Factors associated with referral to mental health services among suicide attempters visiting emergency centers of general hospitals in Korea: does history of suicide attempts predict referral?

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General Hospital Psychiatry 33 (2011) 294 – 299

Factors associated with referral to mental health services among suicide attempters visiting emergency centers of general hospitals in Korea: does history of suicide attempts predict referral? Sun-Jin Jo, Ph.D.a , Myung-Soo Lee, M.D., M.P.H.b,⁎, Hyeon Woo Yim, M.D., Ph.D.a , Han Joon Kim, M.D., Ph.D.c , Kyeongryong Lee, M.D., Ph.D.d , Hyun Soo Chung, M.D., Ph.D.e , Junho Cho, M.D., M.P.H.f , Seung-Pil Choi, M.D., Ph.D.c , Young Mi Seo, M.S.W.b a

Department of Preventive Medicine, College of Medicine, the Catholic University of Korea, and the Clinical Research Center for Depression of Korea, South Korea b Seoul Suicide Prevention Center in Seoul, Gangnam-gu, Seoul, South Korea c Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, South Korea d Department of Emergency Medicine, College of Medicine, Konkuk University, South Korea e Department of Emergency Medicine, College of Medicine, Yonsei University, South Korea f Department of Emergency Medicine, College of Medicine, Inje University, South Korea Received 3 February 2010; accepted 19 January 2011

Abstract Objective: This study examined whether a history of past suicide attempts was a critical factor for referral to mental health services among suicide attempters visiting emergency centers of general hospitals in Korea. Method: In this cross-sectional study, a resident of emergency medicine at each emergency center interviewed 310 suicide attempters visiting five tertiary general hospitals located in Seoul, using standardized questionnaires, during 7 months in 2007. We examined associations between suicide attempt history and referral to mental health services via multiple logistic regressions. Results: Subjects' rate of referral to mental health services was 47.3%. When we controlled for participant age, time of arrival at the emergency center, psychiatric treatment history, use of alcohol, suicide attempt lethality and subjective expectation to suicide attempts, past suicide attempts did not predict referral to mental health services (odds ratio=1.74; 95% confidence interval .88–3.43). Conclusion: Psychiatric interventions for suicide reattempters visiting emergency centers are important for preventing suicide, but providers have not considered suicide attempt history as a critical factor for referral to mental health services. Therefore, we suggest that more effort is needed to systemize psychiatric interventions for suicide reattempters at emergency centers in Korea. © 2011 Elsevier Inc. All rights reserved. Keywords: Suicide attempt; Emergency; Referral; General hospital

1. Introduction In 2008, Korea recorded the highest suicide rate, 26 persons per 100,000, of any Organisation for Economic Cooperation and Development country, and suicide ranked as the fourth leading cause of death, accounting for 5.2% of Korean deaths [1]. A study reported Korea's socioeconomic losses due to suicide were around US$ 2.5 billion [2], and ⁎ Corresponding author. Tel.: +82 2 3444 9934(Dir 211). E-mail address: [email protected] (M.-S. Lee). 0163-8343/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2011.01.008

estimates of its actual losses are higher. The Korean government has therefore created its second national suicide prevention 5-year plan (2009–2013), established several 24-h crisis intervention teams and proceeded to create comprehensive suicide prevention strategies. Many researchers have reported that psychiatric illness closely correlates with suicide [3]. In the USA, 55% of patients visiting emergency centers because of suicide attempts had psychiatric disorders, and 31% of them suffered from depressive disorder [4]. In their review of psychological autopsy studies, Bertolote et al. found that 98% of those

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dead due to suicide had been diagnosed with at least one mental disorder, and about 30% of them had been diagnosed with mood disorders [5]. According to a study by Yamada, 81% of suicide attempters visiting emergency centers had an axis I disorder, with mood disorder occurring most frequently. Previous researchers found the same results [6,7]. Although most persons with psychiatric illnesses do not commit suicide, their suicide attempt risk is higher compared to that of those without such illnesses [8]. A previous suicide attempt is the most dangerous risk factor for death by suicide. In Western countries, the estimated ratios of suicide attempts to completed suicides range from 6–8:1 to 8–25:1 [9–11]. The National Emergency Department Database of Israel reported that over 15% of persons who had attempted suicide at ages 25–44 years tried it again within a year [12]. Persons who intentionally injured themselves have shown a significantly higher rate of completed suicide compared to other persons [13]. According to the crescendo theory [14], repeated suicide attempts increase the risk of suicide. Many researchers found associations between the experience of a suicide attempt and both higher numbers of reattempts and higher odds of suicide completion [15–18]; 15% of suicide attempters commit suicide within 1 year [19]. These previous studies support the importance of care for suicide attempters with previous histories of suicide attempts who visit emergency centers. The emergency center is one of the key sites for suicide prevention because medical service providers most frequently see suicide attempters and reattempters at the emergency center, and these providers can play a role in suicide prevention by providing attempters with referrals to mental health services at the first opportunity. The New South Wales Department of Health in Australia, for example, recommends an assessment of suicide risk for all patients visiting the emergency department and emphasizes that, according to the degree of risk, patients should receive referrals to an appropriate type of mental health service [20]. The National Emergency Department Information System of Korea estimated the annual number of emergency department visits for attempted suicide as around 40,000 [21]. Based on the Injury Fact Book of the Center for Disease Control and Prevention of the United States [22], we would estimate annual suicide attempts at 250,000, which means approximately one sixth of suicide attempters visited emergency centers. Nevertheless, this small proportion must be considered carefully because higher lethality rates are experienced by these persons than by nonvisitor suicide attempters, and interventions for them could be crucial for preventing completed suicides. However, in Korea, there is no nationwide recommendation regarding what should be done for a suicide attempter, at least not for emergency centers. As a result, over 50% of suicide attempters visiting emergency centers were discharged from their center against medical advice, making it difficult for medical service providers to diagnose

295

or intervene in their problems [23]. Most of all, emergency centers' ways of dealing with suicide reattempters differ according to the hospital, even though suicide reattempt is a quite critical risk factor for successful suicide. Moreover, the current situation regarding whether and how emergency center personnel refer suicide attempters to mental health services for psychiatric assessments and interventions is unclear. Therefore, this study investigated the rate at which emergency centers, after providing primary first aid, refer suicide attempters to mental health services and examined whether a history of past suicide attempts was a critical factor in this referral.

2. Methods This cross-sectional study examined suicide attempters visiting five tertiary general hospitals in Seoul that served a population of 1 million as of mid-2008. Patients who met one or more of the following criteria were included in this study: (a) confirmed as a suicide attempter by objective information from the patient, guardians or rescuers; (b) denied making a suicide attempt, but the medical staff thought the person had attempted to commit suicide; (c) lost consciousness following a suicide attempt and was hospitalized, followed by death, or died during treatment and (d) confirmed as a suicide attempter but was transferred to a primary care hospital because the patient could not be accepted by the emergency center due to the low severity of his or her condition. We excluded suicide attempters who were not of Korean nationality. We recruited the study sample between May 15, 2007, and December 15, 2007. It comprised 324 persons who had attempted suicide. Of these, 95.7% (310 persons) consented to take part in this study after receiving a full explanation of the procedure and providing written informed consent. This study was approved by the Institutional Review Board of the Catholic University of Korea. One resident in emergency medicine from each emergency center carried out the assessments using a structured questionnaire. The questionnaire covered the patient's history of psychiatric treatment, family history of suicide, past suicide attempts, lethality of the suicide attempt, suicidal intention and sociodemographic variables. Among the sociodemographic characteristics, we divided age into categories of less than 30 years, 30–39 years and over 40 years for the following reasons. In Korea, persons in their teens and 20s experience fierce competitions, such as college entrance examinations and job seeking. In addition, most young adults live with their parents before marriage until they are around 30 years old (age at first marriage averages 31.6 years in males and 28.7 years in females) [24]. Considering these circumstances, suicidal trends can differ with a standard of age of around 30 years. Furthermore, according to the 2006 Epidemiological Survey on Psychiatric Illness in Korea, the 1-year prevalence of

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mental disorders, except nicotine use disorder, was 14.8%, 13.7% and 11.9% or less in persons aged 18–29 years, 30– 39 years and over 40 years, respectively. Since one of the critical factors in suicide is presence of a mental disorder, dividing age with a standard of around 40 years is considered meaningful. We asked participants whether they had attempted suicide and, if so, how many times. Then we dichotomized each history of suicide attempts as (1) first attempt or (2) repeated attempt. We enrolled these suicide attempters via five emergency centers and categorized the five centers into three groups according to their affiliation with a medical school: (1) C University, (2) Y University or (3) K University. To assess suicide attempt lethality, we used the risk– rescue ratio; the higher the ratio is, the more severe the lethality is. The “risk” domain refers to the method used and the actual damage sustained during a single attempt and comprises five factors: agent used, impaired consciousness, lesions/toxicity, reversibility and treatment required. The “rescue” domain means the observable circumstances and available resources present at the time of the attempt and comprises five factors: location, person initiating rescue, probability of discovery by any rescuer, accessibility to rescue and delay until discovery. The ratio of risk to rescue is a balance of calculated factors related to the degree of irreversible damage and to the resources facilitating or hindering rescue. This ratio can be used to assess an attempt's relative seriousness [25]. Suicidal intent refers to the subjective expectation and desire that a self-destructive act will end in death, and the Suicide Intent Scale, a 15-item questionnaire designed to assess the severity of the suicidal intention associated with an episode of self-harm, can measure intent [26]. In this study, we used a single question (out of 15) to assess suicidal intention, which directly addressed subjective expectations of the results of a suicide attempt. Participants were asked to choose one of three categories: (0) did not want to die, (1) did not care whether he/she lived or died and (2) wanted to die. In addition, we dichotomized this item in terms of the presence of a desire for death: a score of 2 indicated presence, and a score of 1 or below indicated absence. The correlation coefficient between this single question and the entire Suicide Intent Scale was 0.744 (Pb.001). We divided management after critical care at an emergency center into two domains: referral or nonreferral to mental health services. Referral to mental health services meant hospitalizing the patient in a psychiatric ward, making an appointment for the patient to see a psychiatrist as an outpatient or referring the patient to the aftercare services of the Seoul Suicide Prevention Center. We counted patients hospitalized in other wards as a result of physical trauma as referral cases because we ascertained these cases would receive referrals to the psychiatrist of the same hospital. A voluntary discharge from the

emergency center or referral to the emergency center of a secondary hospital or clinic was a nonreferral. Statistical analyses were conducted with SPSS version 12.0, and missing data were excluded from the analyses. Univariate analyses were initially conducted via χ2 tests to generate candidate variables for entry into a multivariate analysis. We introduced significant (Pb.05) or nearly significant (Pb.01) independent variables from the univariate analyses into multiple logistic regression analyses. Also, the emergency center and history of suicide attempts were included in the multiple logistic regression analyses as independent variable, although they were not significant in the univariate χ2 test, since emergency center categories could be an important variable influencing referral to mental health services and suicidal history was a main independent variable in this study. Suicide attempt lethality was included in the multivariate analysis because it was both significant in the univariate analysis and also an important variable to confound the association between suicidal history and referral to mental health services.

3. Results Of the subjects, 47.3% were referred to mental health services. Among the sociodemographic variables, age showed a difference in referral rates. The rates for subjects aged less than 30 years and 30–39 years were 43.9% and 40.0%, respectively, and the rate for those over 40 years was the highest, 63.8% (χ2=10.22, P=.006). Otherwise, there were no differences in referral rates according to gender, job, marital status or household composition. When we analyzed the differences in referral rates according to history of psychiatric problems, 45.5% of suicide nonattempters and 50.8% of suicide attempters received referrals to mental health services, yielding no significant difference between the two groups (χ2=.56, P=.454). Experiencing previous psychiatric treatment and family history of suicide also did not show any significant differences in referral rates. Upon analysis of the differences in the referral rates according to suicide attempt-related characteristics, we found that the emergency center visited (χ2=.66, P=.720) and the use of alcohol or drugs showed no significant differences, but arrival times at the emergency center produced different rates. While the referral rate for suicide attempters visiting the center during the daytime, from 6 AM to 6 PM, was 56.8%, the rate for those visiting it from 6 PM to 6 AM was lower, 39.7% (χ2=7.91, P=.005). The group referred to mental health services correlated with a higher suicide lethality (t=−4.36, Pb001), and the group without ambivalence toward living had a higher referral rate than the other group did (χ2=8.34, P=.004; Table 1). We performed multiple logistic regression analyses to determine whether suicide reattempts affected the rate of

S.-J. Jo et al. / General Hospital Psychiatry 33 (2011) 294–299 Table 1 Characteristics of referred vs. nonreferred suicidal person who sought emergency center after emergency treatmenta Variable

n

Not referred

Referred

n

n

%

Gender Male 83 41 49.4 Female 209 113 54.1 Age ≤29 years 123 69 56.1 30–39 years 100 60 60.0 ≥40 years 69 25 36.2 Occupation Not employed 99 44 44.4 Student or housewife 101 57 56.4 Employed 85 48 56.5 Marital status Single or never married 147 79 53.7 Married or common law 109 55 50.5 Separated, divorced 31 16 51.6 or widowed Single household No 48 25 52.1 Yes 187 98 52.4 History of suicide attempts No 222 121 54.5 Yes 65 32 49.2 History of psychiatric Treatment No 188 101 53.7 Yes 104 53 51.0 Family history of suicideb No 263 144 54.8 Yes 10 3 30.0 Emergency center C University Hospital 122 61 50.0 K University Hospital 74 41 55.4 Y University Hospital 96 52 54.2 Emergency center shift 6 AM to 6 PM 111 48 43.2 174 105 60.3 6 PM to 6 AM Alcohol use No 139 69 49.6 Yes 104 64 61.5 Drug use No 78 43 55.1 Yes 196 101 51.5 Risk–rescue ratio 292 .53±.20 Subjective expectation to suicide attempt Did not want to die or 240 136 56.7 did not care whether he lived or died Wanted to die 52 18 34.6 Total 292 154 52.7 a b

χ2

df P

%

42 50.6 96 45.9

.52 1

.471

54 43.9 10.22 2 40 40.0 44 63.8

.006

55 55.6 44 43.6 37 43.5

3.73 2

.155

68 46.3 54 49.5 15 48.4

.28 2

.871

23 47.9 89 47.6

.00 1

.968

101 45.5 33 50.8

.56 1

.454

87 46.3 51 49.0

.21 1

.651

119 45.2 7 70.0

2.38 1

.195

61 50.0 33 44.6 44 45.8

.66 2

.720

63 56.8 69 39.7

7.91 1

.005

70 50.4 40 38.5

3.40 1

.065

35 44.9 .29 1 95 48.5 .66±.29 −4.36

.590

297

Table 2 Factors influencing the likelihood of aftercare among suicidal attempters who sought emergency center Variable

P

History of suicide attempts Emergency center(vs. C University Hospital) K University Hospital Y University Hospital Age (vs. ≤29 years) 30–39 years ≥40 years Night shift to emergency center (vs. 6 AM to 6 PM) History of psychiatric treatment Alcohol use Risk–rescue ratio Wanted to die (vs. did not want to die or did not care whether he lived or died)

.111 1.74

.88–3.43

.446 .973

.40–1.50 .49–2.00

.668 .710 .053 .946 .260 .014 .056

OR

.77 .99

95% CI

.87 .46–1.65 1.16 .52–2.59 1.77 .99–3.15 .98 .53–1.82 .72 .40–1.28 5.22 1.40–19.50 2.07 .98–4.36

OR, odds ratio.

(P=.111; 95% confidence interval [CI] .88–3.43). Emergency center visited also did not reveal any significant differences in the referral rates. The referral rate for suicide attempters arriving at the emergency center during the daytime was 1.77 times higher than that for those arriving during the nighttime, and this difference was marginally significant (P=.053; 95% CI .99–3.15).

4. Discussion

104 43.3

b.001

8.34 1

.004

34 65.4 138 47.3

Cell numbers vary on the basis of availability of complete data. Fisher's Exact Test.

referral to mental health services among suicide attempters visiting emergency centers, and Table 2 shows the results. When we controlled for certain important variables, such as suicide attempt lethality, the referral rate for suicide reattempters was 1.74 times higher than that for first suicide attempters, but the difference was not significant

Suicide can be primarily prevented with strategies for the general population, and its secondary prevention is possible through interventions for suicide attempters who attempted suicide but did not complete it [27]. The importance of psychological autopsy in studies on suicide is not widely recognized in Korea; Japan shows a similar tendency [28]. However, research on suicide attempts can enhance clinicians' and researchers' understanding of suicide because a person with a failed suicide attempt is at a high risk of future suicide [9–13,29], and medically serious suicide attempters and those dead due to suicide reportedly have common characteristics, constituting two overlapping populations [30,31]. Continuous care for suicide attempters has the potential to prevent suicide [32]. The emergency center may be the first place where suicide attempters receive health care. One of the most important elements in suicide risk assessment and management playing a key role in preventing secondary suicide at emergency centers [4,33,34] is the referral of all people presenting with suicide risk, whenever possible, to mental health services. At a minimum, emergency center staff should have a phone consultation with the mental health service [20]. According to the results of this study, 47% of suicide attempters visiting emergency centers were hospitalized, referred to psychiatrists as outpatients or referred to the aftercare services of the Suicide Prevention Center. According to the research of Doshi et al., which analyzed

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the data of the National Hospital Ambulatory Medical Care Survey of the USA, one third of patients visiting emergency centers because of attempted suicide and selfinflicted injury were immediately hospitalized. Another one third were transferred to other facilities, and the remaining one third were referred to other providers or settings, such as social services [4]. Likewise, the rates of referral to facilities providing mental health services for suicide attempters visiting emergency centers differed according to region because applied guidelines or common practices differed according to country or region [4,35,36]. While any suicide attempt deserves referral for a psychiatric evaluation [36–39] since suicide reattempters increase the risk for subsequent attempts [15,16] and previous attempters who required hospitalization are 21–25 times more likely to die in a subsequent attempt [17], referral for psychiatric evaluation at emergency center is more critical [15,17–19]. However, this study's finding that suicide reattempt did not correlate with referral to mental health services was not similar to that of previous studies. In Korea, there are no detailed emergency center strategies for suicide prevention, and there is still prejudice against seeking psychiatric help. Moreover, the suicide attempt has not been recognized as a critical event connected to completed suicide among the general population. In the meantime, the results of this study show a higher risk–rescue ratio associated with a more probable referral to aftercare. This was likely because the higher suicide attempt lethality made the suicide attempter's family realize that the seriousness of the patient's mental condition needed psychiatric intervention. The group who “wanted to die” as a subjective expectation of their suicide attempt's outcome was more often referred to aftercare, and this difference was nearly statistically significant. Why did suicide attempters who said they “wanted to die” show a higher rate of referral to aftercare than did those who did not want to die, even though they wanted to die? Regarding this issue, one possible explanation is that they did not want to die actually [40]. Another possible explanation is that the persons who wanted to die at the time of their suicide attempt could feel their ambivalence toward life after the suicide attempt. This study found that the emergency center day shift's referral rate was higher than that of the night shift, and the difference was marginally significant. This tendency is one reason why health care providers at such centers found it hard to obtain necessary, relevant information for making an appropriate treatment plan and to cooperate with other providers during nighttime [4]. Further studies on the association between the severity of suicide attempters visiting emergency center and their rates of referral to mental health services according to time of day are necessary.

5. Conclusions Providing care to survivors of suicide attempts is important for suicide prevention, and the cases of repeated suicide attempters deserve special emphasis. Nevertheless, providers have not dealt with suicide attempt history as a critical factor for referrals to mental health services. More effort is needed to systemize emergency center psychiatric interventions for suicide reattempters in Korea. Acknowledgments This study was supported by Seoul Mental Health Center and a grant of the Korea Healthcare technology R&D Project, Ministry for Health, Welfare, & Family Affairs, Republic of Korea (A05–0047–B50704–05N1–00050B). References [1] Korean National Statistical Office. 2008 Cause of death. Seoul: Korean National Statistical Office; 2009. [2] Jung SH. The socioeconomic burden of suicide and depression in South Korea. Seoul: National Seoul Hospital; 2005. [3] Mann JJ. A current perspective of suicide and attempted suicide. Ann Intern Med 2002;136:302–11. [4] Doshi A, Boudreaux ED, Wang N, Pelletier AJ, Camargo CA. National study of US emergency department visits for attempted suicide and self-inflicted injury, 1997–2001. Inj Prev 2005;46(4):369–75. [5] Bertolote JM, Fleischmann A, De Led D, Wasserman D. Psychiatric diagnosis and suicide: revisiting the evidence. Crisis 2005;26:192–3. [6] Nielsen AS, Bille-Brahe U, Hjelmeland H, Hensen B, Ostamo A, Salander-Renberg E, et al. Alcohol problems among suicide attempters in the Nordic countries. Crisis 1996;17:157–66. [7] Persson ML, Runeson BS, Wasserman D. Diagnoses, psychosocial stressors and adaptive functioning in attempted suicide. Ann Clin Psychiatry 1999;11:119–28. [8] Colucciello S, Hockberger RS. Suicide. In: Rosen P, editor. Emergency medicine: concepts and clinical practice, 4th ed, Vol 3. St. Louis, MO: Mosby-Year Book; 1998. p. 2863–71. [9] Moscicki E. Epidemiology of suicide. In: Jacobs DG, editor. The Harvard Medical School guide to suicide assessment and intervention. San Francisco, CA: Jossey–Bass; 1999. p. 40–71. [10] Maris RW, Berman AL, Silverman MM. Comprehensive textbook of suicidology. New York: The Guilford Press; 2000. [11] McIntosh JL. USA suicide: 1999 official final data. www.iusb.edu/ ~jmcintos/USA99Summary.htm (accessed 16 Dec 2009). [12] Iribarren C, Sidney S, Jacobs DR, Weisner C. Hospitalization for suicide attempt and completed suicide: epidemiological features in a managed care population. Soc Psychiatry Psychiatr Epidemiol 2000;35:288–96. [13] Shafii M, Carrigan S, Whittinghill JR, et al. Psychological autopsy of completed suicide in children and adolescents. Am J Psychiatry 1985;142:1061–4. [14] Clark DC, Gibbons RD, Fawcett J, Scheftner WA. What is the mechanism by which suicide attempts predispose to later suicide attempts? A mathematical model. J Abnorm Psychol 1989;98(1):42–9. [15] Wong JPS, Stewart SM, Claassen C, Lee PWH, Rao U, Lam TH. Repeat suicide attempts in Hong Kong community adolescents. Soc Sci Med 2008;66:232–41. [16] Van Aalst JA, Shotts SD, Vitsky JL, Bass SM, Miller RS, Meador KG, et al. Long-term follow-up of unsuccessful violent suicide attempts: risk factors for subsequent attempts. J Trauma 1992;33:457–64.

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