TREATING YOUNG PATIENTS AFTER SELF-HARM

Olfson M, Gameroff MJ, Marcus SC, et al. Emergency treatment of young people following deliberate self-harm. Arch Gen Psychiatry. 2005;62:1122-1128.

Summary

This study examined national patterns in emergency department (ED) treatment of patients aged 7 to 22 years who were seen after episodes of deliberate self-harm. Data were from the 1997-2002 National Hospital Ambulatory Medical Care Survey. Population data from the 2000 US Census Bureau were used to estimate population visit rates for the age group studied.

The national rates of ED visits were determined for the overall population and stratified by sex, age, race, ethnicity, and disposition. The rates of ED visits because of intentional self-inflicted injury by poisoning or cutting/piercing were estimated separately from the overall study group and stratified by age, sex, race, and disposition. ED visits that resulted in inpatient admission were compared with ED visits that resulted in discharge to the community.

Study results showed that the annual incidence of ED visits associated with deliberate self-harm was 225.3 per 100,000 population visits. The number of intentional self-harm ED visits was significantly higher for persons aged 15 to 24 years than for persons aged 7 to 14 years. No significant differences in ED visits were found for sex, ethnicity, or race. The majority of patients were female (56.9%), white (78.4%), and of non-Hispanic origin (82.6%).

Self-inflicted injury by poisoning (67.2%) and cutting/piercing (25.8%) accounted for the majority of self-harm ED visits. Therapy for ingestion was necessary in 41.3% of visits. Approximately 56% of self-harm ED visits resulted in a diagnosis of a mental disorder; depressive disorder was diagnosed in 15.1% of these patients and was strongly associated with inpatient admission, and substance use disorder was diagnosed in 7.3%. Likewise, about 56% of self-harm-related ED visits resulted in inpatient admission.

Commentary

The focus of the February 2005 issue of Psychiatric Issues in Emergency Care Settings was on the growing concern around assessment and treatment of young patients in the psychiatric emergency service (PES). At that time, at least at our local level, I noted that minors accounted for less than 10% of PES volumes in the year 2000; by 2005, that figure had risen to 30%. In the ensuing year, minors accounted for 34% of an ever-expanding total number of patients served.

My colleagues and I speculated about several potential reasons for this increase. One possible explanation is the zero-tolerance policies for violent or self-destructive behavior in schools. However, there was little substantive data upon which to form firmer conclusions.

The study by Olfson and colleagues provides some of that crucial information. Their findings were quite interesting. For example, only slightly more than half (56%) of service recipients received a diagnosis of a mental disorder, and only 1.7% of presentations were firearm-related. Psychotropic medications were provided for 12.1% of patients; the most common medication type was anxiolytics (6.2%). Similar to the percentage of persons with a mental disorder diagnosis, 56.1% of service recipients were admitted to the hospital. These hospital admissions did not differ significantly in terms of sex, age, race, or insurance status.

Although this study provides important information, it does have limitations. Stigma may result in significant underreporting of suicide attempts, and methods for establishing psychiatric diagnoses were not common across sites. Nonetheless, the authors commented on the possibility of "substantial under-recognition of mental illness and likely inadequate referral to follow-up mental health care."

The authors' suggestion of routine administration of brief and clinically useful diagnostic instruments is an excellent one, and they point to work by Lucas and colleagues in that area.¹

Glenn W. Currier, MD, MPH

Associate Professor of Psychiatry and Emergency Medicine

University of Rochester School of Medicine and Dentistry

Medical Director of Hospital Services

Department of Psychiatry

University of Rochester Medical Center

Rochester, NY

References:

REFERENCE

1. Lucas CP, Zhang H, Fisher PW, et al. The DISC Predictive Scales (DPS): efficiently screening for diagnoses.

J Am Acad Child Adolesc Psychiatry.

2001;40:443-449.