow-up period, 9 persons had died by suicide. Borderline personality disorder and affective psychosis, no employment, 2 or more previous attempts, violent method and potential lethal attempt proved to be predictors of suicide later on. Alcohol and drug abuse, lack of social support and loneliness did not influence the risk.     

Tentatives de suicides violentes à l’hôpital général de Fès (Maroc) : évaluation et prise en charge en psychiatrie de liaison. Étude prospective sur six mois

Suicide attempt situations are not only encountered in psychiatric emergency departments, but also in the other medical and surgical units as well. They are often poorly evaluated after the end of physical care, and they rarely happen in facilities of psychiatric care.MethodsThrough a prospective study established over a period of six months, conducted within the university hospital center Hassan II in Fez, we attempted in the context of the activity of the liaison psychiatry to assess, the suicide attempters hospitalized in the medical and surgical units after a violent suicide attempt. The study was spread over a period of 24 months, from January 2010 to December 2011. The objectives of our study were to describe the clinical and epidemiological profile of the suicide attempters that are admitted to the physical units of the university hospital center, to identify the units that are most demanding of psychiatric consultations for suicide attempts, the methods used, the underlying psychiatric disorders, and to assess the risk factors. From 180 requests for psychiatric consultation, 31 cases of suicide attempts were included in our study. The psychiatric evaluation was performed based on a psychiatric interview. Data was collected using questionnaires including 24 items. After an initial psychiatric examination designed to assess the patient's psychiatric condition, follow up examinations were completed at 1, 3 and 6 months intervals.ResultsOf the 31 attempt survivors aged between 13 and 65 included in our work, 60% were male and 45% of the patients had a psychiatric history. Twenty-six percent of our patients were hospitalized in a resuscitation unit and 23% in visceral surgery. The most common means used by the patients was the ingestion of caustic substances and drug toxicity in 26%. Most psychiatric disorders – diagnosed according to DSM-IV – were depressive disorder in 52% of cases, and a psychotic disorder (paranoid schizophrenia, schizophreniform disorder, schizoaffective disorder and brief psychotic disorder) in 36% of cases. The outcome was favorable in 70% of our patients after 6 months.DiscussionLiaison psychiatry is a growing field; it plays a crucial role in the assessment and management of suicidal behavior requiring medical somatic management.ConclusionOur study allowed us to meet the suicide attempters hospitalized in the medical and surgical units, to initiate and continue their support, and to participate in the prevention of any recurrence.     

Patterns of psychiatric consultations in Kuwait general hospitals

Two hundred and nineteen consecutive referrals to psychiatric consultation services from all general hospitals in Kuwait over a 3-month period were studied and compared with a control group of 100 patients who were not referred for psychiatric consultation. The two groups differed significantly in age, sex, marital status, employment, and past psychiatric treatment. Inpatients were more often referred than outpatients with an overall low referral rate of 0.3%. The department of general medicine referred 74.4% of patients in contrast to 11.4% referred by the department of general surgery. The most common reason for referral was for assessment of a suicide attempt in the inpatient group, and the absence of organic cause for patients' physical symptoms in the outpatient group. Acute situational disturbance that resulted in a suicide attempt was the most common psychiatric diagnosis (26%), followed by depressive illness (19.5%) and organic psychotic disorders (8.2%). Our findings are similar to those reported in the literature, and the present study suggests a national underutilization of psychiatric consultation services in 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.     

Management of suicide attempts in Italy and Sweden. A comparison of services offered to consecutive samples of suicide attempters

The aim of the study was to compare the management of suicide attempts by patients in Sweden and Italy with a view to providing a perspective on differences in treatment. Two consecutive samples of suicide attempters from Huddinge (n=97) and Padua (n=100) were studied in terms of sociodemographic characteristics, previous care, referral, medical and psychiatric care, hospitalization, aftercare, and short-term compliance. In Italian somatic management of acute suicidal crises, there are more physicians specializing in anesthesia or internal medicine working in ambulances and emergency wards, and there is a heavier emphasis on somatic care. Swedish management procedures seem to entail more medical examinations and biohumoral tests. Moreover, the procedures at the Swedish hospital give priority to early psychiatric intervention, and admission to psychiatric inpatient care is more frequent. However, it is not normal practice in emergency psychiatric care at either of the centers for specialists to serve in the immediate liaison consultation. There are differences in assessment and treatment between the two countries that may provide a perspective on their procedures, implying that current procedures for managing patients belonging to groups identified as “high-risk” in terms of suicide may be modified.     

Correlates and antecedents of hospital admission for attempted suicide: a nationwide survey in Italy

The present study examined data on symptom patterns in the week prior to admission for suicide attempt, in a nationwide representative sample of patients. Socio-demographic, clinical, and treatment data was gathered for 1,547 patients admitted over a 12-day index period during the year 2004 to 130 public and 36 private psychiatric facilities in Italy. Patients were evaluated in terms of whether they had been admitted for having attempted suicide or not. A detailed checklist was used to assess symptom pattern at admission; diagnoses were based on ICD-10 categories. Two-hundred thirty patients (14.8%) in the sample had been admitted for suicide attempt. Patients with depression or with personality disorders were more frequently observed among suicide attempters. First-contact patients were significantly more likely to have been admitted after a suicide attempt, the only exception being individuals with bipolar disorder, manic phase. No diagnosis was statistically related to admission after suicide attempt, once symptoms pattern at admission had been accounted for. Disordered eating behavior, depressive symptoms, substance abuse, and non-prescribed medication abuse were positively related to attempted suicide, as were any traumatic events in the week prior to admission; symptoms of psychosis (hallucinations/delusions) and lack of self-care were negatively associated with suicide attempt admission. Greater attention to symptoms immediately preceding or concomitant with admission after a suicide attempt can be a key factor in establishing the best treatment plan and discharge strategy, the most effective community-service referral, and targeted intervention programmes for patients hospitalized for a suicide attempt.     

Length of stay,referral to aftercare,and rehospitalization among psychiatric inpatients

OBJECTIVE: This retrospective study explored the interrelationship among aftercare, length of hospital stay, and rehospitalization within six months of discharge in a sample of psychiatric inpatients. METHODS: Data were analyzed for 1,481 patients who had received inpatient care at a state psychiatric hospital from November 1991 to July 1994. Logistic regression models were estimated to predict the likelihood of referral to aftercare and of readmission to a hospital within six months of the index discharge. Variables controlled for were patients' characteristics; psychiatric status at the time of discharge, including length of stay; and the availability of informal support. RESULTS: Sixteen percent of the patients received a referral to aftercare, and about 13 percent of the patients were readmitted within six months of discharge. White patients were twice as likely as African Americans to receive a referral to aftercare. Length of hospitalization and having a diagnosis of schizophrenia were also predictors of referral to aftercare. Referral to aftercare was not shown to mediate the relationship between length of stay and rehospitalization. However, having a schizoaffective disorder, a poor discharge prognosis, and a high number of previous admissions were associated with an increased risk of readmission. No other demographic characteristics were related to readmission within six months of discharge, but referral to aftercare significantly increased the risk of readmission. CONCLUSIONS: The study suggested the possibility of racial disparities in referral to aftercare and a complex relationship between referral and rehospitalization. Both these findings warrant further investigation that gives particular attention to individual-level indicators of need and system-level barriers to and facilitators of psychiatric care.     

Factors predictive of referral to psychiatric hospital among general hospital psychiatric consultations

The aim of this paper was to explore the factors necessitating psychiatric hospital care in a Finnish multi-centre study of general hospital in-patients referred for psychiatric consultation. The study group consisted of 1251 patients referred to psychiatric hospital (n= 181) and a comparison group (n= 1070) consisting of subjects who were not referred. Differences between groups were studied by univariate analysis. Logistic regression analysis was used both to assess the factors contributing to referral to psychiatric hospital and to create predictive models. The validity of the models was analysed by means of receiver operating characteristic (ROC) curves in an independent sample. Psychiatric hospital care during the previous 5 years was associated with a 3.7-fold (odds ratio) increased risk of hospitalization. A diagnosis of psychosis was associated with a 2.9-fold increased risk, and attempted suicide as a reason for consultation was associated with a 2.1-fold increased risk. Not being married doubled the risk, and the odds ratio was also high in cases of poor psychosocial functioning (as assessed by Global Assessment of Functioning (GAF) score). The predictive model differentiated reasonably well between those patients who were hospitalized and the other patients. In conclusion, this multi-centre study of factors predictive of referral to psychiatric hospital among general hospital patients revealed that the most important determinants were previous psychiatric care, diagnosis of psychosis or severe depression, attempted suicide, being unmarried, and poor psychosocial functioning as assessed by GAF score.