Deliberate self-harm patients who leave the accident and emergency department without a psychiatric assessment: A neglected population risk of suicide

Centre for Suicide Research, Oxford University, Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, UK.
Journal of Psychosomatic Research (Impact Factor: 2.74). 03/2001; 50(2):87-93. DOI: 10.1016/S0022-3999(00)00225-7
Source: PubMed


Deliberate self-harm (DSH) patients, despite their risk of suicide, are often discharged directly from accident and emergency (A&E) departments without undergoing a psychiatric assessment. The aims of this study were to determine the characteristics and outcome of these patients.
The characteristics of DSH patients who were discharged directly from an A&E department over a 2-year period were investigated, comparing those who had a psychiatric assessment with those who did not. In a matched control design, the outcome of a group of patients who did not receive a psychiatric assessment was compared with that of a group of patients who were assessed.
Of DSH patients who were discharged directly from the A&E department 58.9% (145/246) did not have a psychiatric assessment. Nonassessed patients were more likely to have a past history of DSH, to be in the 20-34 year age group, and to have exhibited difficult behaviour in the A&E department. Patients presenting between 5 p.m. and 9 a.m. were less likely to be assessed than those attending between 9 a.m. and 5 p.m. Further DSH during the subsequent year occurred in 37.5% of the nonassessed patients compared with 18.2% of matched assessed patients. They were also more likely to have psychiatric treatment.
A substantial proportion of DSH patients discharged directly from A&E departments do not receive a psychiatric assessment. Nonassessed patients may be at greater risk of further DSH and completed suicide than those who are assessed. Hospital services need to be organised such that DSH patients managed in A&E departments can receive an assessment of psychosocial problems and risk.

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    • "Sanders (2000) found that negative attitudes may lead to a reduction in care from nurses. Indeed, negative attitudes are linked with decreased helping behavior (Mackay & Barrowclough, 2005), which is alarming considering that the risk of further SIB is particularly high for patients who leave hospital without adequate assessment (Hickey et al., 2001). This formed the basis of the final hypothesis regarding the consequences of self-injury, whereby it is stated that episodes of NSSI will be followed by lesser level of medical care than episodes of SSI. "
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    ABSTRACT: Nonsuicidal self-injury (NSSI) and suicidal self-injury (SSI) co-occur in adults. The purpose of the current study was to examine differences and similarities in NSSI and SSI in adult women with respect to (1) methods used and lethality of methods, (2) intent and impulsivity of act, (3) precipitating events, and (4) consequences. The data consist of variables pertaining to 46 self-injurious acts committed by 16 Finnish female participants and recorded using Suicide Attempt Self-Injury Interviews (SASII). The data were analyzed using variables weighted by the number of acts. This study found several differences as well as similarities between the acts of SSI and those of NSSI: (a) the respective acts differ in the methods used, in the lethality of the methods, and in the expectations of resulting lethality of the acts, (b) they further differ in the functions the respective acts serve and (c) in some of the precipitating events and consequences. The acts were similar in (d) impulsivity of act and (e) some of the precipitating events and consequences. Because both types of behavior can occur within the same individual, and due to the progressing evolution between them, a thorough assessment of both NSSI and SSI needs to be completed. More emphasis needs to be placed on both the assessment of social connections and interpersonal conflict as well as how it informs the treatment. Because the behavior studied is multifunctional and changing, its treatment too needs to be customized to the multiple and changing needs of the individual patients, as opposed to diagnostic tailored treatment.
    Nordic psychology 02/2015; 67(1):27-45. DOI:10.1080/19012276.2014.997784 · 0.18 Impact Factor
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    • "Absconding was more common in Oxford (11%) than in Newcastle (2%) and absconding patients may be at increased mortality risk [27]. These rates are generally lower than a study of 22 UK hospitals which reported a range of self-discharging from 8.4% to 38.6% [28], roughly equivalent to our concept of absconding. "
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    ABSTRACT: Hospital-treated deliberate self-poisoning (DSP) is common and the existing national monitoring systems are often deficient. Clinical Practice Guidelines (UK and Australia) recommend universal psychosocial assessment within the general hospital as standard care. We compared presentation rates, patient characteristics, psychosocial assessment and aftercare in UK and Australia. We used a cross sectional design, for a ten year study of all DSP presentations identified through sentinel units in Oxford, UK (n=3042) and Newcastle, Australia (n=3492). Oxford had higher presentation rates for females (standardised rate ratio 2.4: CI 99% 1.9, 3.2) and males (SRR 2.5: CI 99% 1.7, 3.5). Female to male ratio was 1.6:1, 70% presented after-hours, 95% were admitted to a general hospital and co-ingestion of alcohol occurred in a substantial minority (Oxford 24%, Newcastle 32%). Paracetamol, minor tranquilisers and antidepressants were the commonest drug groups ingested, although the overall pattern differed. Psychosocial assessment rates were high (Oxford 80%, Newcastle 93%). Discharge referral for psychiatric inpatient admission (Oxford 8%, Newcastle 28%), discharge to home (Oxford 80%, Newcastle 70%) and absconding (Oxford 11%, Newcastle 2%) differed between the two units. Oxford has higher age-standardised rates of DSP than Newcastle, although many other characteristics of patients are similar. Services can provide a high level of assessment as recommended in clinical guidelines. There is some variation in after-care. Sentinel service monitoring routine care of DSP patients can provide valuable comparisons between countries. Copyright © 2015 Elsevier Inc. All rights reserved.
    Journal of Psychosomatic Research 01/2015; 78(4). DOI:10.1016/j.jpsychores.2015.01.006 · 2.74 Impact Factor
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    • "These findings highlight the lack of standardised procedures for the assessment and aftercare of patients presenting with deliberate self harm nationwide. Inadequate assessment of self harm patients will result in failure to diagnose treatable underlying conditions such as alcohol dependence and depression.This will lead to inadequate treatment plans, poor compliance with treatment and increased risk of repeated suicidal behaviour, both fatal and non-fatal (Hickey et al., 2001; Kapur et al., 2002). Thus, work towards the development and implementation of standardised assessment and aftercare procedures for patients presenting to A&E departments with deliberate self harm represents a major research priority. "
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