A Database Review in C-L-Psychiatry

A Database Review in C-L Psychiatry: Characteristics ofHospitalized Suicide Attempters MAHLON HALE, M.D. JAMES JACOBSON. M.D. RICHARD CARSON. M.S.W.

A computerized database was used to study the characteristics ofpsychiatric consulta-

tions in patients admitted to nonpsychiatric services. The authors reviewed a consultation practice with suicide attempters over a four- year period and compared the patients with a patient sample matched for gender and age also seen by the service. For suicide attempters. the time elapsed between admission to the service and the consultation. as well as the lengths of stay. were significantly shorter. Suicide attempters were significantly more likely to have mood disorders and Aris JJ disorders. The authors review the role ofconsultation psychiatrists with these patients and suggest that a triage model fits the sen-ices provided and the needs of nonpsychiatric physicians.

everal authors have called for systematic evaluations of psychiatric consultations to assess the utility ofthese activities. 1.2 Computerized patient databases are ideal for this purpose because they allow large patient samples to be evaluated over long periods of time using the same variables. However, the question of what should be studied remains. and it requires some consideration. Questions regarding frequencies of diagnoses or psychopharmacologic issues commonly justify a request for psychiatric consultations,M but clinical dilemmas that present difficulties for both nonpsychiatric physicians and psychiatrists are more likely to be resolved on the basis of utility.

S

Received May 17. 1989; revised August 28. 1989. accepted September 15. 1989. From the Depanment of Psych iatry. University of Connecticut Health Center. Address reprint requests to Dr. Hale. Director. Consultation-Liaison Psychiatry. Depanment of Psychiatry. University ofConnecticut Health Center. Farmington. IT 06443. Copyright © 1990 The Academy of Psychosomatic Medicine.

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Some patients are difficult to manage from any perspective, and the dislike ofcertain patients by nonpsychiatric physicians has been cited as a basis for consultation with a psychiatrist. ~.6 Since it is axiomatic that consultants readily are blamed for any failures.? they are in danger of acquiring a bad reputation for dealing with such patients, a reputation that can have a negative impact upon carefully cultivated patient-psychiatrist relationships. In recent years, moreover, nonpsychiatric physicians have sought dispositions on all patients more rapidly. With patients who have major psychopathology or who may present management difficulties. the desire to obtain for them a psychiatric disposition can become urgent. One familiar problematic patient in psychiatric consultation is the patient who is hospitalized in a nonpsychiatric service following a suicide attempt. Patients attempting suicide usually are perceived by nonpsychiatric physicians to be persons requiring psychiatric disposition. A perceived failure by a psychiatric consultant to effect a rapid transfer can provoke the rancor of PSYCHOSOMATICS

Hale et al.

nonpsychiatric colleagues. Analysis of the timing of consultations and the lengths of stay for such patients may be useful in demonstrating how well psychiatrists meet this need. In this article, we report our experience with this patient group over a 4.5-year period, with particular attention paid to the issues addressed above. STUDY SITE Our psychiatric consultation service is based at a small university medical center. Over the past

four years, psychiatric consultations have represented slightly more than 4% of all nonpsychiatric adult admissions, consistent with other reports. s We reviewed all patients seen in consultation between January 1984 and July 1988, and we selected for study patients with the admitting diagnosis of suicide attempt. Suicide attempt was defined as intentional self-injury; patients admitted for risk-taking activities or accidental self-injuries were excluded, as were patients under 18. METHODS

TABLE I.

Data collected from patient consulta· tions Reason for consuh Psychiatric DX I Psychiatric DX IA Psychiatric DX II Suicidal ideation Impression Recommendation Disposition Medications Compliance Outcome If deceased Discharge from psychiatry Psychiatric admission days Status Comments Number

Last name First name Unit number Marital status Age Race Gender Residence Admission date Consuh date Days before consuh Discharge date Length of slay Referring service Referring physician Medical diagnosis I Medical diagnosis II

We collected data on a microcomputer database (REFLEX '90 ) of 34 variables (Table I) from 906 patient consultations seen between January 1984 and July 1988. During this period, 127 patients were seen subsequent to a suicide attempt. We compared the group of suicide attempters with a group of 127 patients from the remaining consultation roster matched for age and sex. The matched group was screened for patients with chronic brain syndromes and prolonged hospitalizations (outliers) who were awaiting placement in a long-term care facility. We reviewed the duration of hospitalization before consultation, the lengths of stay before disposition, the incidence of suicidal ideation, DSM-III-R Axis I and Axis II diagnoses, and the eventual dispositions of both groups. Psychiatric diagnoses were made

TABLE 2. Suicide attempters vs. nonattempters Suicide Attempters (N=127)

Nonattempters (N=127)

df

Significance

Average no. of days before request'

1.44

7.5

6.42

254

p<.OOI

Average length of stay (days)'

4.42

18.4

9.37

254

p<.OOI

'Student's t test (two-tailed)

TABLE 3.

Outcomes by percentage of patients: suicide attempters vs. nonattempters

Patients

Against Medical Advice

Suicide attempters

0.8

Nonattempters

3.9

Death

Extended Care Facility

1.6 4.7

2.4

9.4

11.8

25.2

50.4

10.2

44.1

0.9

29.1

7

VOLUME 3\ • NUMBER 3· SUMMER \990

No Referral

Involuntary Referral Voluntary Hospitalization (Outpatient) Hospitalization

283

Characteristics of Suicide Attempters

Psychiatric Diagnoses

jointly by the attending psychiatrist and senior residents on the service. RESULTS Patient Characteristics and Dispositions One hundred twenty-seven patients (14%) were examined following suicide attempts. Seventy-nine patients (62%) were female, and 48 patients (38%) were male. The average age was 34.7 years (F=33.9 and M=36.1 years). The average time elapsed between admission to the service and consultation was 1.44 days, and the average length of stay was 4.42 days. Of the patients who had attempted suicide, 76 (60%) had suicidal ideation at the time of interview. Seventy-nine (62%) were transferred to inpatient psychiatric services. Thirty-two (25%) were referred for outpatient treatment. In order to examine how rapidly patients who attempted suicide were referred and when dispositions were made, we compared this group with the matched patient sample. The remaining group was identical in the proportion of females to males and had the same average age. On the average, however, they had a longer duration of hospitalization before consultation (7.5 days; 1=6.42, p
We examined DSM-III-R Axis I and Axis II diagnoses for the two samples (see Table 4). Forty-nine patients attempting suicide (39%) had mood disorders, compared with 29 (23%) of the matched sample (X 2= 7.4, p
DSM·III·R diagnoses (Axis I) suicide attempters vs. nonattempters

,

Suicide Attempters (N=127)

Nonattempters (N=127)

X-

df

Significance

Adjuslment disorders

31

54

9.35

I

p<.005

Mood disorders

49

29

7.4

I

p<.01

Organic mental disorders Schizophrenia

7 14

5 4

5.97

Substance abuse disorders Other diagnoses

21 5

14 9

NS NS

0

2

NS

Diagnosis

No Axis 1diagnosis

NS' (><.025

'NS=not significant

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PSYCHOSOMATICS

Hale et al.

suicide by disposition. We found that patients with mood disorders and schizophrenia were more likely to be transferred to inpatient units. Patients with adjustment disorders and substance abuse disorders were more likely to have outpatient dispositions. Axis II diagnoses were also more common among the hospitalized suicide attempters than those with outpatient dispositions. Our data indicate that patients admitted following suicide attempts were referred more rapidly to the psychiatric service for consultation than other patients. This supports the clinical impression that nonpsychiatric physicians feel some urgency to obtain dispositions for such patients. The average length of stay for patients who attempted suicide was significantly shorter than the comparison sample. In this regard, our interventions acknowledge a perceived need for rapid disposition. The average length of stay for patients transferred to inpatient psychiatric units was 2.97 days; less than a day (0.88) elapsed between hospitalization and consultation. In reviewing the diagnoses for the patients attempting suicide, we discerned several patterns. First, there was increased psychiatric comorbidity for suicide attempters. Second, they had significantly more Axis II diagnoses. Many suicide attempters exhibited both acute psychological states and noticeable trait behaviors. This is similar to the finding of Friedman et al. of "a synergistic effect" between Axis I depression, Axis II borderline personality disorder, and sui-

cidal behavior.9 Possibly nonpsychiatric physician intuition about these complex conditions further explains their urgency. Thus, inasmuch as patients who are substantially more ill from a psychiatric perspective appear to cluster in this patient group, it should be no surprise that nonpsychiatric staffs feel anxious and frustrated. lo One can empathize with the wish to have such patients transferred quickly. There is, finally, a question of whether these patients fit any previously described patient model. If this is the case, another question presents itself: Could that model be used for teaching purposes with nonpsychiatric physicians? In a frequently cited article, Groves described a group of disturbing patients as "hateful. "II Their domain appeared to be outpatient, rather than inpatient, settings, and they exhibited longstanding dependency traits and clinging behavior. The patients in this study are more reminiscent of refractory psychiatric inpatients with Axis II pathology. 12 Regardless of their behavior on nonpsychiatric services, their manner of arrival marks them as unwanted, and inevitably psychiatry is asked to make a disposition. Analysis of this patient sample raises questions as to which activities of consultation psychiatrists are valued highly by nonpsychiatrists. Meyer and Mendelson 13 proposed that psychiatric consultations arise from the uncertainty of referring physicians. This uncertainty often translates into a feeling of a lack of comprehension, or a loss of

TABLE 5. DSM-III·R diagnoses (Axis II) suicide attempters vs. nonattempters Diagnosis

Suicide Attempters

Nonattempters

(N=127)

(N=127)

Borderline

34

Passive-aggressive

12 7

Dependent

16 4

I

[><.005

I

[><.05

NS' NS NS NS

Avoidant

o

I

Antisocial personality

9

Schizotypal Other diagnoses

2

3 3 3 87

60

8.06 4.26

2

2

No Axis II diagnosis

Significance

8

Mixed

I

dr

NS NS 11.97

[><.001

'NS=not significant

VOLUME 31' NUMBER 3· SUMMER 1990

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Characteristics of Suicide Attempters

control. on the part of the referring physicians;3 the consultant serves as the prime mover of an "operational group." organized to promote a better understanding of patient. staff. or ward issues. This suggests that consultation is a wanted or benevolent entity. Consultation psychiatry should build bridges between psychiatry and other medical specialties. '4 Yet much consultation work may be viewed by nonpsychiatric physicians as dispositional. Perhaps the traditional approach taught in the classroom is not as useful as that which can be taught in the practice setting.'~·'b

Psychiatric consultation in fact is valued when practical help is offered. The pattern of earlier referrals with these patients and our responses to making dispositions tend to confirm this. This is not necessarily an optimistic finding. Referring services quite logically are eager to transfer difficult individuals when their care re-

sponsibilities have ended. and they often view delay as resistance on the part of psychiatry. One way to increase psychiatry's credibility with nonpsychiatric services is to institute concurrent reviews of suicide intention in such patients. In this study. only about 60% of patients who attempted suicide acknowledged suicidal ideation during psychiatric examination. While some patients may be suicidal only under stress or while intoxicated. others conceal suicidal ideation in order to avoid further hospitalization. Several scales exist which assess present and future suicide risks in suicide attempters, including the Risk-Rescue Rating Scale I? and the SAD PERSONS scale. '8 Inasmuch as the management and disposition of these patients may always be an issue. referring services and patients may benefit from systematic evaluations of suicidal intention by consultation psychiatrists.

References I. Strain JJ: Appraisal of marketing approaches for consultation liaison psychiatry. Gen Hosp Psychiatry 9:368371.1987 2. Wise TN: Databased research: antidote to the anecdote? (editorial). Psychosomatics 29:371-372.1988 3. Karasu TB. Plutchik R. Steinmuller RI. et al: Panems of psychiatric consultation in a general hospital. Hosp Community Psychiatry 29:291-294. 1977 4. Bustamente JP. Ford CV: Characteristics of general hospital patients referred for psychiatric consultation. J Clin Psychiatry 42:338-341. 1981 5. Alben HD. Kornfeld DS: The threat to sign out against medical advice. Ann Intern Med 79:888-891. 1973 6. Tupin JP: Management of violent patients. in Manual of Psychiatric Therapeutics. Edited by Shader RI. Boston. Linle. Brown. 1975. pp 125-136 7. Brantley JT. Wise TM. Ahmed SW: Consultation-liaison fellowships: effect on internists' anitudes toward psychiatric consultation. Psychosomatics 26: 12-18. 1985 8. Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine. Psychosom Med 24:201-224. 1967 9. Friedman RC. Aronoff MS. Clarkin JF. et al: History of suicidal behavior in depressed borderline patients. AmJ Psychiatry 140:1023-1026. 1983

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10. Maltsberger JT. Buie DH: Countenransference hate in the treatment of suicidal patients. Arch Gen Psychiatry 30:625--{i33. 1974 II. Groves JE: Taking care of the haleful patient. N Enlll J Med 16:883-887.1978 12. Stone MH. Stone DK. Hun SW: Natural history of borderline personality treated by intensive hospitalization. Psychiatr Clin North Am 10: 185-206. 1987 13. Meyer E. Mendelson J: Psychiatric consultation with patients on medical and surgical wards: panems and processes. Psychiatry 24:197-220.1961 14. Lipowski AJ: Consultation-liaison psychiatry: an overview. Am J Psychiatry 131 :623-t>30. 1974 15. Callen KE: Psychiatric education of nonpsychiatrists: is it relevant to medical practice? Psychosomatics 21 :4354. 1980 16. Kantor SM. Griner PF: Educational needs in general internal medicine as perceived by prior residents. J Med Educ 56:748-756. 1981 17. Weisman AD. Worden JW: Risk-rescue rating in suicide assessment. Arch Gen Psychiatry 26:553-560. 1972 18. Panerson WM. Dohn HH. Bird J. et al: Evaluation of suicidal patients: the SAD PERSONS scale. Psychosomatics 24:343-349.1983

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