Child Development and Learning, Institute of Education, London
Thomas Coram Research Unit, Institute of Education, London.
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Correspondence: Dr J. Hurry, Institute of Education, University of London, 20 Bedford Way, London WCIH 0AL
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ABSTRACT |
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Aims To describe the psychosocial assessment of 12- to 24-year-old patients attending A&E clinics following deliberate self-harm (DSH) and to identify features of service management and provision which maximise specialist assessment.
Method A postal questionnaire was sent to a sample of one in three A&E departments in England. In a representative sample of 18 of these hospitals, staff were interviewed and 50 case notes per hospital were examined.
Results Psychosocial assessment by non-specialist doctors in A&E departments tended to be of variable quality, focused on short-term risk. Around 43% of patients aged 12-24 were assessed by a specialist; specialist assessment was associated with high admission rates and the presence of on-site psychiatric departments and DSH teams.
Conclusions Young DSH patients at risk often go unidentified; as a result their psychological problems may not be treated. Hospitals are frequently unaware of the proportion of patients discharged without adequate assessment.
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INTRODUCTION |
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A straightforward approach to the assessment of patients in the A&E context may be simply to focus on the identification of recognised problems within this patient group for which referral to medical or social services is appropriate, irrespective of increased risk of subsequent self-harm. This avoids the need for predicting the future and anchors assessment firmly in the area of observable problems.
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METHOD |
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Stage one: survey
Sample
The first stage involved a postal questionnaire survey of a one-in-three
sample of A&E departments in England, stratified according to size and
region. In each hospital a senior A&E doctor (usually the consultant) and
a senior nurse were asked to complete the questionnaire. A total of 118
hospitals were selected, and at least one questionnaire was returned from 107
of these, giving an overall response rate of 91%, with 75% of doctors and 81%
of nurses responding.
Questionnaire
Information of as concrete and factual a nature as possible was elicited on
the following: the management of DSH patients aged 12-24; any guidelines or
policies in operation; the existence of self-harm specialist teams; procedures
for assessment, admission and referral of DSH patients; specific training for
A&E staff in the treatment of DSH; and the extent of the statistics
collected for auditing and monitoring the levels of service achieved.
Stage two: case study
Sample
In the second stage, 18 A&E departments of various sizes were selected.
Hospitals were selected from four of the eight regions in England on the basis
of whether they had guidelines and whether a DSH team was operating at the
hospital.
Interview
On average, five members of staff, including a senior doctor, a junior
doctor, a nurse and specialist staff, were interviewed in each hospital, using
a semi-structured interview schedule. The interview covered their knowledge of
hospital policy and guidelines in the area of interest and their observations
of how these work in practice, any training they have received in the
management of the target group and the factors that influence their assessment
and referral practices.
Case notes
The most recent 50 sets of case notes were examined at each hospital for
the target patient group - patients aged 12-24 years who had taken an overdose
or injured themselves deliberately (i.e. where notes indicated a deliberate
injury). This generated a sample of 894 patients (six representing cases were
omitted from the original 900).
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RESULTS |
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In about two-thirds of cases the specialist available for assessment in A&E was a psychiatrist. Although 45% of hospitals possessed attached social workers, three-fifths of such hospitals reported that social workers rarely or never made psychosocial assessments. This goes some way towards explaining why only about 10% of hospitals overall reported social workers as playing a major role in this area. Registered mental nurses (RMNs) were even less frequently used (in around 5% of hospitals).
In the case note sample (n=894), 42.5% of the patients (n=380) were actually seen by a specialist (either in A&E or on a ward) - 54% of 12- to 15-year-olds (96 out of 177 cases) and 40% of 16- to 24-year-olds (286 out of 717 cases). The questionnaires gave an over-optimistic view of the frequency with which specialist assessment occurred. For example, in those case study hospitals where, according to the questionnaire, patients were always or in most cases seen by a specialist in A&E, only 26% were assessed there by a specialist. This tendency to overestimate the frequency with which young DSH patients received specialist assessment was also evident in the interviews.
Admission and specialist assessment on the ward
Admission significantly increased the likelihood of receiving assessment by
a specialist. In the case note study, 67% of admitted patients
(n=361) were seen by a specialist as opposed to only 34% of patients
discharged from A&E (n=322) (2=75.4, d.f.=1,
P < 0.0001) (self-discharging patients and those receiving
psychiatric care at the time were excluded in this comparison as their
inclusion could have been misleading (n=193)). For younger patients
(n=177), for whom admission rates were high (68%), psychosocial
assessment was more frequently carried out on the ward than in A&E, and
over half the younger group in the case note sample were assessed by a
specialist before discharge. However, in the older group (n=717),
admission was less common (43%); as a result, specialist assessment on the
ward was also less frequent. For this age group, the availability of
psychosocial assessment in A&E is therefore of greater importance.
Psychosocial assessment and the deliberate self-harm team
Deliberate self-harm teams have been recommended as a way of improving
service provision for this patient group, specifically in the areas of
psychosocial assessment, referral and aftercare
(Department of Health and Social Security,
1984; Royal College of
Psychiatrists, 1994). According to the questionnaires, hospitals
with a DSH team (n=25) did not offer more frequent specialist
assessment in A&E, but these assessments were more often carried out by
RMNs and social workers and less often by psychiatrists
(Table 1)
(2=7.43, d.f.=1, P < 0.006). This difference was
quite dramatic for the 16- to 24-year-olds. The fact that the presence of a
DSH team had a greater impact on the nature of service provision for older
patients is to be expected, because DSH teams rarely cover those aged under
16.
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According to the case notes, the presence of a DSH team did have an impact
on the availability of psychosocial assessment when A&E, ward and
out-patient assessment were all included. In particular, a significantly
higher percentage of 16- to 24-year-old patients not receiving psychiatric
care at the time (43% v. 35%, 2=3.9, d.f.=1,
P < 0.05) received a specialist assessment before discharge in
hospitals with a DSH team than in hospitals with no team.
It seems that the presence of a DSH team is related to somewhat increased rates of specialist psychosocial assessment but more dramatically to the way in which this specialist assessment is managed.
Guidelines
The presence or absence of guidelines made no significant difference to the
percentage of patients assessed by a specialist. In the seven case-study
hospitals with guidelines to refer all patients, 43% of patients were seen by
a specialist compared with 39% at the seven hospitals with no guidelines on
referral. This finding may be explained by junior doctors' ignorance of the
guidelines. In only four of the twelve case-study hospitals with guidelines
were the junior doctors interviewed aware of the existence of guidelines.
On-site psychiatric services
In view of the major role played by psychiatrists in specialist assessment,
the availability of their services is likely to have an important impact on
the frequency with which young patients receive such assessment. When A&E
staff were interviewed, ease of access to the psychiatric service was
frequently mentioned as a critical factor in offering specialist psychosocial
assessment. As might be expected, medical staff reported easier access to
psychiatric specialists if they were nearby. In the survey, 55% (33/60) of
hospitals with on-site psychiatric departments reported that most patients
were seen by a specialist, as opposed to 32% (13/41) in hospitals where there
was no on-site psychiatry (2=5.2, d.f.=1, P <
0.02).
Similarly, the case note study showed that patients presenting at hospitals
with on-site facilities were significantly more likely to receive a specialist
assessment than those attending hospitals without (53% v. 41%,
2=13.1, d.f.=1, P < 0.0003).
Table 2 shows that the presence of on-site psychiatric facilities is particularly influential for the frequency of specialist assessment for 16- to 24-year-olds at hospitals with no guidelines and no DSH team. At hospitals with guidelines but no DSH team, ease of access is still significant. For hospitals with a DSH team, however, ease of access to the psychiatric department is not a significant factor in providing specialist assessment. This is consistent with the finding that hospitals with DSH teams made greater use of RMNs and social workers and relied less on psychiatrists for specialist assessment.
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Quality of non-specialist psychosocial assessment
Despite the fact that less than half of the young people who present with
DSH see a specialist, the survey indicated that the large majority (over 80%)
will be given a non-specialist, psychosocial assessment in A&E. The Royal
College of Psychiatrists
(1994) sanctions such
assessments in certain circumstances. The key issue is their adequacy. One
guide to the quality of the assessment is the range of information recorded in
the case notes by the A&E staff. Table
3 compares the frequency with which specialists and
non-specialists record key aspects of psychosocial assessment in patients'
case notes. Because patients who are admitted may not be conscious while in
A&E or may be expected to receive a fuller assessment by medical staff on
the ward, the lack of a full assessment in A&E cannot be regarded as poor
practice; such patients have therefore been omitted from the table, as have
self-discharging patients and those in psychiatric care at the time. The case
notes of patients seen by specialists in A&E were significantly more
likely to contain key information (psychiatric history, mental state, social
situation, precipitating event, severity of intent and risk of repetition)
than those of patients assessed by a non-specialist.
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In addition, the staff interviewed in the 18 case-study hospitals were asked about the adequacy of psychosocial assessment made by non-specialist doctors in A&E. In 10 of the 18 hospitals, senior medical staff reported that the junior doctors usually responsible were ill-equipped to make such assessments adequately, owing to lack of time, lack of experience or lack of concern with the psychological aspects of treatment. In only two of these hospitals did senior doctors consider that assessments made by junior doctors were generally adequate or good. The senior doctors in the other 16 hospitals felt that quality of assessment by junior doctors varied with the quality of the senior house officers (SHOs), their experience and the pressures of the time required to undertake a thorough assessment. In those hospitals where there was concern over the quality of non-specialist assessment, senior clinicians frequently reported that admission and specialist assessment were the rule and that this compensated for the problems associated with the non-specialist. However, the case notes demonstrated that many patients were not receiving this specialist attention.
Three-quarters of the SHOs interviewed reported that when they carried out a psychosocial assessment they always attempted to establish a psychiatric history and to assess the risk of further self-harm and the intent of the patient. Just over a half said that they did a mental state examination. However, the focus was on short-term risk - in 11 of the 18 hospitals there was unequivocal evidence from the interviews that the psychosocial assessments carried out in A&E clinics were centrally concerned with the short-term risk of repeated attempts or suicide. Short-term risk was also cited as the deciding factor in immediate referral to a specialist.
Selection for specialist assessment
Some researchers have argued that the psychosocial prognosis for a
proportion of DSH presentations is good and that treatment may therefore be
unnecessary (Hawton, 1987;
Hurry & Storey, 1999). This may mean that the level of specialist assessment identified in the
present study is fairly adequate. However, such a conclusion would rely on the
assumption that those selected for specialist assessment are the
right ones. Table
4 presents the relationship between key patient characteristics
and whether 16- to 24-year-olds are assessed by a specialist. A series of
logistic regressions was carried out in order to establish statistically
significant effects.
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Consistent with the interviews, where notes recorded patients either as having suicidal intent or as being at risk of subsequent attempts, they were much more likely to see a specialist. Patients with past psychiatric care or those diagnosed with depression were also more likely to be passed to a specialist, but it is likely that the presence or absence of depression was frequently not established, and only a little over half of those diagnosed with depression were actually seen by a specialist. Patients with a previous recorded episode of self-harm were not significantly more likely to see a specialist. Only half the patients who had made a previous attempt were assessed by a specialist. Where alcohol was involved, patients were no more likely to see a specialist; where drugs were involved, they were significantly less likely to be seen. We failed to find any evidence that guidelines or the existence of a DSH team improved the selection process. The existence of a DSH team did increase the likelihood of specialist assessment but it did so equally for patients with no risk and those with some risk.
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DISCUSSION |
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Non-specialist assessment
Although less than half of young self-harm patients receive a specialist
assessment, most are assessed by an A&E doctor. However, the evidence from
the present study suggests that such assessments are likely to be inadequate.
In the majority of case notes reviewed, important information concerning
previous psychiatric history, current mental state and even risk of a repeated
attempt was not recorded if the patient had not been seen by a specialist.
Similar levels of important omissions in the case notes of self-harm patients
have been found by others (O'Dwyer et
al, 1991; Ebbage et
al, 1994). It is possible that these areas were covered but
simply not recorded. However, junior doctors almost invariably claimed to
record all information elicited on risk, present mental state and history of
psychiatric care or previous attempts. Also, the overwhelming majority of
staff interviewed in the 18 case-study hospitals felt that junior doctors were
unreliable as psychosocial assessors, particularly in the area of long-term
risk.
Assessment in the A&E context
The A&E clinic is geared towards the immediate, and towards the
physical rather than the psychological. Junior doctors working in such an
environment are not encouraged to spend with patients the time that
psychosocial assessment requires. The underlying problems of depression,
family upheavals and alcohol and drug misuse, which may be at the root of
self-harm, require treatment, but in the short-term view of the A&E doctor
they will tend to be ignored in favour of risk factors surrounding the
likelihood of immediate repetition. It is questionable whether an A&E
junior doctor can reliably determine something as complex as suicidal intent
in a young adolescent, or whether A&E - where the young person may be
suffering from the effects of an overdose and where parents may be emotional,
angry or feeling guilty - is the best place to make such an assessment.
Specialist assessment
Patients with certain risk factors, such as depression or a previous
history of psychiatric care, recorded in their case notes, were more likely to
be assessed by a specialist, but even in this group rates of discharge without
specialist assessment were worryingly high. Despite the implications for risk
of both re-attempting and other negative sequelae, 16- to 24-year-olds whose
self-harm attempt reportedly involved alcohol were not typically seen by a
specialist, while those using street drugs were significantly less likely to
receive specialist attention than other self-harm patients. The percentage of
patients with a clear indication of these risk factors not being seen by a
specialist is a cause for concern.
Understanding levels of service provision
Senior clinicians want to provide a good service and are aware of the
problems of non-specialist assessment in A&E. However, they tend to
overestimate both the proportion of young self-harm patients admitted and the
proportion assessed by a specialist. Where short-term risk is the key to
immediate specialist referral, patients with chronic difficulties but no
serious suicidal intent will receive little more than a medical response to
their crisis. The available evidence suggests that, in the opinion of
clinicians, the large majority of young self-harm patients do not have serious
suicidal intent (Hawton et al,
1982a,b;
Hurry & Storey, 1999).
Psychiatrists are normally responsible for specialist assessment, but many self-harm patients may not be diagnosed at clinical interview as suffering from the classic mental illnesses such as depression, anxiety or schizophrenia - perhaps only about a quarter or a third are so diagnosed (Hawton, 1986; Kerfoot, 1988; House et al, 1992). The psychological problems associated with repeated self-harm, with alcohol and drug misuse and with a generally chaotic lifestyle are less comfortably embraced by psychiatry. This may explain the fact that young self-harm patients involved with alcohol and drug misuse do not attract particular attention despite the fact that they are in a high-risk group for attempting, for suicide and for other negative psychosocial sequelae.
Future implications
An important gateway to treatment for young people who deliberately harm
themselves is appropriate psychosocial assessment following hospital
presentation. Such assessment is only reliably given by a specialist. The
factors associated with increased rates of specialist assessment are high
in-patient admission rates, the presence of a DSH team and the presence of
on-site psychiatric facilities. The evidence presented cannot demonstrate a
causal relationship between in-patient admission, DSH teams, on-site
psychiatry and increased rates of specialist assessment. However, the range of
potential options identified offers hospitals a useful degree of flexibility
when planning their response to this patient group. The case-study hospitals
not adopting one of these strategies had very low rates of specialist
assessment (Hurry & Storey,
1999).
The relatively low rates of specialist assessment offered to young self-harm patients, even those at quite high risk of long-term problems, should cause both A&E and psychiatric departments to reassess their provision. An important finding emerging from our study was the lack of awareness of senior clinicians of the level of service provided to young self-harm patients. Audit of service provision may be the first step necessary at the local level to identify difficulties.
There is a particular need to address the specific and problematic nature of this patient group. House et al (1992) commented that there is "a general perception that psychiatric intervention is ineffective for patients who are admitted to hospital having harmed themselves", and they remark that this in itself does not encourage A&E departments to take psychosocial assessment and referral very seriously. We need to know more about how to treat these patients effectively; this should be the focus of future research.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication March 9, 1999. Revision received July 6, 1999. Accepted for publication July 9, 1999.