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.     

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.     

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.     

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     

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.     

Factors associated with referral to mental health services among suicide attempters visiting emergency centers of general hospitals in Korea: does history of suicide attempts predict referral?

Objective

This study examined whether a history of past suicide attempts was a critical factor for referral to mental health services among suicide attempters visiting emergency centers of general hospitals in Korea.

Method

In this cross-sectional study, a resident of emergency medicine at each emergency center interviewed 310 suicide attempters visiting five tertiary general hospitals located in Seoul, using standardized questionnaires, during 7 months in 2007. We examined associations between suicide attempt history and referral to mental health services via multiple logistic regressions.

Results

Subjects' rate of referral to mental health services was 47.3%. When we controlled for participant age, time of arrival at the emergency center, psychiatric treatment history, use of alcohol, suicide attempt lethality and subjective expectation to suicide attempts, past suicide attempts did not predict referral to mental health services (odds ratio=1.74; 95% confidence interval .88-3.43).

Conclusion

Psychiatric interventions for suicide reattempters visiting emergency centers are important for preventing suicide, but providers have not considered suicide attempt history as a critical factor for referral to mental health services. Therefore, we suggest that more effort is needed to systemize psychiatric interventions for suicide reattempters at emergency centers in Korea.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

Substance use and male gender as risk factors for deaths and suicide

OBJECTIVE: The aim of this study was to determine the mortality by suicide and other causes of death in a cohort of suicide attempters and identify predictive factors, including contact to healthcare after the attempt. METHOD: All consecutive 1198 deliberate self-harm patients treated in hospital emergency rooms in Helsinki during a 12-month period were identified. Data were gathered on healthcare contacts preceding and following the index attempt, and cause-specific mortality over a 5-year period. RESULTS: By the end of the 5-year follow-up period, 171 (14%) of the patients had died. A total of 57 (5%) had committed suicide. The age- and sex-adjusted risk for suicide among deliberate self-harm patients was 40-fold, and for death overall tenfold, compared to general population during the 5-year follow-up period. Risk factors for subsequent suicide were a diagnosis of substance use disorder, male gender and previous suicide attempts. A diagnosis of substance use disorder and male gender predicted death. Furthermore, male gender and substance use disorders had a strong interaction for both classes of death. CONCLUSIONS: The findings of this study suggest that deliberate self-harm patients have a high risk for both suicide and other causes of death. Male gender and substance use disorders are significant risk factors for both later suicide and other causes of death. Male suicide attempters with substance use disorders have remarkably high total and suicide mortality.     

Salivary cortisol and suicidal behavior--a follow-up study

INTRODUCTION: Hyperactivity of the hypothalamic-pituitary-adrenal (HPA)-axis is a common finding in major depressive disorder. Similar studies on suicide attempters are less abundant, and the results are divergent. The main aim of the present study was to investigate HPA-axis parameters by the time of a suicide attempt and at follow-up in search for associations between HPA-axis function and suicidal behavior. METHODS: Thirty-five suicide attempters and 16 non-suicidal controls were admitted to a psychiatric ward between the years of 1986 and 1992. Corticotrophin-releasing hormone (CRH) in cerebrospinal fluid and urinary cortisol were obtained for the suicide attempters. The patients were followed up approximately 12 years after the index admission. Cortisol was measured in saliva, and additional suicide attempts and current psychiatric symptoms were registered. RESULTS: At follow-up, evening salivary cortisol was lower in suicide attempters compared to controls. Low cortisol levels at follow-up were associated with severe psychiatric symptoms. Among women, repeated suicide attempts were associated with low morning and lunch salivary cortisol, and in this subgroup we also found significant correlations between salivary cortisol at follow-up, and CRH as well as urinary cortisol at index. CONCLUSION: We found evidence for an association between low HPA-axis activity and suicidal behavior. This could be due to long-lasting and severe psychiatric morbidity, which in turn has exhausted the HPA-axis of these patients. The potential role of hypocortisolism should be given more attention in studies on suicidal patients.     

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.     

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.