Assessment following deliberate self-harm: who are we seeing and are we following the guidelines?

Adjustment Disorder and Suicidal Behaviours Presenting in the General Medical Setting: A Systematic Review

Background: Adjustment disorder (AD) is a condition commonly encountered by clinicians in emergency departments and liaison psychiatry settings and has been frequently reported among patients presenting with suicidal behaviours. A number of previous studies have noted the strong association between suicidal ideation and behaviours, and AD. In this paper, we aimed to explore this relationship, by establishing the incidence of AD in patients who present with self-harm and suicidal ideation, and the rates of self-harm among patients with a diagnosis of AD. Methods: We conducted a review of the literature of well-established databases using specific key words then synthesised the results into a descriptive narrative as well as representing it in table form. Results: Sample sizes and study methods varied significantly across the review. A majority of studies were retrospective chart-based reviews, and only three used structured diagnostic instruments. A high prevalence of AD (ranging from 9.8 to 100%) was found, with self-poisoning representing the most common form of suicide attempt in the majority of studies. Interpersonal difficulties were the main precipitant in studies which examined this. Conclusions: This study suggests there is a strong association between AD and suicidal behaviours. Given the paucity of research in the area, there is a need to build the evidence base for effective treatment strategies.

Ensuring quality immediate discharge letters from mental health

Purpose Immediate discharge letters (IDLs) from the mental health unit at Forth Valley Royal Hospital are vital in ensuring safe patient transfer to primary care. The purpose of this paper is to develop a standardised list of information that should be included in all IDLs, and to assess its use in practice. Design/methodology/approach Three audit cycles analysed IDLs over two-week periods for their inclusion of the standardised list. The data were assessed qualitatively. Findings Baseline measurement showed 48.7 per cent of discharges had a brief reason for admission, 15.4 per cent included a description of the patient's progress during inpatient admission, 35.9 per cent had medication alterations included and 23.1 per cent included follow-up arrangements. Following a series of interventions, analysis of subsequent IDLs demonstrated that 76.2 per cent of discharges had a brief reason for admission, 76.2 per cent included a description of the patient's progress during inpatient admission, 76.2 per cent had medication alterations included and 71.4 per cent included follow-up arrangements. Originality/value The standardised list developed will ensure quality communication and safe patient transfer to primary care; the application of this list was effective and cost neutral.

Problems experienced by young men and attitudes to help-seeking in a rural Irish community

Objectives: Suicide is now the commonest cause of death among young Irish males. The literature identifies a wide range of contributory risk factors in suicide. However, a number of realities have frustrated clinicians' efforts in the area, including the reluctance of young males to engage in mental health services. In this study, we sought to explore the problems experienced by young men in a rural setting and their attitudes towards seeking help.

Methods: Focus groups were employed to generate themes for a qualitative and quantitative questionnaire which was administered to a community sample of 71 young men (22.4% of the total number of males aged 16-30 years in the area) and 79 key informants. The questionnaires contained demographic items and examined available social outlets, types and extent of difficulties experienced by young men and perceptions of and access to potential sources of support.

Results: Both young men and key informants reported that peer pressure and alcohol misuse are areas of most difficulty, that friends and family are the preferred sources of support and that young men view much existing professional help as unacceptable.

Conclusions: This study provides a basis for the next stage in the research cycle and also supports the viability of building a partnership between the health services and the local community in developing future suicide prevention strategies for young men.

Communication between community mental health services and primary care

OBJECTIVES

This study aims to assess the rate of six monthly communications between specialised psychiatric services and primary care and to determine factors which predict such communication.

METHODS

A retrospective review of the clinical records of all patients attending the relevant local psychiatric outpatient clinic was carried out by all members of the multidisciplinary team to identify patient demographic and clinical variables as well as to determine if there has been documentation of communication with primary care in the preceding six months. Letters were sent to the relevant primary care teams regarding progress on their patients in cases where it was identified that no communication had occurred in the preceding six months.

RESULTS

A total of 145 patients' charts were reviewed. Of these, 53.3% of the patients were females and 46.7% were males. The mean age was 47.9 years (SD = 14). Patients' diagnoses included; depression (41%), bipolar affective disorder (6.7%), schizophrenia/schizoaffective disorder (27.6%), anxiety disorders (6.7%), alcohol dependency syndrome (11%) and other disorders (7%). Overall, only 36% of patients' charts had a record of communication with primary care in the last six months. Only one variable, 'changes made to the patents medication in the last six months' was significantly associated with the likelihood that there had been communication with primary care with an odds ratio of 15 and a p-value of 0.00.

CONCLUSION

A six monthly review has a potential to improve the level of communication between specialised psychiatric services and primary care.

Communication between secondary and primary care following self-harm: are National Institute of Clinical Excellence (NICE) guidelines being met?

BACKGROUND

Most patients contact their general practitioner (GP) following presentation to an Emergency Department (ED) after a self-harm incident, and strategies to help GPs manage these patients include efficient communication between services. The aim of this study was to assess the standard of documentation and communication to primary care from secondary care as recommended by the National Institute of Clinical Excellence (NICE) guidelines on the short-term management of people who self-harm.

METHODS

An audit of medical records (ED and Psychiatric) on people aged 16 years and over who had presented to the ED following self-harm, benchmarked according to government guidelines, was performed. Data were collected over a 4-week period at a general teaching hospital.

RESULTS

We collected data on 93 consecutive episodes of self-harm; 62% of episodes were communicated to primary care, 58% of these communications were within 24 h and most within 3 days. Patient identifying details and follow-up arrangements were specified in most cases. Communication via psychiatric staff was most detailed. ED clinicians provided few communications and were of limited content. Communication with the patient's GP was not made in half of those cases seen by a mental health specialist.

CONCLUSION

Government guidelines are only partially being met. Reliance on communication by ED staff would leave a substantial proportion of patients discharged from the ED with no or minimal communication to primary care. Psychiatric services need to improve the rate of communication to the patient's GP following assessment A national sample of National Health Service (NHS) trusts would establish if this is a problem elsewhere.

Accuracy of diagnosis at routine psychiatric assessment in patients presenting to an accident and emergency department

OBJECTIVE

This study aimed to compare diagnoses obtained from routine psychiatric assessment in accident and emergency (A&E) settings with those from a standardized diagnostic interview.

METHODS

Using Cohen's kappa, the agreement between diagnoses from routine psychiatric assessment and structured interview was calculated. Further statistical analysis was used to investigate differences between some of the main diagnostic subgroups.

RESULTS

The overall kappa value for all diagnoses was .47. Adjustment disorder, major depressive disorder and alcohol misuse/dependence were commonly identified, both at routine assessment and on structured interview. There was a disparity between the two diagnostic systems in the extent to which major depressive disorder and adjustment disorder were identified. Further analysis between these two groups was inconclusive as to the reasons for this difference.

CONCLUSIONS

There was moderate agreement between clinical and standardized diagnoses. Anxiety disorders were poorly identified at routine assessment. There is difficulty distinguishing between adjustment disorder and depressive episode in the A&E setting.