Many Self-Harm Patients Don't get Psych Evaluation

Doctors in the emergency room often don't evaluate the mental health of patients who've cut or otherwise hurt themselves before sending them home, a new study shows.

As many as half of patients who aren't admitted to the hospital leave without a psychiatric checkup, and an equal proportion of them don't get follow-up therapy in the next month, researchers found.

Yet those people have higher rates of suicide and are especially vulnerable soon after a self-harm incident, according to researchers led by Dr. Mark Olfson, a psychiatrist at Columbia University in New York.

"If you present to an emergency department with deliberate self-harm, that is something that should receive a mental health assessment during the visit," he told Reuters Health.

Olfson argued that doctors need to look carefully at whether self-harm patients intended to kill themselves and what their risks are going forward.

He and his colleagues examined data from a year's worth of claims made to Medicaid, the government insurance program for the poor.

In 2006, when more than 40 million people were covered by Medicaid, the researchers found 7,400 visits to ERs for self-harm injuries in adults, for example from cutting or overdosing on pills. For 4,600 of those visits, which included multiple visits by the same people, patients were treated and then discharged without being hospitalized.

Less than 48 percent of patients who were discharged after self-harming had a mental health assessment while in the ER. The "lethality" of patients' self-harm attempts, such as if they had shot or burned themselves, versus cutting, didn't dictate how likely they were to get an assessment.

Similarly, about 52 percent of discharged patients had an outpatient mental health care visit in the 30 days after the self-harm incident. Patients who lived in states where Medicaid covered visits to mental health clinics were more likely to get follow-up care than people whose states didn't have those services.

Olfson and colleagues report in the Archives of General Psychiatry that the rate of suicide for people who have recently been hospitalized for self-harm is between 30 and 130 times higher than in the general public.

In the U.S. in 2007, there were about 11 suicide deaths for every 100,000 people, and more than ten times that number attempted suicide.

Still, many people who self-harm don't have any intention of killing themselves, experts say.
Dr. Cameron Crandall, from the University of New Mexico's Department of Emergency Medicine in Albuquerque, said that for patients who self-harm but aren't suicidal, "putting them under a forced evaluation is not always practical or advisable."

The current study, he said, might not reflect some patients who were discharged and referred to their primary care doctors to discuss mental health, without an official psychiatric diagnosis -- which may work fine for people who aren't at high risk.

It's also possible that some people were offered evaluations or follow-up care but turned them down, researchers explained.

Psychiatric patients are a particularly difficult group for emergency doctors to treat, said Dr. Larry Baraff, from the University of California, Los Angeles, Emergency Medicine Center, because it takes a lot of time to determine how serious their condition is, and they present with a range of different medical problems.

"By the time they are in the ER...they frequently say, 'I had thoughts about (suicide), but now I feel better and I'm not going to do it,'" Baraff, who was not involved in the new study, told Reuters Health.

However, for patients who hurt themselves with a gun, for instance, or older males who are at higher risk for suicide, "you really do need psychiatric evaluation," said Crandall, who also did not participate in the new research.

"It would be great if we had rapid and available psychiatric evaluation in the emergency room," he told Reuters Health, adding that ER overcrowding may be hitting psychiatric patients especially hard.

"Emergency departments sometimes are oriented to the next patient who comes in, and they don't have the resources to make those kinds of sustained efforts and follow-up calls," Olfson agreed.

Yet even without the funding for extra mental health practitioners, he added, other ER staff can be trained to do a basic assessment to see if the patient seems suicidal.

Olfson said his team is working on two other studies looking at what happens to teens who land in the ER for self-harm, and to adults who have private insurance.

"There's an opportunity here...for these emergency departments to play an active role in preventing suicide by making adequate assessments and really becoming engaged in what may be lifesaving patient referrals," he told Reuters Health.

"Currently we're falling short."