Emergency Treatment of Deliberate Self-harm

Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York State Psychiatric Institute, New York, NY 10032, USA.
Archives of general psychiatry (Impact Factor: 14.48). 09/2011; 69(1):80-8. DOI: 10.1001/archgenpsychiatry.2011.108
Source: PubMed


Although concern exists over the quality of emergency mental health services, little is known about the mental health care of adults who are admitted to emergency departments for deliberately harming themselves and then discharged to the community.
To describe the predictors of emergency department discharge, the emergency mental health assessments, and the follow-up outpatient mental health care of adult Medicaid beneficiaries treated for deliberate self-harm.
A retrospective longitudinal cohort analysis.
National Medicaid claims data supplemented with county-level sociodemographic variables and Medicaid state policy survey data.
Adults aged 21 to 64 years who were treated in emergency departments for 7355 episodes of deliberate self-harm, focusing on those who were discharged to the community (4595 episodes).
Rates and adjusted risk ratios (ARRs) of discharge to the community, mental health assessments in the emergency department, and outpatient mental health visits during the 30 days following the emergency department visit.
Most patients (62.5%) were discharged to the community. Emergency department discharge was directly related to younger patient age (21-31 years vs 45-64 years) (ARR, 1.18 [99% confidence interval {CI}, 1.10-1.25]) and self-harm by cutting (ARR, 1.18 [99% CI, 1.12-1.24]) and inversely related to poisoning (ARR, 0.84 [99% CI, 0.80-0.89]) and recent psychiatric hospitalization (ARR, 0.74 [99% CI, 0.67-0.81]). Approximately one-half of discharged patients (47.5%) received a mental health assessment in the emergency department, and a similar percentage of discharged patients (52.4%) received a follow-up outpatient mental health visit within 30 days. Follow-up mental health care was directly related to recent outpatient mental health care (ARR, 2.30 [99% CI, 2.11-2.50]) and treatment in a state with Medicaid coverage of mental health clinic services (ARR, 1.13 [99% CI, 1.05-1.22]) and inversely related to African American (ARR, 0.86 [99% CI, 0.75-0.96]) and Hispanic (ARR, 0.86 [99% CI, 0.75-0.99]) race/ethnicity.
Most adult Medicaid beneficiaries who present for emergency care for deliberate self-harm are discharged to the community, and many do not receive emergency mental health assessments or follow-up outpatient mental health care.

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    • "This finding has been consistently shown in the literature (Hawton et al., 2002). Adolescent depression and hospital-treated self-harm may play a role, as the numbers are higher for female adolescents compared to males (Olfson et al., 2005), Of note is that sex difference did not reach significance levels when the regression was run for the suicide intent and the suicide attempt groups, suggesting that females are more likely to engage in ultimately non-lethal self-harming behavior without suicide intent, in contrast to a previous study where no significant gender difference was found in the frequency, duration or number of methods of NSSI (Nock et al., 2006). Interestingly, a ratio of 4 male to 1 female deaths by suicide was reported in adult U.S. population, highlighting the significance male gender and older age play in intent and severity of attempt (McIntosh, 2006). "
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    ABSTRACT: Adolescents comprise a unique and often challenging group of patients with diverse presentations to the Mental Health Services; suicidal behavior being one of them. The main aim of this naturalistic project was to investigate demographic and clinical correlates of adolescent suicidal and self-harm events, which may be of value to decision-making in clinical practice. All adolescents (n = 149) registered and actively managed by a specialist community mental health service in South London were included in the study. Clinical information from their files was used to determine suicidality/self-harm events. The Columbia Classification Algorithm of Suicide Assessment (C-CASA) was utilised for classification purposes. Logistic regression was used to explore the effects of age, sex, diagnosis, medication, substance use (alcohol and/or cannabis) and ethnicity on suicidality/self-harming behaviors. Age, sex and use of psychotropic medication were identified to play a significant role in determining the risk of engaging in self-harming behavior. The risk was higher with increasing age and female sex. Medication seemed to have a protective effect. Reporting a 20% prevalence of non-suicidal self-injury (NSSI) in our population, we highlight the importance of NSSI as a distinct diagnostic category. Our findings have implications for risk assessment and appropriate decision-making in clinical settings. Results are translatable and relevant to other metropolitan areas.
    Journal of Mental Health 07/2015; 24(4):1-5. DOI:10.3109/09638237.2015.1022249 · 1.01 Impact Factor
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    • "Suicide risk screening – the proactive identification of adolescents at risk for suicide – has substantial public health significance because, without screening, many adolescents at high risk go unrecognized and untreated (King et al. 2009b; Bridge et al. 2012; Olfson et al. 2012). Many adolescents who die by suicide have never received any mental health services (Brent et al. 1988; Marttunen et al. 1992; Shaffer et al. 1996). "
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    ABSTRACT: We investigated whether health insurance type (private vs Medicaid) influences the delivery of acute mental health care to patients with deliberate self-harm. Using National Medicaid Analytic Extract Files (2006) and MarketScan Research Databases (2005-2007), we analyzed claims focusing on emergency episodes of deliberate self-harm of Medicaid- (n=8,228) and privately (n=2,352) insured adults. We analyzed emergency department mental health assessments and outpatient mental health visits in the 30 days following the emergency visit for discharged patients. Medicaid-insured patients were more likely to be discharged (62.7%), and among discharged patients they were less likely to receive a mental health assessment in the emergency department (47.8%) and more likely to receive follow-up outpatient mental health care (52.9%) than were privately insured patients (46.9%, 57.3%, and 41.2%, respectively). Acute emergency management of deliberate self-harm is less intensive for Medicaid- than for privately insured patients, although discharged Medicaid-insured patients are more likely to receive follow-up care. Programmatic reforms are needed to improve access to emergency mental health services, especially in hospitals that serve substantial numbers of Medicaid-insured patients.
    American Journal of Public Health 04/2012; 102(6):1145-53. DOI:10.2105/AJPH.2011.300598 · 4.55 Impact Factor
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