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Emergency Department Visits: A Missed Opportunity for Suicide Prevention?

July 29, 2010 — Emergency department (ED) visits by patients presenting with mental health concerns may represent a missed opportunity to detect those at high risk for suicide, new research suggests.

A small study by investigators at the University of Manchester in the United Kingdom found that up to 43% of individuals who committed suicide attended the ED at least once in the year before their death and 28% attended the ED on more than 3 occasions before suicide completion. These "frequent attenders" died by suicide significantly sooner after their final, nonfatal attendance to the ED than their counterparts who presented to the ED less frequently.

"Although psychiatric services clearly have a prominent role in preventing suicide in mental health patients, EDs may represent an important additional setting for suicide prevention," the study authors, led by Damian Da Cruz, The National Confidential Inquiry, University of Manchester, write.

The study is published online July 26 in Emergency Medicine Journal.

Effective Point of Intervention

According to the investigators, mental illness is one of the strongest risk factors for suicide, and although previous research suggests the ED may be an effective opportunity to intervene, few studies have examined ED contacts before suicide in clinical samples of mental health patients.

For the study the researchers reviewed ED records in the Northwest of England for 286 suicide completers who died between 2003 and 2005 and who had been in contact with mental health services within 12 months of death.

The age of the study sample ranged from 19 to 95 years, with a mean age of 47 years. There were twice as many males as females, and the most common method of suicide was hanging/strangulation followed by self-poisoning.

More than half the sample (55%) was unemployed or on long-term sick leave at the time of death.

Twenty percent of the sample had a primary diagnosis of schizophrenia and other delusional disorders, 48% had affective disorders including bipolar disorder and depression, 9% had alcohol dependence, and 3% had drug dependence.

Of the total sample, 124 individuals (43%) had attended the ED at least once in the year before their death, and of these 35 (38%) had attended the ED on more than 3 occasions.

Psychosocial Assessments Not Happening

The investigators found the most common reasons for the final, nonfatal attendance were self-harm (39%), requests for psychiatric help (28%), physical injury/illness (24%), and alcohol intoxication (7%).

In addition to being significantly more likely to die by suicide soon after their last visit than those who attended the ED less often, further analyses of "frequent attenders" revealed this subgroup was more likely to have a history of self-harm and alcohol misuse. They were also more likely to be unemployed and to have sought help for psychological reasons, including self-harm.

Of concern, note the researchers, was the fact that there was a low documented level of psychosocial assessment. However, they add, "this does not appear to reflect a lack of care" because most self-harm patients were admitted to hospital or discharged with follow-up. Only 4% were discharged without further treatment or follow-up.

Nevertheless, they note, 34% of patients requesting psychiatric help were discharged without referral.

Frequent attenders to the ED, the researchers suggest, may be a particularly high-risk group and should be recognized by ED health professionals as such. The study authors suggest that other potential red flags for increased suicide risk include alcohol misuse and unemployment.

"All people who attend the ED following self-harm should receive psychosocial assessment at triage and a more detailed assessment if required, but this study and several others show this is not happening," they write.

The study authors have disclosed no relevant financial relationships.

Emerg Med J. Published online July 26, 2010.