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Self-harm is a major public health problem in the southern parts of India. This survey was undertaken to assess the nature of psychiatric services available in hospitals attached to medical colleges for those who have attempted suicide.
After reviewing the relevant literature, a questionnaire was prepared. We sent this questionnaire to 94 medical colleges in South India.
The response rate of the survey was 50%. Psychiatric assessment of suicide attempters in the casualty department are done by mental health professionals in 23 (66%) hospitals. Psychotropic medications are prescribed for appropriate patients in 33 (94%) hospitals, while talking therapies are available in 31 (89%) hospitals. Six (17%) centers have training sessions for casualty staff in mental health assessment of patients who have attempted suicide. A majority of hospitals have medical students posted in the psychiatry department.
The services available for people who have attempted suicide appear to be patchy in south Indian teaching hospitals. Training of frontline staff in the assessment and management of people who have attempted suicide is extremely important.
According to the World Health Organization (WHO) reports, approximately one million people die from suicide every year and 10-20 times more attempt suicide. Among the suicide attempters, 2% repeat the attempt and succeed within 10 years, with most of them succeeding within 2 years.[2–4] Eighty-five per cent of suicides in the world occur in low- and middle-income countries. Southern India has a high rate of suicide and the average suicide rate for young women is as high as 148 per 100,000 and 78 per 100,000 in men.
Self-harm is a major public health problem and it confers a considerable risk of completed suicide. Services for self-harm thus have great potential in suicide prevention. Clinical guidelines and standard operating procedures should specify how best to manage individual patients when they present to health services. There is a pressing need for epidemiological surveillance and appropriate local research for contributing to a better understanding of this major public health problem and improve the possibilities of prevention.
Service provision for self-harm remain extremely variable even in Western countries. The care of patients who attempt suicide needs to include psychiatric and psychosocial assessment and systematic referral to professional services after discharge. There is research evidence that individuals who leave accident and emergency (A and E) settings without psychosocial assessment have higher rates of repetition of self-harm. Several documents published in the West elaborating guidelines to care for those who self-harm emphasize the role of psychosocial assessments, multidisciplinary approaches to working, adequate training and supervision, and the organization of services.[15,16]
There are few studies looking at provision of services to patients who visit hospital following attempted self-harm in low- and middle-income countries. The infrastructure for healthcare in India is extensive and the provision and quality of services provided vary enormously. This study was conducted to survey the nature of services and training facilities provided by psychiatry departments of teaching hospitals in South India for managing patients presenting after an attempted suicide. These centers are considered to provide better services when compared to other government-run hospitals.
After reviewing relevant literature, a questionnaire was prepared. The questions related to the nature of the service, professionals available, details of treatment offered, liaison services, and training available, in managing individuals presenting after a suicide attempt. (The questionnaire is available from the authors on request). This questionnaire was sent to the head of psychiatry departments of all teaching hospitals in South India that are recognized by Medical Council of India (MCI). MCI is the statutory body that regulates medical education in the country. South India mainly comprises the four states – Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, and the Union Territory of Pondicherry – with a total population of more than 220 million.
Among the 94 medical colleges approved by MCI, the state of Karnataka had the highest number of medical colleges (28), closely followed by Andhra Pradesh (27). There were 20 medical colleges in Tamil Nadu, 14 in Kerala, and 5 in Pondicherry. The completed questionnaire was returned by 43 hospitals. We sent another copy of the questionnaire to all the non-responders and received four more responses. The response rate of the survey was 50%, with 12 of the responding colleges reporting that they do not have psychiatric services. The following results are for the 35 medical colleges who responded and have a psychiatry department.
The psychiatric assessment of suicide attempters in the casualty department are done by mental health professionals in 23 (66%) hospitals. This assessment is done by a psychiatrist in 17 (49%) centers and by a psychiatrist or a psychiatry trainee in 6 (17%) centers. In 9 (26%) centers, the initial assessment is done by casualty staff, mostly doctors and nurses.
In 13 (37%) hospitals, staff members in medical wards do an initial assessment of mental status before referring inpatients to psychiatrists. A detailed psychosocial assessment is done in the medical wards by a psychiatrist or a psychiatry trainee in 32 (92%) hospitals. Suicide attempters in the medical/surgical wards are assessed within 24 hours of their medical condition becoming stable in 33 (94%) hospitals. In this survey, 77% of the hospitals have clear cut guidelines regarding the referral routes for assessing patients who have attempted suicide.
Psychotropic medications are prescribed when indicated in 33 (94%) of the hospitals and talking therapies are available in 31 (89%) of the centers. Non-medical professionals like clinical psychologists are available in 19 (54%) and social workers in 20 (57%) of those centers. Of these, 31 (89%) arrange routine follow-ups for individuals who have attempted suicide and relatives of the patients are seen in 27 (77%) hospitals.
Six (17%) centers have training sessions for casualty staff (non-psychiatric) in the initial assessment of mental health of patients who have attempted suicide. A total of 27 (77%) hospitals have clear arrangements regarding ways to contact mental health professionals to assess patients admitted following a suicide attempt. A majority (94%) of the hospitals have medical students posted in the psychiatry department and 13 (57%) have postgraduate trainees in psychiatry. Ongoing training regarding assessment and management of patients who have attempted suicide are available at 12 (34%) centers.
This survey was done to assess the nature of psychiatric services for suicide attempters provided by MCI-recognized teaching hospitals in South India. We chose these hospitals as they are inspected and regulated by the statutory body to train medical students and are considered to be at the forefront of service provision and training. We believe that the response rate of 50% is satisfactory for this type of surveys. It is likely that many of the non-responders have no services of this nature. This may reflect the patchy nature of the services and the need for policies at the national level to rectify the situation.
It was found in this survey that only 66% of the centers have a system where a mental health professional assesses those who have self-harmed in the casualty department. Deliberate self-harm (DSH) patients who are not assessed and are discharged directly from the A and E may be at greater risk of further DSH and completed suicide as compared to those who are assessed. Further, DSH during the subsequent year occurred in 37.5% of the non-assessed patients as compared to 18.2% of matched assessed patients. Having a clear policy for referral to specialist psychosocial assessment of patients admitted to general medical wards is mandatory. A referral for self-harm assessment should be made when the patient is fully conscious and able to complete a psychosocial assessment. All hospital attendance following self-harm should lead to a specialist psychosocial assessment. This should aim to identify motives for the act and associated problems that might be amenable to intervention, such as psychological or social problems, mental disorder, and alcohol or other substance abuse. Presence of mental illness increases the suicide intent and lethality of the attempt.
Training in assessing suicide risk should be made widely available to staff working in areas where contact with suicidal patients regularly occurs, including accident and emergency departments and general medical wards. Non-specialist staff can be trained to perform assessments following self-harm. Studies have demonstrated that certain key skills in both assessment and management of people at risk of suicide can be taught to non-mental health professionals.[20,21] Given the patchy availability of psychiatric services even in teaching hospitals with psychiatry departments, training emergency physicians to perform psychosocial assessments and referring only those at a higher risk of repetition is more likely to succeed. Patients with a psychiatric diagnosis are at an increased risk of a repeat self-harm and appropriate management of mental illness is the cornerstone of any suicide prevention efforts. Psychological therapies like problem solving therapy and cognitive behavior therapy have been found to be useful in reducing repetition rates of deliberate self-harm. The importance of psychological therapies is obtaining more recognition, but funding and recruitment issues continue to be major hurdles. Professionals should remember the major role relatives can play in providing collateral information and supporting the patients. Successful interventions for suicide prevention in this sociocultural background would include the family as well.
Exposure to psychiatry is essential to attract medical students to become career psychiatrists. It is essential that skills for assessment of suicidal patients are taught during this attachment, as this is one of the essential skills identified by the World Psychiatric Association in its core curriculum in psychiatry for medical students. Only 34% of colleges have any ongoing training programmes in assessing and managing suicide attempters. This roughly corresponds to the number of colleges with postgraduate training courses in psychiatry. Training is essential to refresh and keep oneself abreast with information. The importance of refresher courses cannot be overemphasized in this area of psychiatry.
This study has a few limitations. We assessed the nature of services available only in teaching hospitals, which are generally better resourced than other hospitals where these findings might not be replicated. The next generation of studies should look at mapping services in other settings as well. We also did not try to assess the attitudes and satisfaction of the respondents with the care they provide. We acknowledge that this report suffers from the general limitations of a postal survey and the information provided in the response sheets cannot be verified.
Currently, there are few suicide prevention plans from this part of the world. Services available for psychosocial assessment and management of patients who present to emergency departments following attempted suicide are still patchy even in teaching hospitals in the southern part of India. It requires a concerted effort from the professionals to ensure a better service for this vulnerable population. Training of non-psychiatric medical personnel in psychosocial assessment and management of those who attempt suicide is a way forward in addressing this issue to some extent. However it is important to ensure that effective liaison psychiatry services are put in place to offer these patients a detailed psychiatric assessment and follow-up, as patients admitted to hospital are likely to represent a group with high psychiatric morbidity. It is important to set standards and formulate national guidelines for service provisions for those who attempt suicide.
We acknowledge the help provided by Dr. Saji Joseph, Dr. Manjumol S. and Dr. Rajesh Mohan at various stages of this study.
Source of Support: Nil
Conflict of Interest: None declared.