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Emergency Treatment of Self-Injurious Behavior: Are We Doing Our Best?

Many patients with self-injury, including those with the greatest risks, never receive a psychiatric evaluation.

A single emergency department (ED) visit for deliberately self-injurious behavior is associated with a sixfold increased lifetime risk for suicide. To examine how patients with self-injury are treated, researchers reviewed Medicaid records for adults treated in EDs for self-harm in 2006. Of 7355 visits, 4595 visits (62%; 4440 patients) involved discharge to the community, and 2760 visits (38%) involved admission to the hospital.

Of the patients who were sent home, only 48% had a mental health evaluation in the ED, and 52% received outpatient follow-up in the next 30 days. Compared with patients sent home, admitted patients were more likely to be older and to have had a more lethal form of self-harm (e.g., gunshot) and previous mental health treatment, but were no more likely to have had previous self-harm, depression, schizophrenia, or a substance use disorder. Among patients who went home, a history of previous mental health treatment increased the likelihood of outpatient follow-up — but having potentially more lethal self-harm behavior did not increase that likelihood.

Comment: According to this study, almost two thirds of patients who have ED visits for self-harm are discharged home, and only half of these have a psychiatric assessment before discharge. Of those who are discharged home, only half have a mental health follow-up. The patients most likely to receive outpatient care are probably individuals who are continuing previous treatment, not those with the most dangerous behavior or those with previous self-harm, even though dangerous behavior is the standard of care for hospital admission. In the year after an ED visit for self-harm, suicide risk is 30 to 130 times higher than in the general population. More education of ED staff is needed to increase appropriate evaluation and treatment.

— Steven Dubovsky, MD

Published in Journal Watch Psychiatry January 30, 2012

Citation(s):

Olfson M et al. Emergency treatment of deliberate self-harm. Arch Gen Psychiatry 2012 Jan; 69:80.

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Reader Remarks:

Review and add to remarks on this article

• why the neglect with the psychiatric patient?
  Walter Doege, private office, 31 Jan 2012 12:25 PM EST
  Specialty: Psychiatry
  I observe till now the neglect with the self injury harmed patient and with the the violent patient in emergency... [more]
• Are We Doing Our Best?
  Mark M Paulsen, Rural Colorado, 2 Feb 2012 12:30 PM EST
  Specialty: Family Medicine
  I didn't see any evidence that supports the conclusion that more education for ED staff is needed. My experience suggests... [more]
• Emergency Department Staff's Attitude towards People who Attempt Suicide
  Judith Ronat M. D., 7 Feb 2012 12:18 PM EST
  Specialty: Psychiatry
  ED Staff, like all medical personnel, are dedicated to keeping people alive. Most of them have contempt for people who... [more]
• self-harm/injury attitudes of professionals
  Bruce Wallace, 16 Feb 2012 1:07 PM EST
  Specialty: Psychiatry
  It would appear from literature and discussions with 'service users' that education can play a part in adjusting negative attitudes... [more]

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