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.[14
] Having a clear policy for referral to specialist psychosocial assessment of patients admitted to general medical wards is mandatory.[15
] A referral for self-harm assessment should be made when the patient is fully conscious and able to complete a psychosocial assessment.[16
] 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.[17
] Presence of mental illness increases the suicide intent and lethality of the attempt.[18
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.[19
] 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
] 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.[22
] Psychological therapies like problem solving therapy[23
] and cognitive behavior therapy[23
] 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.[24
Exposure to psychiatry is essential to attract medical students to become career psychiatrists.[25
] 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.[26
] 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.[27
] 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.[28
] It is important to set standards and formulate national guidelines for service provisions for those who attempt suicide.