Annotated Abstracts of Journal Articles
2015, 1st Quarter
Annotations by Scott Simpson, MD, MPH
of the APM Emergency Psychiatry SIG
Milner AJ, Carter G, Pirkis J, Robinson J, Spittal MJ
Br J Psychiatry 2015; 206(3):184-190
ANNOTATION (Scott Simpson)
The Finding: The authors conducted a meta-analysis to examine the value of brief contact interventions for reducing self-harm after a hospital or healthcare encounter. Twelve studies comprising over 7000 patients were included; studied interventions included postcard, telephone, and letter follow-ups. These interventions did not statistically reduce self-harm or completed suicide. In a subsequent analysis on the effect of the total number of self-harm episodes over time, these interventions reduced repeated self-harm by 33% (IRR = 0.66, 95% CI 0.54-0.80).
Strength and Weaknesses: This meta-analysis helpfully summarizes different low-cost, brief follow-up interventions applicable to emergency psychiatric services. Multiple analyses clarify that these interventions may be most helpful for those with prior and repeated self-harm attempts. As most of the included studies are smaller, a meta-analysis is aptly suited to making sense of the literature.
However, to maximize, the authors collected a heterogeneous collection of trials. Interventions varied widely, several studies were of low quality, were quite old, or had a “high risk of bias.” The statistically significant report of reduction in repeated self-harm is based on only three of the twelve studies. Even with a meta-analysis, there is probably not enough power to detect a difference on completed suicide. Finally, the authors cannot exclude publication bias.
Relevance: The value of follow-up contact interventions for reducing self-harm after a healthcare encounter remains unclear. The overall evidence base for these interventions is not strong, but there may be nuanced benefit for patients with multiple self-harm episodes.
Background: There is growing interest in brief contact interventions for self-harm and suicide attempt.
Aims: To synthesise the evidence regarding the effectiveness of brief contact interventions for reducing self-harm, suicide attempt and suicide.
Method: A systematic review and random-effects meta-analyses were conducted of randomised controlled trials using brief contact interventions (telephone contacts; emergency or crisis cards; and postcard or letter contacts). Several sensitivity analyses were conducted to examine study quality and subgroup effects.
Results: We found 14 eligible studies overall, of which 12 were amenable to meta-analyses. For any subsequent episode of self-harm or suicide attempt, there was a non-significant reduction in the overall pooled odds ratio (OR) of 0.87 (95% CI 0.74-1.04, P = 0119) for intervention compared with control. The number of repetitions per person was significantly reduced in intervention v. control (incidence rate ratio IRR = 066, 95% CI 0.54-0.80, P<0001). There was no significant reduction in the odds of suicide in intervention compared with control (OR = 0.58, 95% CI 0.24-1.38).
Conclusions: A non-significant positive effect on repeated self-harm, suicide attempt and suicide and a significant effect on the number of episodes of repeated self-harm or suicide attempts per person (based on only three studies) means that brief contact interventions cannot yet be recommended for widespread clinical implementation. We recommend further assessment of possible benefits in well-designed trials in clinical populations.
ANNOTATION (Scott Simpson)
The Finding: All emergency psychiatrists are familiar with “high utilizing” patients. In this study, a cohort of 210 patients who frequently utilized an urban psychiatric emergency service (PES) was followed for three years. After one year, most patients (78%) ceased to be high utilizers. Only 4% of the cohort continued to be high utilizers through all three subsequent years. Besides a history of frequent PES visits preceding the study period, only a personality disorder diagnosis predicted continued high utilization.
Strength and Weaknesses: This work extends prior descriptions of high utilizers by following recurrent utilization over several years. This longitudinal description helps differentiate short-term and longer-term high utilizers. In this study, patients with new, “incident” high utilization frequently had no prior psychiatric history; long term, recurrent high utilization was associated with a personality disorder in multivariate analysis (but not homelessness, social support, substance abuse, or psychosis).
Several weaknesses should be noted. As with most studies in emergency psychiatry, only one hospital site was included. The authors note that demographic variables were not associated with high utilization, but a very high proportion of patients were homeless or unemployed (65% of the initial cohort and 78% of those patients with high utilization every year of the study). Social chaos likely plays a role in frequent utilization even if it does not stand out in this analysis. Finally, the study’s setting in Switzerland may limit generalizability to countries with less supportive social systems, though the urban environment described is similar to that of many PES units.
Relevance: The concept of “high utilization” remains poorly defined, and multiple years may be necessary to adequately characterize a patient’s PES utilization. Personality disorders appear to contribute a particular risk for recurring PES utilization over time.
Objective: Many patients visit psychiatric emergency services several times per year, which raises questions about the limits of this treatment setting. Previous studies have focused on recurrent visits over one year of follow-up. This study examined sociodemographic and diagnostic predictors of recurrent visits (three or more visits a year) to a psychiatric emergency service over three consecutive years.
Methods: This three-year retrospective cohort study used data from computerized administrative and medical records of 4,322 patients who visited the psychiatric emergency service of the University Hospitals of Geneva, Switzerland, at least once in 2008.
Results: A total of 210 (5%) of the 4,322 patients had three or more visits in 2008. Of these, 22% also had recurrent use (three or more visits per year) in 2009, 2010, or 2011, and 78% did not. Recurrent visits were not predicted by sociodemographic characteristics, such as age, gender, marital status, professional activity, and citizenship. Two variables were significant predictors of recurrent visits: a diagnosis of a personality disorder and recurrent use of the emergency service in the 18 months before study entry in 2008.
Conclusions: Patients with personality disorders and past recurrent use of emergency services appeared to rely more on psychiatric emergency services for continuous psychiatric care than patients without past recurrent use of emergency services and patients with mood, substance use, anxiety, or psychotic disorders. Creation of a follow-up treatment program for this clinical population within the psychiatric emergency setting itself may provide better access to care for these patients.