Impact of the COVID-19 pandemic on suicide and self-harm among patients presenting to the emergency department of a teaching hospital in Nepal.
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SUBMITTER: Shrestha R
PROVIDER: S-EPMC8087018 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundReliable assessment of suicide and self-harm risk in emergency medicine is critical for effective intervention and treatment of patients affected by mental health disorders. Teams of clinicians face the challenge of rapidly integrating medical history, wide-ranging psychosocial factors, and real-time patient observations to inform diagnosis, treatment, and referral decisions. Patient outcomes therefore depend on the reliable flow of information through networks of clinical staff and information systems. This study aimed to develop a quantitative data-driven research framework for the analysis of information flow in emergency healthcare settings to evaluate clinical practice and operational models for emergency psychiatric care.Methods and findingsWe deployed 2 observers in a tertiary hospital emergency department during 2018 for a total of 118.5 h to record clinical interactions along patient trajectories for presentations with risk of self-harm or suicide (n = 272 interactions for n = 43 patient trajectories). The study population was reflective of a naturalistic sample of patients presenting to a tertiary emergency department in a metropolitan Australian city. Using the observational data, we constructed a clinical interaction network to model the flow of clinical information at a systems level. Community detection via modularity maximization revealed communities in the network closely aligned with the underlying clinical team structure. The Psychiatric Liaison Nurse (PLN) was identified as the most important agent in the network as quantified by node degree, closeness centrality, and betweenness centrality. Betweenness centrality of the PLN was significantly higher than expected by chance (>95th percentile compared with randomly shuffled networks) and removing the PLN from the network reduced both the global efficiency of the model and the closeness centrality of all doctors. This indicated a potential vulnerability in the system that could negatively impact patient care if the function of the PLN was compromised. We developed an algorithmic strategy to mitigate this risk by targeted strengthening of links between clinical teams using greedy cumulative addition of network edges in the model. Finally, we identified specific interactions along patient trajectories which were most likely to precipitate a psychiatric referral using a machine learning model trained on features from dynamically constructed clinical interaction networks. The main limitation of this study is the use of nonclinical information only (i.e., modeling is based on timing of interactions and agents involved, but not the content or quantity of information transferred during interactions).ConclusionsThis study demonstrates a data-driven research framework, new to the best of our knowledge, to assess and reinforce important information pathways that guide clinical decision processes and provide complementary insights for improving clinical practice and operational models in emergency medicine for patients at risk of suicide or self-harm. Our findings suggest that PLNs can play a crucial role in clinical communication, but overreliance on PLNs may pose risks to reliable information flow. Operational models that utilize PLNs may be made more robust to these risks by improving interdisciplinary communication between doctors. Our research framework could also be applied more broadly to investigate service delivery in different healthcare settings or for other medical specialties, patient groups, or demographics.
| S-EPMC10786386 | biostudies-literature
Project description:AimsSuicidal ideation constitutes a central element of most theories of suicide and is the defining facet separating suicide from other causes of death such as accidents. However, despite a high worldwide prevalence, most research has focused on suicidal behaviours, such as completed suicide and suicide attempts, while the greater proportion who experienced ideation, which frequently precedes suicidal behaviour, have received much less attention. This study aims to examine the characteristics of those presenting to EDs with suicidal ideation and quantify the associated risk of suicide and other causes of death.MethodsRetrospective cohort study was performed based on population-wide health administration data linked to data from the Northern Ireland Registry of Self-Harm and centrally held mortality records from April 2012 to December 2019. Mortality data, coded as suicide, all-external causes and all-cause mortality were analysed using Cox proportional hazards. Additional cause-specific analyses included accidental deaths, deaths from natural causes and drug and alcohol-related causes.ResultsThere were 1,662,118 individuals aged over 10 years, of whom 15,267 presented to the ED with ideation during the study period. Individuals with ideation had a 10-fold increased risk of death from suicide (hazard ratio [HRadj] = 10.84, 95% confidence interval [CI] 9.18, 12.80) and from all-external causes (HRadj = 10.65, 95% CI 9.66, 11.74) and a threefold risk of death from all-causes (HRadj = 3.01, 95% CI 2.84, 3.20). Further cause-specific analyses indicated that risk of accidental death (HRadj = 8.24, 95% CI 6.29, 10.81), drug-related (HRadj = 15.17, 95% CI 11.36, 20.26) and alcohol-related (HRadj = 10.57, 95% CI 9.07, 12.31) has also significantly increased. There were few socio-demographic and economic characteristics that would identify which of these patients are most at risk of suicide or other causes of death.ConclusionsIdentifying people with suicidal ideation is recognized to be both important but difficult in practice; this study shows that presentations to EDs with self-harm or suicide ideation represent an important potential intervention point for this hard-to-reach vulnerable population. However, and unlike individuals presenting with self-harm, clinical guidelines for the management and recommended best practice and care of these individuals are lacking. Whilst suicide prevention may be the primary focus of interventions aimed at those experiencing self-harm and suicide ideation, death from other preventable causes, especially substance misuse, should also be a cause of concern.
| S-EPMC10130835 | biostudies-literature
Project description: Not available
| S-EPMC10506508 | biostudies-literature
Project description:ObjectiveTo compare and analyze the differences in the sociodemographic and clinical characteristics of suicide attempters who visited an emergency department (ED) before and during the coronavirus disease (COVID-19) pandemic.MethodsThis single center, retrospective study was conducted by reviewing the medical records of patients in the "self-injury/suicide" category of the National Emergency Department Information System who visited an ED between January 2019 and December 2020. We obtained information on baseline characteristics, suicide attempt, and disposition. Data were analyzed using the chi-squared test.ResultsA total of 456 patients were included. The number of patients visiting the ED for suicide attempts increased by 18.2% (from 209 to 247 cases) during the COVID-19 pandemic, and the ratio of suicide attempters to the total number of ED visits increased by 48.8% (from 0.43% to 0.64%, P<0.001). There were significant differences in methods of suicide attempt, endotracheal intubation, ED disposition, and the presence of mental illness. Drug overdose (42.1% vs. 53.4%) and gas inhalation (5.7% vs. 8.5%) increased, and hanging decreased (6.0% vs. 2.0%) during the pandemic. Endotracheal intubation (13.9% vs. 5.7%) and intensive care unit admission (29.7% vs. 14.6%) decreased. More patients with the history of mental illness visited during the pandemic (54.0% vs. 70.1%).ConclusionSince the COVID-19 pandemic began, suicide attempts have increased in this single ED although the lethality of those attempts is low.
| S-EPMC9288878 | biostudies-literature
Project description:BackgroundEmergency department (ED) visits show a high volatility over time. Therefore, EDs are likely to be crowded at peak-volume moments. ED crowding is a widely reported problem with negative consequences for patients as well as staff. Previous studies on the predictive value of weather variables on ED visits show conflicting results. Also, no such studies were performed in the Netherlands. Therefore, we evaluated prediction models for the number of ED visits in our large the Netherlands teaching hospital based on calendar and weather variables as potential predictors.MethodsData on all ED visits from June 2016 until December 31, 2019, were extracted. The 2016-2018 data were used as training set, the 2019 data as test set. Weather data were extracted from three publicly available datasets from the Royal Netherlands Meteorological Institute. Weather observations in proximity of the hospital were used to predict the weather in the hospital's catchment area by applying the inverse distance weighting interpolation method. The predictability of daily ED visits was examined by creating linear prediction models using stepwise selection; the mean absolute percentage error (MAPE) was used as measurement of fit.ResultsThe number of daily ED visits shows a positive time trend and a large impact of calendar events (higher on Mondays and Fridays, lower on Saturdays and Sundays, higher at special times such as carnival, lower in holidays falling on Monday through Saturday, and summer vacation). The weather itself was a better predictor than weather volatility, but only showed a small effect; the calendar-only prediction model had very similar coefficients to the calendar+weather model for the days of the week, time trend, and special time periods (both MAPE's were 8.7%).ConclusionsBecause of this similar performance, and the inaccuracy caused by weather forecasts, we decided the calendar-only model would be most useful in our hospital; it can probably be transferred for use in EDs of the same size and in a similar region. However, the variability in ED visits is considerable. Therefore, one should always anticipate potential unforeseen spikes and dips in ED visits that are not shown by the model.
| S-EPMC8196936 | biostudies-literature
Project description:BackgroundThere is a lack of consensus about the effect of the COVID-19 pandemic on the mental health of children and adolescents. We aimed to compare rates of paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation during the pandemic with those before the pandemic.MethodsFor this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO for studies published between Jan 1, 2020, and Dec 19, 2022. Studies published in English with data on paediatric (ie, those aged <19 years) emergency department visits before and during the COVID-19 pandemic were included. Case studies and qualitative analyses were excluded. Changes in attempted suicide, self-harm, suicidal ideation, and other mental-illness indicators (eg, anxiety, depression, and psychosis) were expressed as ratios of the rates of emergency department visits during the pandemic compared with those before the pandemic, and we analysed these with a random-effects meta-analysis. This study was registered with PROSPERO, CRD42022341897.Findings10 360 non-duplicate records were retrieved, which yielded 42 relevant studies (with 130 sample-estimates) representing 11·1 million emergency department visits for all indications of children and adolescents across 18 countries. The mean age of the samples of children and adolescents across studies was 11·7 years (SD 3·1, range 5·5-16·3), and there were on average 57·6% girls and 43·4% boys as a proportion of emergency department visits for any health reasons (ie, physical and mental). Only one study had data related to race or ethnicity. There was good evidence of an increase in emergency department visits for attempted suicide during the pandemic (rate ratio 1·22, 90% CI 1·08-1·37), modest evidence of an increase in emergency department visits for suicidal ideation (1·08, 0·93-1·25), and good evidence for only a slight change in self-harm (0·96, 0·89-1·04). Rates of emergency department visits for other mental-illness indications showed very good evidence of a decline (0·81, 0·74-0·89), and paediatric visits for all health indications showed strong evidence of a reduction (0·68, 0·62-0·75). When rates for attempted suicide and suicidal ideation were combined as a single measure, there was good evidence of an increase in emergency department visits among girls (1·39, 1·04-1·88) and only modest evidence of an increase among boys (1·06, 0·92-1·24). Self-harm among older children (mean age 16·3 years, range 13·0-16·3) showed good evidence of an increase (1·18, 1·00-1·39), but among younger children (mean age 9·0 years, range 5·5-12·0) there was modest evidence of a decrease (0·85, 0·70-1·05).InterpretationThe integration of mental health support within community health and the education system-including promotion, prevention, early intervention, and treatment-is urgently needed to increase the reach of mental health support that can mitigate child and adolescent mental distress. In future pandemics, increased resourcing in some emergency department settings would help to address their expected increase in visits for acute mental distress among children and adolescents.FundingNone.
| S-EPMC10097509 | biostudies-literature
Project description:ObjectiveEmergency department visits for self-harm and suicidal ideation have increased for US older adults. The purpose of this study was to examine discharge disposition, clinical recognition of mental disorder, and 30-day follow-up mental health outpatient care of older adults treated in emergency departments for suicide attempt (SA), suicidal ideation (SI), or deliberate self-harm (DSH).MethodsRetrospective cohort analysis using 2015 Medicare claims for adults ≥65 years of age with suicide-related emergency encounters (N = 52,383). Demographic, clinical, and service use characteristics from claims were merged with county-level Area Health Resource File data. Rates and adjusted risk ratios were assessed for discharge to the community, mental health diagnosis in the emergency department, and outpatient mental health visits with 30 days after the emergency encounter.ResultsEncounters for SA (7.8%) and SI (17.2%) were less likely than those for DSH (29.1%) to be discharged to the community. Among community discharges, SA (95.6%) and SI (95.1%) encounters were more likely than DSH (52.3%) encounters to be diagnosed with a mental disorder in the emergency department. Encounters for SA (52.1%) and SI (59.9%) were also more likely than DSH (31.3%) encounters to receive follow-up mental care.ConclusionsAlthough most older adults treated in EDs for suicide-related reasons are hospitalized, a substantial proportion of patients discharged back to the community do not receive follow-up mental healthcare within 30 days.
| S-EPMC7246137 | biostudies-literature
Project description:ObjectiveAccurate identification of self-harm presentations to Emergency Departments (ED) can lead to more timely mental health support, aid in understanding the burden of suicidal intent in a population, and support impact evaluation of public health initiatives related to suicide prevention. Given lack of manual self-harm reporting in ED, we aim to develop an automated system for the detection of self-harm presentations directly from ED triage notes.Materials and methodsWe frame this as supervised classification using natural language processing (NLP), utilizing a large data set of 477 627 free-text triage notes from ED presentations in 2012-2018 to The Royal Melbourne Hospital, Australia. The data were highly imbalanced, with only 1.4% of triage notes relating to self-harm. We explored various preprocessing techniques, including spelling correction, negation detection, bigram replacement, and clinical concept recognition, and several machine learning methods.ResultsOur results show that machine learning methods dramatically outperform keyword-based methods. We achieved the best results with a calibrated Gradient Boosting model, showing 90% Precision and 90% Recall (PR-AUC 0.87) on blind test data. Prospective validation of the model achieves similar results (88% Precision; 89% Recall).DiscussionED notes are noisy texts, and simple token-based models work best. Negation detection and concept recognition did not change the results while bigram replacement significantly impaired model performance.ConclusionThis first NLP-based classifier for self-harm in ED notes has practical value for identifying patients who would benefit from mental health follow-up in ED, and for supporting surveillance of self-harm and suicide prevention efforts in the population.
| S-EPMC8800520 | biostudies-literature
Project description:OBJECTIVE:This study investigated patient- and area-level characteristics associated with adolescent emergency department (ED) patients' risk of subsequent ED visits for self-harm. METHOD:Retrospective analysis of adolescent patients presenting to a California ED in 2010 (n?=?480,706) was conducted using statewide, all-payer, individually linkable administrative data. We examined associations between multiple predictors of interest (patient sociodemographic factors, prior ED utilization, and residential mobility; and area-level characteristics) and odds of a self-harm ED visit in 2010. Patients with any self-harm in 2010 were followed up over several years to assess predictors of recurrent self-harm. RESULTS:Self-harm patients (n?=?5539) were significantly more likely than control patients (n?=?16,617) to have prior histories of ED utilization, particularly for mental health problems, substance abuse, and injuries. Residential mobility also increased risk of self-harm, but racial/ethnic minority status and residence in a disadvantaged zipcode decreased risk. Five-year cumulative incidence of recurrent self-harm was 19.3%. Admission as an inpatient at index visit, Medicaid insurance, and prior ED utilization for psychiatric problems or injury all increased recurrent self-harm risk. CONCLUSIONS:A range of patient- and area-level characteristics observable in ED settings are associated with risk for subsequent self-harm among adolescents, suggesting new targets for intervention in this clinical context.
| S-EPMC6353680 | biostudies-literature
Project description:BackgroundEvidence from high income countries (HICs) suggests that individuals who present to hospital after self-harm are an important target for suicide prevention, but evidence from low and middle-income countries (LMICs) is lacking. We aimed to investigate the risk of repeat self-harm and suicide, and factors associated with these outcomes, in a large cohort of patients presenting to hospital with self-harm in rural Sri Lanka.MethodsIn this cohort study, hospital presentations for self-harm at 13 hospitals in a rural area of North Central Province (population 224 000), Sri Lanka, were followed up with a self-harm surveillance system, established as part of a community randomised trial, and based on data from all hospitals, coroners, and police stations in the study area. We estimated the risk of repeat non-fatal and fatal self-harm and risk factors for repetition with Kaplan-Meier methods and Cox proportional hazard models. Sociodemographic (age, sex, and socioeconomic position) and clinical (past self-harm and method of self-harm) characteristics investigated were drawn from a household survey in the study area and data recorded at the time of index hospital presentation. We included all individuals who had complete data for all variables in the study in our primary analysis.OutcomesBetween July 29, 2011, and May 12, 2016, we detected 3073 episodes of self-harm (fatal and non-fatal) in our surveillance system, of which 2532 (82·3%) were linked back to an individual in the baseline survey. After exclusion of 145 ineligible episodes, we analysed 2259 index episodes of self-harm. By use of survival models, the estimated risk of repeat self-harm (12 months: 3· 1%, 95% CI 2·4-3·9; 24 months: 5·2%, 4·3-6·4) and suicide (12 months: 0·6%, 0·4-1·1; 24 months: 0·8%, 0·5-1·3) in our study was considerably lower than that in HICs. A higher risk of repeat self-harm was observed in men than in women (fatal and non-fatal; hazard ratio 2·0, 95% CI 1·3-3·2; p=0·0021), in individuals aged 56 years and older compared with those aged 10-25 years (fatal; 16·1, 4·3-59·9; p=0·0027), and those who used methods other than poisoning in their index presentation (fatal and non-fatal; 3·9, 2·0-7·6; p=0·00027). We found no evidence of increased risk of repeat self-harm or suicide in those with a history of self-harm before the index episode.InterpretationAlthough people who self-harm are an important high-risk group, focusing suicide prevention efforts on those who self-harm might be somewhat less important in LMICs compared with HICs given the low risk of repeat self-harm and subsequent suicide death. Strategies that focus on other risk factors for suicide might be more effective in reducing suicide deaths in LMICs in south Asia. A better understanding of the low incidence of repeat self-harm is also needed, as this could contribute to prevention strategies in nations with a higher incidence of repetition and subsequent suicide death.FundingWellcome Trust.
| S-EPMC6639451 | biostudies-literature