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Patients who attempted suicide and failed to attend mental health centres
Eur Psychiatry 1999 ; 14 : 205-9 © Elsevier, Paris
ORIGINAL ARTICLE
Patients who attempted suicide and failed to attend mental health centres J. Jauregui1, M.L. Martínez2, G. Rubio1, J. Santo-Domingo2 Sagrado Corazón Hospital, C/ Jardines, n° 1; Ciempozuelos, Madrid, Spain
1
2
Psychiatric Service, La Paz University Hospital, 283 500
(Received 27 October 1998; final version 27 April 1999; accepted 3 May 1999)
Summary – Different studies report non-attendance to treatment of between 20 to 70% of patients after a suicide attempt. However, few studies have analyzed the characteristics of this non-attending population. To determine therefore the characteristics or profile of individuals who do not attend outpatient centres to which they are referred after a suicide attempt, we performed this study. A total of 232 patients who had attended the Emergency Department of our general hospital were interviewed. Instruments used included the suicide risk scale, the violent behaviour scale, the impulsivity scale, the hopelessness scale, and the Beck’s depression scale. Seventy-three percent of the sample did not attend the mental health centre to which they had been referred. In comparison to the attending group, the non-attending group had the following characteristics: unmarried, residing in an urban area, took less precautions not to be discovered, were more critical of the attempt, and the purpose of the attempt was to resolve a conflict. Our data emphasize the importance of social and interpersonal aspects in determining the nature of the psychiatric care required by these types of patients. © 1999 Elsevier, Paris prevention / suicide / suicide attempts
INTRODUCTION
Suicide and attempted suicide are an important problem for European health services today. Attempted suicide is a frequent motive for psychiatric consultations in general hospitals [1-3]. In the psychiatric service of La Paz Hospital, it constitutes 17.4% of psychiatric emergencies. Some authors consider that the most suitable therapeutic procedure for patients who have attempted suicide is for these patients to systematically attend psychiatric consultation [3]. However, others suggest that suitably trained and experienced non-medical staff (social workers and nursing staff) can adequately assess and treat these kinds of patients [4].
During the first year after a suicide attempt the risk of death by suicide is about 1% [5]. Authors who have studied the autopsies of individuals who have committed suicide have observed that almost half of these patients presented evidence of having made at least one previous suicide attempt (42% according to Beskow, and 60% according to Runeson) [6]. These findings suggest that individuals who attempt suicide should be a target group in its prevention, especially during the first year after the attempt which constitutes a high risk period. The objective of our study was to: (1) study the rate of assistance in community mental health services of the suicide attempts of patients referred from the general hospital; and, (2) identify the characteristics of the patient not attending the group in order to promote prevention strategies.
206
J. Jauregui et al.
MATERIAL AND METHODS Sample This study was conducted at the Psychiatric Department of La Paz Hospital, a Madrid health centre that serves approximately 500,000 people. All patients who attended the Emergency Department of our general hospital for attempted suicide or suicidal intentions were psychiatrically assessed. A one year follow-up study of 232 patients attending the Emergency Department of our hospital was carried out from July 1993 to December 1994. Patients directly admitted to the Intensive Care Unit were not included in the study. After the attempt, patients were either discharged or admitted to the Psychiatric Unit of the hospital. In both cases, on discharge all patients completed the questionnaires used in the study. Psychiatric diagnosis was made according to CIE-10 criteria [7]. Instruments An interview was designed to assess suicidal behaviour in our general hospital. The resident psychiatrists participating in the study all attended the same training course on interviewing patients who had attempted suicide. Interview data were recorded in a questionnaire that included the following sections: (1) sociodemographic data; (2) circumstances related to the suicide attempt: method used, precautions taken to prevent discovery, signs of intent to commit suicide, purpose, criticism after the attempt, the psychiatrist’s reaction to the patient after the attempt; (3) important events occurring in the six months prior to the attempt; (4) personal background; and, (5) family background. Each section contained a series of direct and open questions which enabled the interviewer to obtain the information necessary to complete the questionnaire. Scales The suicide risk scale (SR) [8] consisted of a selfapplied questionnaire designed and validated by Plutchick et al. [10]. The Spanish version [9] had a reliability of 0.90. The violent behaviour scale (VB) [10] was a selfapplied questionnaire designed and validated by Plutchick and Van Praag [10]. In the initial validation of the questionnaire with psychiatric patients it had a
reliability of 0.77, and the Spanish version had a reliability of 0.87 [11]. The impulsivity scale (IS) [12] consisted of a selfapplied questionnaire that was designed by Plutchick and Van Praag [10]. The Spanish version had a high reliability (Cronbach alpha of 0.90) [13]. The Beck’s hopelesness scale (HS) [14] and the Beck’s depression inventory (BDI) [15] (a shortened version with 13 items) were also used. Follow-up One year after the first evaluation, attendance at the outpatient centres of patients who had been referred from the Emergency Department or the Hospital Psychiatric Unit was recorded. The clinical record of the patients in each of the outpatient centres was consulted. The patient was classed as an ‘attender’ if he had visited the centre within three months of referral. Statistical procedure Qualitative variables were compared using the chisquare test and quantitative variables by analysis of variance (ANOVA). Discriminant variables between attenders and non-attenders were introduced in a forward logistic regression model. The statistical package SPSS-PC was applied. RESULTS Of the 232 patients attending the Emergency Department, 70.4% were referred to their corresponding mental health centre (MHC), 23.1% were admitted for psychiatric hospitalization, and 6.5% were referred to other centres. A total of 75% of patients did not attend the mental health centre to which they were referred (n = 174). Sociodemographic data From table I, the group with the poorest attendance at their MHC was predominated by 30 year old unmarried women of urban residence and of middle socioeconomic class. The only statistically significant variables were unmarried status in the non-attendance group and rural dwelling in the subjects who attended these centres. Table II shows the characteristics of the suicide attempts. The method predominantly used in both groups was drug overdose and most attempts had
207
Patients who attempted suicide and failed to attend mental health centres Table I. Socio-demographic characteristics of the sample of suicide attempters referred for psychiatric consultations. Variables
Attenders at the mental health centre (n = 58)/%
Gender - female: n (%) Age (x ± SD) Civil status Married Unmarried Other Residence Town Country Socio-economic level I. Middle grade, professionnals II. Administrative workers and skilled workers III. Non-skilled workers Education Primary Technical college/secondary education University
39 (67.2) 33.8 ± 14.2
Non-attenders at the mental health centre (n = 174)/% 68.3% 31.1 ± 14.3
27 (47.0) 19 (33.0) 12 (20.0)
43 (24.7) 104 (59.8)* 27 (15.5)
47 (81.0) 11 (19.0)
161 (92.5) 13 (7.5) 31 (17.8) 81 (46.6) 62 (35.6)
7 (12.1) 31 (53.4) 20 (35.5) 35 (60.3) 17 (29.3) 6 (10.3)
104 (59.8) 42 (24.1) 28 (16.1)
* P > 0.05.
not been planned previously. Non-attenders had taken few precautions to prevent discovery and had made little criticism of the attempt afterwards. With regards to the purpose of the attempt, this was generally related to the desire to hurt themselves, to escape from suffering, or to resolve a conflict. There was no significant difference between the scores obtained by the two patient groups in the scales. However, non-attenders scored lower in the impulsivity and violent conduct scales. In the non-attenders, 66.5% had a personal background of psychiatric
problems, 59.2% had a family psychiatric background, and 36% had previously attempted suicide. In attenders, these values were 75, 54.3, and 52% respectively. The differences between these groups were not statistically significant. Adaptative disorders were the most common psychiatric diagnosis in both groups (88.0 vs. 78.1%), followed by substance abuse (5.1 vs. 12%). No diagnosis was discriminative between both groups. Regarding the events occurring in the six months before the attempt, family problems were the most
Table II. Characteristics of the suicide attempters referred for psychiatric consultations. Variables Method used Drug overdose Other methods No previous planing Precautions not to be discovered Patient’s reaction to the attempt No criticism of the attempt Partial or total criticism of the attempt Purpose of attempt revealed by patient Death Escape suffering Resolve a conflict Others * P < 0.05.
Attenders at the mental health centre (n = 58)/%
Non-attenders at the mental health centre (n = 174)/%
51 (87.9) 7 (12.1) 57 (98.2) 17 (29.3)
141 (81.0) 33 (18.9) 169 (97.1) 18 (10.3)
19 (32.7) 39 (67.2)
25 (14.3) 149 (85.6)
29 (50.0) 21 (36.2) 4 (6.8) 4 (6.8)
78 (44.8) 43 (24.7) 21 (12.1)* 32 (18.4)
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J. Jauregui et al.
Table III. Variables that enter the logistic regression model to explain the low assistance at the mental health centre of suicide attempters. Variable Urban residence Total or partial criticism of the attempt Purpose of the attempt
Odds ratio adjusted for other variables
Confidence interval (95%)
P
2.3 2.7 2.3
16.09–14.51 7.14– 4.66 5.40– 3.40
0.05 0.01 0.04
prevalent in both groups (90.4% vs. 93.5%; χ2 = 0.19, df = 1, P = 0.65), followed by work-related problems (66% vs. 68%; χ2 = 0.02, df = 1, P = 0.89). The variables used in the logistic regression model to predict attendance at the medical health center were: urban residence, total or partial criticism of the attempt afterwards, and resolution of a conflict as a motive for the attempt (table III). The chi-square value for the model was 12.3. DISCUSSION Of our sample, 73.3% of the patients did not attend the outpatient centre to which they were referred. The main impediment for the secondary prevention of suicide attempts was the fact that approximately twothirds of these patients did not attend appointments at the outpatient centres, in spite of previous agreement to do so when in hospital [16]. This difficulty has been described in other studies in which rates of attendance ranging from 20–70% have been reported [17-19]. Our figures are within the range described. To our knowledge there is no reference in the literature as to the characteristics of non-attenders at outpatient centres after a suicide attempt. In our study, the prototype non-attender was a 30 year old unmarried woman of urban residence and middle socio-economic level. The method used was drug overdose without previous planning, no precautions were taken to prevent discovery, and in most cases the intention was fatal. Variables associated with nonattendance were: urban residence, total or partial criticism of the attempt, and the resolution of a conflict as a motive. Traditionally, higher suicide rates are recorded in urban areas although in some countries these differences are no longer found. The urban environment is complex and conflictive due to a number of factors: social isolation and anonymity, little feeling of belonging to a group (family, work team, political, or religious group), and problems related to competition and employment. These circumstances could favour a
decreased motivation or pressure to attend the outpatient treatment centres. Regarding the patient’s criticism of the attempt, a number of aspects must be taken into account. On the one hand, most of the subjects who did not consider themselves suffering from a serious psychiatric disorder had adaptative disorders with difficulty in dealing with a range of problems. Given the non-severity of their disorders, the failure of these patients to attend could be because they consider mental health centres as unsuitable to treat their kind of problem. Also, the fact that their treatment is not pharmacological could result in these patients underestimating the importance of their disorder and, in consequence, not attending treatment. With regards to the motive for the suicide attempt, in most non-attenders this was associated with a family conflict. In these cases, the attempt itself could, at least partially, resolve the problem as follows: (1) by increasing the attention paid to the patient by the family; (2) by more discussion, negotiation and possible resolution of the problem; and, (3) guilty feelings could either increase the patient’s effort to resolve the problem or postpone its resolution. These factors could therefore lead to the generation of a new equilibrium, and the patient could now consider it unnecessary to attend the medical health center. Some studies have found an association between suicide risk and modes of confrontation, such as low minimization [20] and the external locus of control [21]. One would expect these behaviours to generate strong anxiety and a feeling of inability to resolve conflicts alone. The suicide attempt would therefore decrease this anxiety and facilitate the participation of others in the resolution of the conflict. From our results, one could hypothesize that patients did not attend the centres because of a discordance between the help offered (psychiatric treatment), and their idea of suitable strategies to resolve their problem. One measure of the efficacy of the assessment and treatment procedures is in the levels of assistance at the outpatient centres [4]. Levels of assistance recorded in our study are very low (although they are within the
Patients who attempted suicide and failed to attend mental health centres
range described in the literature), which leads us to question the services offered to attend to these kinds of problems. Here, only psychiatric treatment was offered to patients both in hospital and in outpatient centres. A new approach could consist of a multidisciplinary team such as that proposed by Hawton in 1979 [4]. In this case, most of the evaluation and treatment is carried out by non-medical staff (a nurse and social workers), supervised closely by a psychiatrist. Therefore, patients can receive the most appropriate assistance with a minimum delay. The main conclusions of these authors after a six year study were that: (1) if trained correctly the non-medical staff can suitably assess and treat patients; (2) the care offered by this kind of team appears to meet the patients’ needs since most of the patients do not suffer a psychiatric disorder, but are rather under stress because of social and interpersonal problems; and, (3) patient attendance at the outpatient centres is high. One of the methodological limitations of our study was a bias in the sample. The more serious patients tended to be admitted to the intensive care unit whereas the others were referred directly to the psychiatric hospital. This would explain the low prevalence of psychotic disorders in our sample. Like other authors, we also believe that protective factors should be based on the nature of the psychiatric care offered. Planning for community care should emphasize early detection and preventive care in high risk patients. A priority in research into the community care of suicide is to study the relation between suicide and the psychiatric services including their location, nature, and referral procedure involved [22]. Clinical evaluation that considers both the disorder and the circumstance of the patient is still the primary preventive measure. REFERENCES 1 Hawton K, Catalan J. The nature of attempted suicide. In: Hawton K, Catalan J, eds. Attempted suicide, a practical guide to its nature and management. New York: Oxford University Press; 1987. p. 725. 2 Sarro B, Cruz C. Introduccion. In: Sarro B, Cruz C, eds. Los suicidios. Barcelona: Ediciones Martínez Roca; 1991. p. 136.
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3 Suokas J, Lönnqvist J. Selection of patients who attempted suicide for psychiatric consultation. Acta Psychiatr Scand 1991 ; 83 : 179-82. 4 Hawton K, Gath D, Smith E. Management of attempted suicide in Oxford. Br Med J 1979 ; 2 : 1040-2. 5 Hawton K. Assesment of suicide risk. Br J Psychiatry 1984 ; 144 : 139-48. 6 Nordström P, Samuelsson M, Asberg M. Survival analysis of suicide risk after attempted suicide. Acta Psychiatr Scand 1995 ; 91 : 336-40. 7 World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; 1992. 8 Plutchik R, VanPraag HM, Conte HR, Pichard S. Correlates of suicide and violent risk (I): the suicide risk measure. Compr Psychiatr 1990 ; 30 : 296-302. 9 Rubio G, Montero I, Jauregui J, Martinez ML, Marin JJ, Antodomingo J. Validación de la Escala de Riesgo Suicida de Plutchick en población española. Arch Neurobiol (Madr) 1998 ; 61 : 143-52. 10 Plutchick R, VanPraag HM, Conte HR. A self-report measure of violent risk (II). Compr Psychiatr 1990 ; 31 : 450-6. 11 Rubio G, Montero I, Jauregui J, Perez P, Marin JJ, Santodomingo J. Validación de la Escala de Riesgo de Violencia de Plutchick en población española. Arch Neurobiol (Madr) 1998 ; 61 : 307-16. 12 Plutchick R, VanPraag HM. The measurement of suicidality, aggressivity, and impulsivity. Prog Neuropsychopharmcol Biol Psychiatr 1989 ; 13 : 23-4. 13 Rubio G, Montero I, Jauregui J, Salvador M, Marin JJ, Santodomingo J. Validación de la Escala de Impulsividad de Plutchick en población española. Arch Neurobiol (Madr) 1998 ; 61 : 223-32. 14 Beck AT, Weissman A, Lester D, Trexler J. The measurement of pessimism: the hopelessness scale. J Consult Clin Psychol 1974 ; 42 : 861-5. 15 Beck AT, Rial WY, Rickels K. Short form of depression inventory (cross-validation). Psychol Reports 1974 ; 34 : 1184-6. 16 Morgan HG, Jones EM, Owen JH. Secondary prevention of non-fatal deliberate self-harm. The green card study. Br J Psychiatry 1993 ; 163 : 111-2. 17 Blake DR, Mitchell JR. Self-poisoning management of patients in Nottingham. Br Med J 1978 ; 1 : 1032-5. 18 Platt S, Bille-Brahe E, Berkof A, Schmidtke A, Bjerki T, Crepet P, et al. Parasuicide in Europe: the WHO/EURO multicentre study on parasuicide I. Introduction and preliminary analysis for 1989. Acta Psychiatr Scand 1992 ; 85 : 97-104. 19 Greer S, Cristopher B. Effect of psychiatric intervention in attempted suicide. Br Med J 1971 ; 1 : 310-2. 20 Pearce CM, Martin G. Locus of control as an indicator of risk for suicidal behaviours among adolescents. Acta Psychiatr Scand 1993 ; 88 : 409-14. 21 Moshe K, Plutcher RC, Comte HR, Van Praag HM. Correlates of suicide and violence risk in an inpatient population: coping styles and social support. Psychiatr Res 1996 ; 47 : 281-90. 22 Appleby L. Suicide in psychiatric patients: risk and prevention. Br J Psychiatry 1992 ; 161 : 749-58.
ORIGINAL ARTICLE
Patients who attempted suicide and failed to attend mental health centres J. Jauregui1, M.L. Martínez2, G. Rubio1, J. Santo-Domingo2 Sagrado Corazón Hospital, C/ Jardines, n° 1; Ciempozuelos, Madrid, Spain
1
2
Psychiatric Service, La Paz University Hospital, 283 500
(Received 27 October 1998; final version 27 April 1999; accepted 3 May 1999)
Summary – Different studies report non-attendance to treatment of between 20 to 70% of patients after a suicide attempt. However, few studies have analyzed the characteristics of this non-attending population. To determine therefore the characteristics or profile of individuals who do not attend outpatient centres to which they are referred after a suicide attempt, we performed this study. A total of 232 patients who had attended the Emergency Department of our general hospital were interviewed. Instruments used included the suicide risk scale, the violent behaviour scale, the impulsivity scale, the hopelessness scale, and the Beck’s depression scale. Seventy-three percent of the sample did not attend the mental health centre to which they had been referred. In comparison to the attending group, the non-attending group had the following characteristics: unmarried, residing in an urban area, took less precautions not to be discovered, were more critical of the attempt, and the purpose of the attempt was to resolve a conflict. Our data emphasize the importance of social and interpersonal aspects in determining the nature of the psychiatric care required by these types of patients. © 1999 Elsevier, Paris prevention / suicide / suicide attempts
INTRODUCTION
Suicide and attempted suicide are an important problem for European health services today. Attempted suicide is a frequent motive for psychiatric consultations in general hospitals [1-3]. In the psychiatric service of La Paz Hospital, it constitutes 17.4% of psychiatric emergencies. Some authors consider that the most suitable therapeutic procedure for patients who have attempted suicide is for these patients to systematically attend psychiatric consultation [3]. However, others suggest that suitably trained and experienced non-medical staff (social workers and nursing staff) can adequately assess and treat these kinds of patients [4].
During the first year after a suicide attempt the risk of death by suicide is about 1% [5]. Authors who have studied the autopsies of individuals who have committed suicide have observed that almost half of these patients presented evidence of having made at least one previous suicide attempt (42% according to Beskow, and 60% according to Runeson) [6]. These findings suggest that individuals who attempt suicide should be a target group in its prevention, especially during the first year after the attempt which constitutes a high risk period. The objective of our study was to: (1) study the rate of assistance in community mental health services of the suicide attempts of patients referred from the general hospital; and, (2) identify the characteristics of the patient not attending the group in order to promote prevention strategies.
206
J. Jauregui et al.
MATERIAL AND METHODS Sample This study was conducted at the Psychiatric Department of La Paz Hospital, a Madrid health centre that serves approximately 500,000 people. All patients who attended the Emergency Department of our general hospital for attempted suicide or suicidal intentions were psychiatrically assessed. A one year follow-up study of 232 patients attending the Emergency Department of our hospital was carried out from July 1993 to December 1994. Patients directly admitted to the Intensive Care Unit were not included in the study. After the attempt, patients were either discharged or admitted to the Psychiatric Unit of the hospital. In both cases, on discharge all patients completed the questionnaires used in the study. Psychiatric diagnosis was made according to CIE-10 criteria [7]. Instruments An interview was designed to assess suicidal behaviour in our general hospital. The resident psychiatrists participating in the study all attended the same training course on interviewing patients who had attempted suicide. Interview data were recorded in a questionnaire that included the following sections: (1) sociodemographic data; (2) circumstances related to the suicide attempt: method used, precautions taken to prevent discovery, signs of intent to commit suicide, purpose, criticism after the attempt, the psychiatrist’s reaction to the patient after the attempt; (3) important events occurring in the six months prior to the attempt; (4) personal background; and, (5) family background. Each section contained a series of direct and open questions which enabled the interviewer to obtain the information necessary to complete the questionnaire. Scales The suicide risk scale (SR) [8] consisted of a selfapplied questionnaire designed and validated by Plutchick et al. [10]. The Spanish version [9] had a reliability of 0.90. The violent behaviour scale (VB) [10] was a selfapplied questionnaire designed and validated by Plutchick and Van Praag [10]. In the initial validation of the questionnaire with psychiatric patients it had a
reliability of 0.77, and the Spanish version had a reliability of 0.87 [11]. The impulsivity scale (IS) [12] consisted of a selfapplied questionnaire that was designed by Plutchick and Van Praag [10]. The Spanish version had a high reliability (Cronbach alpha of 0.90) [13]. The Beck’s hopelesness scale (HS) [14] and the Beck’s depression inventory (BDI) [15] (a shortened version with 13 items) were also used. Follow-up One year after the first evaluation, attendance at the outpatient centres of patients who had been referred from the Emergency Department or the Hospital Psychiatric Unit was recorded. The clinical record of the patients in each of the outpatient centres was consulted. The patient was classed as an ‘attender’ if he had visited the centre within three months of referral. Statistical procedure Qualitative variables were compared using the chisquare test and quantitative variables by analysis of variance (ANOVA). Discriminant variables between attenders and non-attenders were introduced in a forward logistic regression model. The statistical package SPSS-PC was applied. RESULTS Of the 232 patients attending the Emergency Department, 70.4% were referred to their corresponding mental health centre (MHC), 23.1% were admitted for psychiatric hospitalization, and 6.5% were referred to other centres. A total of 75% of patients did not attend the mental health centre to which they were referred (n = 174). Sociodemographic data From table I, the group with the poorest attendance at their MHC was predominated by 30 year old unmarried women of urban residence and of middle socioeconomic class. The only statistically significant variables were unmarried status in the non-attendance group and rural dwelling in the subjects who attended these centres. Table II shows the characteristics of the suicide attempts. The method predominantly used in both groups was drug overdose and most attempts had
207
Patients who attempted suicide and failed to attend mental health centres Table I. Socio-demographic characteristics of the sample of suicide attempters referred for psychiatric consultations. Variables
Attenders at the mental health centre (n = 58)/%
Gender - female: n (%) Age (x ± SD) Civil status Married Unmarried Other Residence Town Country Socio-economic level I. Middle grade, professionnals II. Administrative workers and skilled workers III. Non-skilled workers Education Primary Technical college/secondary education University
39 (67.2) 33.8 ± 14.2
Non-attenders at the mental health centre (n = 174)/% 68.3% 31.1 ± 14.3
27 (47.0) 19 (33.0) 12 (20.0)
43 (24.7) 104 (59.8)* 27 (15.5)
47 (81.0) 11 (19.0)
161 (92.5) 13 (7.5) 31 (17.8) 81 (46.6) 62 (35.6)
7 (12.1) 31 (53.4) 20 (35.5) 35 (60.3) 17 (29.3) 6 (10.3)
104 (59.8) 42 (24.1) 28 (16.1)
* P > 0.05.
not been planned previously. Non-attenders had taken few precautions to prevent discovery and had made little criticism of the attempt afterwards. With regards to the purpose of the attempt, this was generally related to the desire to hurt themselves, to escape from suffering, or to resolve a conflict. There was no significant difference between the scores obtained by the two patient groups in the scales. However, non-attenders scored lower in the impulsivity and violent conduct scales. In the non-attenders, 66.5% had a personal background of psychiatric
problems, 59.2% had a family psychiatric background, and 36% had previously attempted suicide. In attenders, these values were 75, 54.3, and 52% respectively. The differences between these groups were not statistically significant. Adaptative disorders were the most common psychiatric diagnosis in both groups (88.0 vs. 78.1%), followed by substance abuse (5.1 vs. 12%). No diagnosis was discriminative between both groups. Regarding the events occurring in the six months before the attempt, family problems were the most
Table II. Characteristics of the suicide attempters referred for psychiatric consultations. Variables Method used Drug overdose Other methods No previous planing Precautions not to be discovered Patient’s reaction to the attempt No criticism of the attempt Partial or total criticism of the attempt Purpose of attempt revealed by patient Death Escape suffering Resolve a conflict Others * P < 0.05.
Attenders at the mental health centre (n = 58)/%
Non-attenders at the mental health centre (n = 174)/%
51 (87.9) 7 (12.1) 57 (98.2) 17 (29.3)
141 (81.0) 33 (18.9) 169 (97.1) 18 (10.3)
19 (32.7) 39 (67.2)
25 (14.3) 149 (85.6)
29 (50.0) 21 (36.2) 4 (6.8) 4 (6.8)
78 (44.8) 43 (24.7) 21 (12.1)* 32 (18.4)
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J. Jauregui et al.
Table III. Variables that enter the logistic regression model to explain the low assistance at the mental health centre of suicide attempters. Variable Urban residence Total or partial criticism of the attempt Purpose of the attempt
Odds ratio adjusted for other variables
Confidence interval (95%)
P
2.3 2.7 2.3
16.09–14.51 7.14– 4.66 5.40– 3.40
0.05 0.01 0.04
prevalent in both groups (90.4% vs. 93.5%; χ2 = 0.19, df = 1, P = 0.65), followed by work-related problems (66% vs. 68%; χ2 = 0.02, df = 1, P = 0.89). The variables used in the logistic regression model to predict attendance at the medical health center were: urban residence, total or partial criticism of the attempt afterwards, and resolution of a conflict as a motive for the attempt (table III). The chi-square value for the model was 12.3. DISCUSSION Of our sample, 73.3% of the patients did not attend the outpatient centre to which they were referred. The main impediment for the secondary prevention of suicide attempts was the fact that approximately twothirds of these patients did not attend appointments at the outpatient centres, in spite of previous agreement to do so when in hospital [16]. This difficulty has been described in other studies in which rates of attendance ranging from 20–70% have been reported [17-19]. Our figures are within the range described. To our knowledge there is no reference in the literature as to the characteristics of non-attenders at outpatient centres after a suicide attempt. In our study, the prototype non-attender was a 30 year old unmarried woman of urban residence and middle socio-economic level. The method used was drug overdose without previous planning, no precautions were taken to prevent discovery, and in most cases the intention was fatal. Variables associated with nonattendance were: urban residence, total or partial criticism of the attempt, and the resolution of a conflict as a motive. Traditionally, higher suicide rates are recorded in urban areas although in some countries these differences are no longer found. The urban environment is complex and conflictive due to a number of factors: social isolation and anonymity, little feeling of belonging to a group (family, work team, political, or religious group), and problems related to competition and employment. These circumstances could favour a
decreased motivation or pressure to attend the outpatient treatment centres. Regarding the patient’s criticism of the attempt, a number of aspects must be taken into account. On the one hand, most of the subjects who did not consider themselves suffering from a serious psychiatric disorder had adaptative disorders with difficulty in dealing with a range of problems. Given the non-severity of their disorders, the failure of these patients to attend could be because they consider mental health centres as unsuitable to treat their kind of problem. Also, the fact that their treatment is not pharmacological could result in these patients underestimating the importance of their disorder and, in consequence, not attending treatment. With regards to the motive for the suicide attempt, in most non-attenders this was associated with a family conflict. In these cases, the attempt itself could, at least partially, resolve the problem as follows: (1) by increasing the attention paid to the patient by the family; (2) by more discussion, negotiation and possible resolution of the problem; and, (3) guilty feelings could either increase the patient’s effort to resolve the problem or postpone its resolution. These factors could therefore lead to the generation of a new equilibrium, and the patient could now consider it unnecessary to attend the medical health center. Some studies have found an association between suicide risk and modes of confrontation, such as low minimization [20] and the external locus of control [21]. One would expect these behaviours to generate strong anxiety and a feeling of inability to resolve conflicts alone. The suicide attempt would therefore decrease this anxiety and facilitate the participation of others in the resolution of the conflict. From our results, one could hypothesize that patients did not attend the centres because of a discordance between the help offered (psychiatric treatment), and their idea of suitable strategies to resolve their problem. One measure of the efficacy of the assessment and treatment procedures is in the levels of assistance at the outpatient centres [4]. Levels of assistance recorded in our study are very low (although they are within the
Patients who attempted suicide and failed to attend mental health centres
range described in the literature), which leads us to question the services offered to attend to these kinds of problems. Here, only psychiatric treatment was offered to patients both in hospital and in outpatient centres. A new approach could consist of a multidisciplinary team such as that proposed by Hawton in 1979 [4]. In this case, most of the evaluation and treatment is carried out by non-medical staff (a nurse and social workers), supervised closely by a psychiatrist. Therefore, patients can receive the most appropriate assistance with a minimum delay. The main conclusions of these authors after a six year study were that: (1) if trained correctly the non-medical staff can suitably assess and treat patients; (2) the care offered by this kind of team appears to meet the patients’ needs since most of the patients do not suffer a psychiatric disorder, but are rather under stress because of social and interpersonal problems; and, (3) patient attendance at the outpatient centres is high. One of the methodological limitations of our study was a bias in the sample. The more serious patients tended to be admitted to the intensive care unit whereas the others were referred directly to the psychiatric hospital. This would explain the low prevalence of psychotic disorders in our sample. Like other authors, we also believe that protective factors should be based on the nature of the psychiatric care offered. Planning for community care should emphasize early detection and preventive care in high risk patients. A priority in research into the community care of suicide is to study the relation between suicide and the psychiatric services including their location, nature, and referral procedure involved [22]. Clinical evaluation that considers both the disorder and the circumstance of the patient is still the primary preventive measure. REFERENCES 1 Hawton K, Catalan J. The nature of attempted suicide. In: Hawton K, Catalan J, eds. Attempted suicide, a practical guide to its nature and management. New York: Oxford University Press; 1987. p. 725. 2 Sarro B, Cruz C. Introduccion. In: Sarro B, Cruz C, eds. Los suicidios. Barcelona: Ediciones Martínez Roca; 1991. p. 136.
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