بیماران خوداسیبی عمدی که حادثه و اورژانس را بدون ارزیابی روانشناختی ترک کردند: جمعیت مورد غفلت قرار گرفته در معرض خطر خودکشی

Objectives: Deliberate self-harm (DSH) patients, despite their risk of suicide, are often discharged directly from accident and emergency (A&E) departments without undergoing a psychiatric assessment. The aims of this study were to determine the characteristics and outcome of these patients. Methods: The characteristics of DSH patients who were discharged directly from an A&E department over a 2-year period were investigated, comparing those who had a psychiatric assessment with those who did not. In a matched control design, the outcome of a group of patients who did not receive a psychiatric assessment was compared with that of a group of patients who were assessed. Results: Of DSH patients who were discharged directly from the A&E department 58.9% (145/246) did not have a psychiatric assessment. Nonassessed patients were more likely to have a past history of DSH, to be in the 20–34 year age group, and to have exhibited difficult behaviour in the A&E department. Patients presenting between 5 p.m. and 9 a.m. were less likely to be assessed than those attending between 9 a.m. and 5 p.m. Further DSH during the subsequent year occurred in 37.5% of the nonassessed patients compared with 18.2% of matched assessed patients. They were also more likely to have psychiatric treatment. Conclusion: A substantial proportion of DSH patients discharged directly from A&E departments do not receive a psychiatric assessment. Nonassessed patients may be at greater risk of further DSH and completed suicide than those who are assessed. Hospital services need to be organised such that DSH patients managed in A&E departments can receive an assessment of psychosocial problems and risk.

Suicide prevention has been at the forefront of mental health strategy for some years [1] and [2]. Effective management of deliberate self-harm (DSH) patients must be an important element in any suicide prevention policy [3]. This is because of the significant risk of completed suicide following deliberate self-poisoning or self-injury [4], [5], [6] and [7] and the fact that approximately half of all suicides in the United Kingdom have a history of DSH [8] and [9]. In 1984 the Department of Health advised that all patients presenting to hospital with an episode of self-harm should have a psychosocial assessment [10]. However a significant subgroup of such patients leave hospital without receiving an assessment that meets this recommendation [11], patients who are not admitted to hospital being particularly likely not to have an assessment [12]. Direct discharge of DSH patients from accident and emergency (A&E) departments has become increasingly prevalent [13]. Surprisingly little attention has been paid to patients who present to A&E departments following DSH but who do not then receive a psychosocial assessment. The aims of this study were (a) to identify the characteristics of DSH patients leaving hospital without a psychosocial assessment from the psychiatric service, and b) to compare the outcome of these patients over a 12-month period with that of a matched group of patients who received such an assessment. The matching was on some of the characteristics of DSH patients known to be associated with risk of subsequent suicide (gender and age [5]) and repetition (self-injury [14]).