Effect of previous emergency psychiatric consultation on suicide re-attempts – A multi-center observational study

BackgroundThe emergency department (ED) is one of the first gateways when suicide attempt patients seek health care services. The purpose of this study was to analyze the hypothesis that people who received emergency psychiatric services in previous suicide attempts will have a lower mortality rate in current ED visits owing to subsequent suicide attempts.MethodThis retrospective study included patients who visited six EDs, and participated in the injury surveillance and in-depth suicide surveillance for 10 years, from January 2008 to December 2017. The study subjects were adult patients 18 years or older who visited EDs due to suicide attempts. The main explanatory variable is whether psychiatric treatment was provided in previous suicide attempts. The main outcome variable was suicide related mortality.ResultsThe study included 2144 suicide attempt patients with a previous history of suicide attempts. Among these, 1335 patients (62.2%) had received psychiatric treatment in previous suicide attempts. Mortality was significantly different between the psychiatric consultation group (n = 33, 2.5%) and non-consultation group (n = 47, 5.8%) (P < 0.01). In multivariate logistic regression analysis, previous psychiatric consultation showed a significant association with low mortality (adjusted OR 0.41; 95% CI [0.23–0.72]) and selecting non-fatal suicide methods (adjusted OR 0.47; 95% CI [0.36–0.61]).ConclusionPatients who received psychiatric consultation in previous suicide attempts had a lower suicide-related mortality in current ED visits as compared to patients who did not, and this may have been related to choosing non-fatal suicide methods.     

Suicidal behavior in psychiatric emergency room patients

BACKGROUND: Psychiatric emergency room (ER) patients are thought to be at increased risk of suicide. The prevalence and characteristics of suicidal behavior in a recent sample of patients who came to the ER for psychiatric evaluation were examined. METHODS: Charts of 311 consecutive psychiatric ER patients were reviewed. Suicidal behavior was considered present if current suicidal ideation or attempts within 24 hours of or during the emergency evaluation were noted in the chart. RESULTS: Suicidal behavior was present in 38% of the psychiatric ER patients. Younger age, white race, affective disorders in female patients, and substance abuse disorders in male patients were features of the suicidal group. Sex of the patient was not associated with suicidal behavior. CONCLUSIONS: Suicidal behavior is prevalent in the psychiatric ER. Effective suicide prevention in this setting will hinge on finding more specific risk factors.     

Literature-based Recommendations for Suicide Assessment in the Emergency Department: A Review

Background

Suicidal ideation and attempted suicide are important presenting complaints in the Emergency Department (ED). The Joint Commission established a National Patient Safety Goal that requires screening for suicidal ideation to identify patients at risk for suicide.

Objectives

Given the emphasis on screening for suicidal ideation in the general hospital and ED, it is important for Emergency Physicians to be able to understand and perform suicide risk assessment.

Methods

A review of literature was conducted using PubMed to determine important elements of suicide assessment in adults, ages 18 years and over, in the ED. Four typical ED cases are presented and the assessment of suicide risk in each case is discussed.

Results

The goal of an ED evaluation is to appropriately determine which patients are at lowest suicide risk, and which patients are at higher or indeterminate risk such that psychiatry consultation is warranted while the patient is in the ED. Emergency clinicians should estimate this risk by taking into account baseline risk factors, such as previous suicide attempts, as well as acute risk factors, such as the presence of a suicide plan.

Conclusion

Although a brief screening of suicide risk in the ED does not have the sensitivity to accurately determine which patients are at highest risk of suicide after leaving the ED, patients at lowest risk may be identified. In these low-risk patients, psychiatric holds and real-time psychiatric consultation while in the ED may not be needed, facilitating more expeditious dispositions from the ED.     

Prevalence and associated factors of suicide among hospitalized schizophrenic patients

BACKGROUND Previous studies found several factors associated with suicide in schizophrenic patients,such as age,sex,education level,history of suicide attempts,psychotic symptoms,social factors,and substance abuse.However,there might be some additional factors that were not considered in previous studies but may be correlated with a greater likelihood of suicide attempts,such as medication and treatment.AIM To investigate the prevalence of suicide attempts and identify the risk of suicidality in hospitalized schizophrenia patients.METHODS This is a cross-sectional study of schizophrenic patients admitted to a psychiatric hospital who were 18 years of age or more.The outcomes and possible suicide risk factors in these patients were collated.The current suicide risk was evaluated using the mini-international neuropsychiatric interview module for suicidality and categorized as none(0 points),mild(1-8 points),moderate(9-16 points),or severe(17 or more points).This study used ordinal logistic regression to assess the association of potential risk factors with the current suicide risk in schizophrenic patients.RESULTS Of 228 hospitalized schizophrenia patients,214(93.9%)were included in this study.The majority(79.0%)of patients were males.Females appeared to have a slightly higher suicidality risk than males,with borderline significance.With regard to the current suicide risk assessed with the mini-international neuropsychiatric interview,172(80.4%)schizophrenic patients scored zero,20(9.4%)had a mild risk,8(3.7%)had a moderate risk,and 14(6.5%)had a severe risk.The total prevalence of current suicide risk in these schizophrenic patients was 19.6%.Based on multivariable ordinal logistic regression analysis with backward elimination,it was found that younger age,a current major depressive episode,receiving fluoxetine or lithium carbonate in the previous month,or a relatively higher Charlson comorbidity index score were all significantly and independently associated with a higher level of suicide risk.CONCLUSION The prevalence rate of suicide attempts in schizophrenia is high.Considering risk factors in routine clinical assessments,environmental manipulations and adequate treatment might prevent or decrease suicide in these patients.     

Depression and suicide assessment

Depressed patients and suicidal patients are common Emergency Department patrons with the potential for serious morbidity or death. Dysphoric mood, vegetative symptoms, and negative perceptions of oneself, the environment, and the future are characteristic of depression. Often, the patient is unaware of the depression and presents with a variety of somatic complaints, chronic fatigue, or pain syndromes. In these instances, the physician must consider the diagnosis of depression and ask the patient about any history of depressive symptoms. In all depressed patients, a careful history and physical examination are needed to identify any drugs or concurrent medical illnesses which might cause or exacerbate the depression. If depression is suspected or if the patient presents after a suicide attempt, then a thorough evaluation of suicide potential is mandatory. Several risk factors for completed suicide exist. Male sex, age under 19 or over 45, few social supports, and a history of previous suicide attempts are all factors associated with increased suicide rates. Concurrent chronic or severe medical illnesses and certain psychiatric illnesses, notably depression, schizophrenia, and substance abuse, also increase an individual's risk for suicide. The method of suicide attempt and the chance for rescue must also be considered when determining risk as well as the presence of an organized plan. Acute psychosis in the suicidal patient is an ominous finding and these patients should be admitted to the hospital. The physician must adopt an empathetic and nonjudgmental attitude when caring for potentially suicidal patients. Disposition can be determined after careful evaluation of risk factors, circumstances surrounding the attempt, and the patient's current feelings. Consultation with a psychiatrist or another mental health professional is desirable for any potentially suicidal patient. Many such patients can be safely treated as outpatients with proper referral; certain high-risk individuals will need to be admitted to the hospital. The decision to either hospitalize or discharge can be difficult and the emergency physician should admit the patient if doubt exists.     

La filière de soin des suicidants aux urgences

In France, a suicide attempt is recorded every 40 seconds, and a death by suicide occurs every 40 minutes. Suicide is the primary cause of mortality in people aged between 15 and 45 years. Suicidal tendencies have been identified as a major public health issue since the 1990s. Mental illnesses (including depression, schizophrenia, and addictions) as well as any personal and family history of suicidal behaviour are major risk factors. Identification and treatment of people in a suicide crisis and/or making a suicide attempt can help prevent repeated suicide attempts. Recommendations for good practice make a hospital, and in particular the emergency departments, a requisite location where a multidisciplinary approach is available. This leads to the need to organize a care process from reception to guidance based on an evaluation in three steps: physical, psychological, and social. The implementation of hospital care and/or intensive outpatient follow-up needs to be adjusted to match each situation. Training general practitioners in detection and treatment of suicidal patients and/or those suffering from depression is critical. Training is also necessary for teams in the emergency departments and in the crisis services with specialisation in handling suicidal adolescents or elderly people in some of them. The emergency wards are also, in a large number of cases, the first place of contact with a psychiatric. The quality of welcoming initial cares, relationships between the nursing staff and carers within the hospital and between the downstream organisations will determine to what extent the patients being treated will continue their treatment, will ensure the continuity of care, and will help to prevent repeated attempts.     

Psychiatry in the emergency department: factors associated with treatment and disposition

Patients with psychiatric problems present difficult treatment and dispositional decisions to physicians in general hospital emergency departments (ED). We studied the relationships between the psychosocial characteristics of patients given psychiatric diagnoses and clinical decisions made by nonpsychiatrists and psychiatrists in our ED. Decisions concerning psychiatric consultation in the ED, dispositional decisions (admission, discharge), and referral for psychiatric outpatient care for patients discharged were reviewed for 246 patients. The relationships between decisions and 13 indicators of patients' psychosocial characteristics were evaluated by use of stepwise logistic regression techniques. Psychiatric-related variables (severity of symptoms, history of psychiatric hospitalization or outpatient treatment, and psychotropic medications at entry to the ED) were associated with decisions made by both psychiatrists and nonpsychiatrists. However, nonpsychiatric variables including patient's age, "rudeness," diffuseness of medical complaints, time of day, and month of presentation also were related to decisions. Practitioners should be sensitive to social factors that affect their decisions about psychiatric patients.     

Failure of a patient-centered intervention to substantially increase the identification and referral for-treatment of ambulatory emergency department patients with occult psychiatric conditions: a randomized trial [ISRCTN61514736

BACKGROUND: We previously demonstrated that a computerized psychiatric screening interview (the PRIME-MD) can be used in the Emergency Department (ED) waiting room to identify patients with mental illness. In that trial, however, informing the ED physician of the PRIME-MD results did not increase the frequency of psychiatric diagnosis, consultation or referral. We conducted this study to determine whether telling the patient and physician the PRIME-MD result would result in the majority of PRIME-MD-diagnosed patients being directed toward treatment for their mental illness. METHODS: In this single-site RCT, consenting patients with non-specific somatic chief complaints (e.g., fatigue, back pain, etc.) completed the computerized PRIME-MD in the waiting room and were randomly assigned to one of three groups: patient and physician told PRIME-MD results, patient told PRIME-MD results, and neither told PRIME-MD results.The main outcome measure was the percentage of patients with a PRIME-MD diagnosis who received a psychiatric consultation or referral from the ED. RESULTS: 183 (5% of all ED patients) were approached. 123 eligible patients consented to participate, completed the PRIME-MD and were randomized. 95 patients had outcomes recorded. 51 (54%) had a PRIME-MD diagnosis and 8 (16%) of them were given a psychiatric consultation or referral in the ED. While the frequency of consultation or referral increased as the intervention's intensity increased (tell neither = 11% (1/9), tell patient 15% (3/20), tell patient and physician 18% (4/22)), no group came close to the 50% threshold we sought. For this reason, we stopped the trial after an interim analysis. CONCLUSION: Patients willingly completed the PRIME-MD and 54% had a PRIME-MD diagnosis. Unfortunately, at our institution, informing the patient (and physician) of the PRIME-MD results infrequently led to the patient being directed toward care for their psychiatric condition.     

Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients

OBJECTIVE: The purpose of this study was to examine the effect of proactive palliative care consultation on length of stay for high-risk patients in the medical intensive care unit (MICU). DESIGN: A prospective pre/post nonequivalent control group design was used for this performance improvement study. SETTING: Seventeen-bed adult MICU. PATIENTS: Of admissions to the MICU, 191 patients were identified as having a serious illness and at high risk of dying: 65 patients in the usual care phase and 126 patients in the proactive palliative care phase. To be included in the sample, a patient had to meet one of the following criteria: a) intensive care admission following a current hospital stay of >or=10 days; b) age >80 yrs in the presence of two or more life-threatening comorbidities (e.g., end-stage renal disease, severe congestive heart failure); c) diagnosis of an active stage IV malignancy; d) status post cardiac arrest; or e) diagnosis of an intracerebral hemorrhage requiring mechanical ventilation. INTERVENTIONS: Palliative care consultations. MEASUREMENTS AND MAIN RESULTS: Primary measures were patient lengths of stay a) for the entire hospitalization; b) in the MICU; and c) from MICU admission to hospital discharge. Secondary measures included mortality rates and discharge disposition. There were no significant differences between the usual care and proactive palliative care intervention groups in respect to age, gender, race, screening criteria, discharge disposition, or mortality. Patients in the proactive palliative care group had significantly shorter lengths of stay in the MICU (8.96 vs. 16.28 days, p = .0001). There were no differences between the two groups on total length of stay in the hospital or length of stay from MICU admission to hospital discharge. CONCLUSIONS: Proactive palliative care consultation was associated with a significantly shorter MICU length of stay in this high-risk group without any significant differences in mortality rates or discharge disposition.     

综合医院精神科急会诊与需会诊患者临床特征分析

目的探讨综合医院精神科急会诊与需会诊患者的临床特征。方法对综合医院精神科急会诊283例与需会诊240例患者的人口学资料、会诊时精神检查的主要症状、精神障碍诊断和会诊医师用药等临床资料进行回顾性分析。结果急会诊组的女性患者比例高,精神检查不合作、精神运动性兴奋或抑制、意识障碍、幻觉、定向障碍、自知力丧失等症状的比率均显著高于需会诊组（P〈0．01）,感觉障碍症状的比率显著低于需会诊组（P〈0．05）;诊断待定的患者比例高于需会诊组（P〈0．05）,而心境障碍诊断的比率显著低于需会诊组（P〈0．05）;应用典型抗精神病药的比率高于需会诊组（P〈0．01）,应用抗抑郁剂的比率显著低于需会诊组（P〈0．01）。结论综合医院精神科急会诊与需会诊患者均有不同的临床特征,加强综合医院各科医师联络会诊培训中的精神疾病知识培训,对提高其正确识别各类精神障碍的能力具有重要意义。     

Deliberate self-poisoning: factors associated with recurrent self-poisoning

Objective

To investigate potential risk factors associated with the repetition of deliberate self-poisoning (DSP).

Methods

Retrospective medical record review of all patients who presented to the emergency department of a tertiary teaching hospital after DSP between January 1, 2000, and December 31, 2009. Repetition of a suicide attempt was determined from reported episodes before the index episode or from 2 visits to the same hospital during the study period. Demographic information, clinical variables, and other variables at the first suicide attempt were investigated for factors associated with repetition of DSP.

Results

Of the 967 patients, 203 (21%) presented with repeated suicide attempts. Patients with repeat suicide attempts differed in sex, occupation, living condition, method of DSP, history of psychiatric treatment, reversibility, and psychiatric diagnosis. In the multivariate regression analysis, the only reliable associated factors for repeat suicide attempt were sex (P = .001), living condition (P < .001), method of DSP (P < .036), and history of psychiatric treatment (P < .001).

Conclusion

Early psychological intervention and close observation is required for patients who are female, living without a family, use antidepressants, and have a history of psychiatric treatment.     

Study Protocol: A randomized controlled trial of suicide risk reduction in the year following jail release (the SPIRIT Trial)

PurposeThis article describes the protocol for a randomized effectiveness and cost-effectiveness trial of Stanley and Brown's Safety Planning Intervention (SPI) during pretrial jail detention to reduce post-release suicide events (suicide attempts, suicide behaviors, and suicide-related hospitalizations).BackgroundWith 10 million admissions per year and short stays (often days), U.S. jails touch many individuals at risk for suicide, providing an important opportunity for suicide prevention that is currently being missed. This study (N = 800) is the first randomized evaluation of an intervention to reduce suicide risk in the vulnerable year after jail release. Given that roughly 10% of all suicides in the U.S. with known circumstances occur in the context of a criminal legal stressor, reducing suicide risk in the year after arrest and jail detention could have a noticeable impact on national suicide rates.DesignPretrial jail detainees at risk for suicide were randomized to SPI during jail detention plus post-release phone follow-up or to enhanced Standard Care. Outcomes assessed through 12 months post-release include suicide events, suicide attempts, weeks of active suicide ideation, severity of suicide ideation, time to first event, psychiatric symptoms, functioning, and cost-effectiveness. Methods accommodate short jail stays and maximize trial safety and follow-up in a large sample with severe suicide risk, access to lethal means including substances and firearms, high rates of psychiatric illness, and unstable circumstances.ConclusionAdequate funding was important to create the infrastructure needed to run this large trial cleanly. We encourage funders to provide adequate resources to ensure clean, well-run trials.     

Gender and deprivation and rates of referral and thereby admission to a national neurorehabilitation service

OBJECTIVE: To investigate the association between gender and deprivation and rates of admission to a national neurorehabilitation facility following subarachnoid haemorrhage or traumatic brain injury. DESIGN: Retrospective analysis of hospital activity data. SETTING: Lothian Health Board hospital activity; national neurorehabilitation centre. SUBJECTS: Patients with subarachnoid haemorrhage or traumatic brain injury. METHODS: We obtained data for hospital discharge for subarachnoid haemorrhage and traumatic brain injury for patients living in the Lothian Health Board area for the five years 1995 to 1999 by age (15 and over), sex and deprivation category of home residence from nationally held data sets. Similar data were extracted for discharges from the national neurorehabilitation unit. MAIN MEASURES: Rates of neurorehabilitation admission per 1000 hospital admissions. Chi-squared testing was used to assess statistical significance. RESULTS: Data for 13338 hospital admissions and 329 neurorehabilitation admissions were available. We observed higher than expected rates of rehabilitation admission for men with subarachnoid haemorrhage and for patients from more affluent postcode sectors with traumatic brain injury. CONCLUSION: Higher rehabilitation rates are seen among men following subarachnoid haemorrhage and may indicate a focus on return-to-work in the referral or assessment of those suitable for or requiring neurorehabilitation. Higher rehabilitation rates in head injury in those from Carstairs Deprivation Category (DepCat) 2 postcode sectors may represent a bias favouring those from affluent areas in the interaction between the individual and the health service in this group.     

Self-inflicted burn injuries: an 11-year retrospective study

The burns unit at the Royal Brisbane Hospital accepted a total of 2275 admissions from 1986 to 1996. During this 11-year period, 65 cases of self-inflicted burn injury were treated, which made up 2.9% of the total number of admissions. A mortality rate of 21.5% (14 patients) is noted, with all patients dying after admission to the hospital. A common feature of people that self-inflict burn injuries is a psychiatric history, with many patients having histories of self-harm or suicide attempts. Two distinct groups were identified--those with suicidal intent and those with intent of self-harm. Those patients with self-inflicted injuries have an increased mean of 31.4% total body surface area burned as compared with those patients whose injuries are accounted for as accidental, which have a mean total body surface area burned of 10%. Additionally, the mean length of stay in the hospital for patients with self-inflicted injuries was 40 days for acute injuries, which is prolonged; the mean length of stay for acute injuries that were not self-inflicted was 14 days. This investigation discovered 3 cases of repeated self-inflicted burn injury.     

Long-term results and quality of life after parasuicidal multiple blunt trauma

OBJECTIVE: This study evaluates the somatic, socioeconomic, and psychiatric long-term results, as well as the factors for adverse outcome, in a significant subset of patients with severe multiple injuries resulting from attempted suicide. DESIGN: The follow-up study 6.1 +/- 3 (SD) yrs after trauma was based on prospectively documented data of patients with multiple injuries. SETTING: Level I university trauma center in a major German city. MEASUREMENTS AND MAIN RESULTS: Data derived from thorough physical and psychiatric evaluations. The Brief Psychiatric Rating Scale and the Global Assessment of Functioning Scale served to describe psychiatric outcome. PATIENTS: In a series of 539 severely injured patients (Abbreviated Injury Score in two regions > or = 3), 65 (12%) attempted suicides were reported (Injury Severity Score, 40 +/- 15; age, 38 +/- 18 yrs). Twenty-one patients of the study cohort died during the hospital stay, and six subjects died thereafter, none because of suicide. Three patients were lost to follow-up, resulting in 35 individuals eligible for examination. None of the latter had reattempted suicide. Seventeen (48%) had good or satisfactory outcomes reflected by absent or ambulatory psychiatric treatment, employment, normal psychiatric findings (Brief Psychiatric Rating Scale), and good psychosocial ability (Global Assessment of Functioning Scale). For eight patients (24%), the result was indeterminate. The adverse outcomes in ten patients (28%) were mainly influenced by the presence of chronic schizophrenia (n = 4), affective disorder (n = 2), or severe traumatic brain injury (n = 3). CONCLUSIONS: Despite the parasuicidal origin, the long-term results after severe trauma were good or satisfactory in approximately half the cases and without further suicide attempts in any of the patients. Good recovery of the parasuicidal patients in our study is approximately 20% lower than in an unselected group of patients with multiple injuries and may be attributed mainly to the underlying chronic psychiatric disease.     

Depression in children after recovery from severe burns.

This outcome study of children and adolescents with severe burns (ages 7 to 19 years) reports that unrecognized depression is common during their lifetimes. Thirty children who had severe burns (range, 5% to 95% body surface area) were assessed for depression at a mean of 9 years after burn injury. This article presents an analysis of depression items from the Diagnostic Interview for Children and Adolescents, which was used in face-to-face interviews to assess child psychiatric disorders with diagnostic criteria from the American Psychiatric Association's Diagnostic and Statistical Manual--Third Edition. At the time that the interviews took place, only one child had symptoms of major depression and only three children had symptoms of dysthymic disorder. However, eight children had a lifetime history of major depression; two of them had been abused by burning and two had been physically or sexually abused. Four had made suicide attempts: one suicide attempt was the cause of the burn injury and three attempts were made after burn injury. Thirteen children had had suicidal thoughts, and their parents were often unaware of this. Other types of affective disorders were prevalent. There was no statistically significant association between depression and burn size or disfigurement. Although burn-related factors were associated with some depressive episodes, other biologic and social risk factors were also very important. The authors conclude that referral for diagnostic services and psychotherapy, and for some, treatment with antidepressant medication, is often a necessary part of medical services for children with burns.     

Characteristics of patients referred by police to a psychiatric hospital

To identify any differences between patients referred by police compared with patients referred from other sources, to a psychiatric hospital in Australia, a retrospective audit of 200 patient files was undertaken. The two most common reasons for the involuntary referral of patients by police were bizarre ideas (33%) and threats of suicide (28%). When 101 patients referred by police were compared with 99 patients from other sources, police referrals were three times more likely to be diagnosed with a mental and behavioural disorder because of psychoactive substance use, less likely to be diagnosed with a mood disorder, and less likely to be diagnosed as psychotic. Police referrals were more likely to have worse functional scores; exhibit aggressive behaviour; spend fewer days in hospital; more likely to be admitted to the psychiatric intensive care unit, and to be secluded. The most important predictor for a police referral was drug or alcohol problems. The study indicates that patients referred by the police were more likely to demonstrate particular characteristics compared with patients referred by other sources.     

Does the Nursing Care Plan help in the management of psychiatric risk?

The Nursing Care Plan (NCP) is routinely used to direct the nursing care of psychiatric in-patients, but the impact of NCPs on patient care and clinical outcome is not firmly established NCPs from 246 patients, chosen at random from admissions to acute psychiatric wards, were analysed The NCPs were scored for quality and also specifically for the presence of recorded risk assessment and appropriate level of nursing supervision NCPs were evaluated in relation to psychiatric risk factors present prior to admission, and in relation to risk behaviour during hospitalization Quality of NCP records was generally poor, with scores in all areas assessed being approximately half of the possible maximum Patients with a perceived high risk of suicide prior to admission had significantly better NCP quality than other patients, but about a third of these high risk patients had no recorded risk assessment or supervision level in the nursing notes Patients who had actually self-harmed within 4 weeks prior to admission were more likely to have a recorded risk assessment but did not score more highly than the rest of the patient population on any other measures of NCP quality Patients who had made suicidal threats prior to admission but who were not deemed to be of high suicide risk before admission had significantly lower quality NCPs and were less likely to have a record of supervision level than the rest of the patients The highest rate of supervision records occurred in patients who had shown dangerous behaviour prior to admission Outcome in terms of two risk behaviours during admission (self-harm and violence) was not related to whether or not risk assessment and supervision levels had been recorded Patients admitted compulsory to hospital were more likely to have a supervision level recorded but were also more likely to abscond It is concluded that issues of psychiatric risk were not raise serious questions about the usefulness of the NCP in helping to predict and prevent risky behaviour amongst psychiatric in-patients