Deliberate self poisoning accounts for 100 000 hospital admissions in England and Wales every year, and its incidence is increasing.1 One per cent of patients kill themselves in the year following attendance.2 Good services to manage deliberate self poisoning in general hospitals might therefore help to achieve the targets set out by the Health of the Nation strategy to reduce suicide rates. Existing services have not been planned coherently; the care provided by hospitals varying greatly, even in the same region.3 We assessed the management of self poisoning in four teaching hospitals in England by using standardised methods of notification.
Subjects, methods, and results
We prospectively identified all patients over 16 years of age who attended four teaching hospitals in Leeds, Leicester, Manchester, and Nottingham for deliberate self poisoning during 4 weeks (November to December 1996). We obtained data by examining computerised databases on wards and in the accident and emergency department, referral ledgers, accident and emergency notes, and copies of specialist assessments of deliberate self poisoning. We checked all inpatient data retrospectively against information on admission and discharge for deliberate self poisoning that we obtained from the patient administration system in each hospital. We collected demographic details of patients, along with details of substance dependence, previous overdoses, and contact with psychiatric services. We also recorded information on the management of the current episode of self poisoning.
During the study period 458 patients accounted for 477 hospital attendances for deliberate self poisoning; 223 (49%) of these were women. The mean age of the patients was 30.9 years (SD 11.8 years); 65 (14%) were dependent on alcohol or drugs, 177 (39%) had taken a previous overdose, and 119 (26%) were in contact with psychiatric services. These percentages and the substances ingested were similar across study centres. By contrast, there were striking variations in the management of episodes between study centres, with a fourfold difference in discharge rates from accident and emergency departments, and almost a twofold difference in the proportion of subjects receiving a specialist psychosocial assessment (table). In 220 out of 477 hospital attendances (46%) the patient had no psychosocial assessment at any time during their hospital contact.
Comment
The average rate of patients with self poisoning presenting to hospital services in this study was 310 per 100 000 population per year, which suggests that deliberate self poisoning accounts for 170 000 hospital attendances in the United Kingdom annually. Yet services for this important problem remain in disarray. Striking variations in clinical practice were not accounted for by differences in patients’ characteristics. We also discovered that, notwithstanding guidelines issued by the Department of Health,4 almost half of the patients in this study did not receive a specialist psychosocial assessment.
Our findings may reflect a high risk approach to intervention or a lack of consensus on the psychiatric management of self poisoning.5 We believe they probably reflect the low medical and psychiatric priority given to patients who have taken an overdose. A reduced number of beds means that medical staff are reluctant to admit patients who are judged to be at low physical risk and often seen as difficult and unrewarding. Meanwhile, psychiatric services are increasingly reserved for those with serious mental illness, a term which is not taken to include most cases of self poisoning. The current situation should not be allowed to continue because self poisoning represents a major social and clinical problem. At least, large scale intervention studies are required to inform practice and ensure that our management of deliberate self poisoning in the future is less arbitrary than it has been for the past three decades.
Table.
Management of 477 episodes of deliberate self poisoning in each study centre. Values are numbers (percentages) of patients
| Centre (No of episodes) | Discharged from accident and emergency department | Discharged from accident and emergency department without psychosocial assessment | Received psychosocial assessment | Admitted to psychiatric ward | Followed up* |
|---|---|---|---|---|---|
| Leeds (101) | 18 (18) | 15 (15) | 65 (65) | 6 (6) | 46 (45), general practitioner 16 (16), deliberate self harm team 28 (28), psychiatric services 10 (10), alcohol services |
| Leicester (111) | 61 (55) | 23 (21) | 76 (68) | 18 (16) | 50 (45), general practioner 12 (11), deliberate self harm team 44 (40), psychiatric services 2 (2), alcohol services |
| Manchester (100) | 71 (71) | 46 (46) | 36 (36) | 11 (11) | 67 (67), general practitioner 0, deliberate self harm team 31 (31), psychiatric services 1 (1), alcohol services |
| Nottingham (165) | 53 (32) | 42 (25) | 80 (48) | 13 (8) | 98 (59), general practitioner 14 (8), deliberate self harm team 43 (26), psychiatric services 6 (4), alcohol services |
| All centres (477) | 203 (43) | 126 (26) | 257 (54) | 48 (10) | 261 (55), general practitioner 42 (9), deliberate self harm team 146 (31), psychiatric services 19 (4), alcohol services |
Nine episodes were followed up by a variety of agencies, mostly social services or non-statutory agencies.
Acknowledgments
We thank hospital staff at all four centres for their help with data collection, and Dr David Owens and an anonymous referee for their comments on earlier drafts of this paper.
Footnotes
Funding: This study was funded by the Medical Research Council, grant number G9533540, to AH, FC, Professor K Hawton, and Professor M Williams. At the time of this study NK was supported by the Medical Research Council and Leeds Community Mental Health Trust.
Conflict of interest: None.
References
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