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Emergency Department Recognition of Mental Disorders and Short-Term Outcome of Deliberate Self-Harm
Mark Olfson, M.D., M.P.H.; Steven C. Marcus, Ph.D.; Jeffrey A. Bridge, Ph.D.
Am J Psychiatry 2013;170:1442-1450. doi:10.1176/appi.ajp.2013.12121506
View Author and Article Information

Dr. Marcus has served as a consultant for Ortho-McNeil Janssen and Forest Research Institute. The other authors report no financial relationships with commercial interests.

Supported by the American Foundation for Suicide Prevention (a Distinguished Investigator Award to Dr. Olfson); NIMH grant MH093552 (to Dr. Bridge); and Centers for Disease Control and Prevention grant CE002129 (to Dr. Bridge).

From the Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and New York State Psychiatric Institute, New York; the Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia; the School of Social Policy and Practice, University of Pennsylvania, Philadelphia; and the Center for Innovation in Pediatric Practice, Research Institute, Nationwide Children’s Hospital, Columbus, Ohio.

Address correspondence to Dr. Olfson (mo49@columbia.edu).

Copyright © 2013 by the American Psychiatric Association

Received December 03, 2012; Revised February 20, 2013; Accepted March 28, 2013.

Abstract

Objective  The authors sought to characterize the short-term risks of repeat self-harm and psychiatric hospital admission for deliberate self-harm patients discharged from emergency departments to the community, focusing on recognition of mental disorders in the emergency department.

Method  A retrospective longitudinal cohort analysis of national Medicaid claims data was conducted of adults 21–64 years of age with deliberate self-harm who were discharged from emergency departments (N=5,567). Rates and adjusted risk ratios are presented of repeat self-harm visits and inpatient psychiatric admission during the 30 days following the initial emergency visit.

Results  Approximately 9.7% of self-harm visits were followed by repeat self-harm visits and 13.6% by inpatient psychiatric admissions within 30 days after the initial emergency visit. The rate of repeat self-harm visits was inversely related to recognition of a mental disorder in the emergency department (adjusted risk ratio [ARR]=0.66, 95% CI=0.55–0.79) and directly related to recent diagnosis of anxiety disorders (ARR=1.56, 95% CI=1.30–1.86) or personality disorders (ARR=1.67, 95% CI=1.19–2.34). Recognition of a mental disorder in the emergency department was inversely related to repeat self-harm among patients with no recent mental disorder diagnosis (ARR=0.57, 95% CI=0.41–0.79); any recent mental disorder diagnosis (ARR=0.70, 95%=0.57–0.87); and depressive (ARR=0.71, 95% CI=0.54–0.94), bipolar (ARR=0.70, 95% CI=0.51–0.94), and substance use (ARR=0.71, 95% CI=0.53–0.96) disorder diagnoses. Recognition of a mental disorder was also inversely related to subsequent inpatient psychiatric admission (ARR=0.81, 95% CI=0.71–0.93).

Conclusions  Adults who are discharged to the community after emergency visits for deliberate self-harm are at high short-term risk of repeat deliberate self-harm and hospital admission, although these risks may be attenuated by clinical recognition of a mental disorder in the emergency department.

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TABLE 1.Rates of Repeat Deliberate Self-Harm Within 30 Days of Emergency Department Visit for Deliberate Self-Harm, Total and Stratified by Patient Characteristicsa
Table Footer Note

a Based on national Medicaid data. Risk ratios are from log-binomial regressions using the SAS GENMOD procedure. Adjusted risk ratios involve stepwise selection among all listed variables as independent variables.

Table Footer Note

b Based on 60 days before emergency department visit.

Table Footer Note

c Violent methods include firearm, drowning, suffocation, fall, fire, electrocution, extreme cold, and motor vehicle; nonviolent methods include cutting, poisoning, air gun, and paintball gun; unknown includes unspecified or poorly specified.

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TABLE 2.Rates of Repeat Self-Harm Within 30 Days of Emergency Department Visit for Deliberate Self-Harm Among Patients With Recent Treatment of Various Mental Disorders, by Emergency Department Recognition of a Mental Disordera
Table Footer Note

a Based on national Medicaid data. N1=sample with emergency department recognition of a mental disorder; N2=sample with no emergency department recognition of a mental disorder. Adjusted risk ratios are from log-binomial regressions using the SAS GENMOD procedure. Adjusted risk ratios involve a propensity score for mental health assessment and stepwise selection among all variables listed in Table 1 as independent variables.

Table Footer Note

b Based on 60 days before emergency department deliberate self-harm visit.

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TABLE 3.Rates of Psychiatric Hospital Admission Within 30 Days of Emergency Department Visit for Deliberate Self-Harm, Total and Stratified by Patient Characteristicsa
Table Footer Note

a Based on national Medicaid data. Risk ratios are from log-binomial regressions using the SAS GENMOD procedure. Adjusted risk ratios involve stepwise selection among all listed variables as independent variables.

Table Footer Note

b Based on 60 days before emergency department visit.

Table Footer Note

c Violent methods include firearm, drowning, suffocation, fall, fire, electrocution, extreme cold, and motor vehicle; nonviolent methods include cutting, poisoning, air gun, and paintball gun; unknown includes unspecified or poorly specified.

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TABLE 4.Rates of Psychiatric Hospital Admission Within 30 Days of Emergency Department Visit for Deliberate Self-Harm Among Patients With Recent Treatment of Various Mental Disorders, by Emergency Department Recognition of a Mental Disordera
Table Footer Note

a Based on national Medicaid data. N1=sample with emergency department recognition of a mental disorder; N2=sample with no emergency department recognition of a mental disorder. Adjusted risk ratios are from log-binomial regressions using the SAS GENMOD procedure. Adjusted risk ratios involve a propensity score for mental health assessment and a stepwise selection among all variables listed in Table 1 as independent variables.

Table Footer Note

b Based on 60 days before emergency department deliberate self-harm visit.

Table Footer Note

c Unadjusted analysis; adjusted analysis did not converge.

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