Actu Psychiutr Scund 1999: 100: 309-311 Printed in UK. All rights reserved

Copyright 63 Munksgaurd 1999

A CTA PS YCHIATRICA SCANDINA VICA ISSN 0902-4441

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Is suicide risk taken seriously in heavy drinkers who harm themselves?

Taylor C, Cooper J, Appleby L. Is suicide risk taken seriously in heavy drinkers who harm themselves? Acta Psychiatr Scand 1999: 100: 309-311. 0 Munksgaard 1999.

Objective: The aim of the study was to examine whether a known history of heavy drinking adversely influences the assessment and management of deliberate self-harm (DSH) by accident and emergency department staff. Method: Standard assessment forms on a consecutive series of 909 DSH cases were examined. Estimated suicide risk and clinical management were compared in patients who reported high (more than 7 units per day) and low/moderate alcohol intake. Results: Heavy drinkers had higher rates of several risk factors for suicide. They were more likely to be judged as at high risk of suicide and further self-harm, and were more likely to receive clinical management appropriate to people at high risk. However, a logistic regression analysis revealed that it was not alcohol use itself but risk factors that were more common in heavy drinkers that predicted clinical management. Conclusion: The results suggest that heavy drinkers are in general judged to be at higher risk of suicide and managed accordingly. However, training for accident and emergency department staff should emphasize the importance of alcohol as an independent risk factor for suicide.

Introduction

Alcohol misuse is an important risk factor for suicide in the general population (1) and a key predictor of suicide after deliberate self-harm (DSH) (2, 3). However, patients who are alcohol dependent may produce a number of hostile attitudes in clinicians, making them less likely to offer help (4). We used a large DSH database to determine whether the assessment and management of self-harming patients was influenced if the patients were known to be drinking heavily. The study hypotheses were (a) that DSH patients who were heavy drinkers would have high rates of many of the main risk factors for suicide and (b) that, despite this, they would be less likely to be considered at high risk of suicide or to require specialist services.

C. Taylor, J. Cooper, 1. Appleby School of Psychiaty and Behavioural Sciences. University of Manchester. Withington Hospital. Manchester. UK

Key words risk assessment, accident and emergency, alcohol, suiclde. deliberate self-harm

Louis Appleby. School of Psychiatry and Behavioural Sciences, University of Manchester, Withington Hospital. Manchester, M20 8LR. UK

Accepted for publication May 11, 1999

Material and methods

Four hospitals participate in the Manchester and Salford Self-Harm (MASSH) project, a city-wide monitoring system which collects information on individuals presenting to accident and emergency departments as a result of DSH. Standard assess- ment forms covering social and clinical character- istics, details of self-harm, estimated risk of suicide and further self-harm (high, moderate or low) and clinical management are completed for each patient by accident and emergency staff. We examined subgroups of patients defined by their habitual alcohol consumption and compared them with regard to estimated risk of suicide and further self-harm, and clinical management. High alcohol use is defined in the assessment forms as reported consumption of 7 or more units per day. Estimated

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Table 1 Comparison of prevalence of suicide risk factors in high and low alcohol users

High alcohol users l o w alcohol users Chi-square test Risk factor n ( % I ” n (%)” (df = I in all cases)

Demographic characteristics Male No partner Living alone Unemployed long-term unemployed

( > 26 weeks) Psychiatric characteristics

Previous self-harm Previous psychiatric treatment Current psychiatric treatment Current drug abuse

Attempt was premeditated Tried to avoid discovery Left suicide note Wanted to die

Current assessment Suicidal thoughts Suicidal plans High medical risk

Details of attempt

108 (58) 129 (72) 72 (40)

109 (59) 86 (58)

134 (75) 113 (64) 76 (42) 27 (IS)

66 (39) 28 (17) 13 (8)

107 (66)

103 (61) 63 (38) 97 (53)

225 (40) 406 (73) 170 (31) 227 (41) 310 (12)

291 (53) 265 (48) 192 134) 58 ( I 1 )

182 (33) 89 (17) 71 (13)

321 (60)

268 (50) 125 (24) 277 (50)

x2-174, P<OOOl x2=O0O, P=0960 x2 = 4 37. P= 0 037 xZ=1790. P tO001 x2=941, P=OOO2

x2=21.5. P<OOOl x2=12.4. P<OOOl x2=3.19, P=0074 xZ=2.65, P=O 104

xZ=1.l5. P=0.185

xZ = 3 19. P = 0.074 x2=1 67, P=0196

xZ=6O1, P=0014 x2=12.5, P<O.OOl x2=024, P=0625

x2 = 0 00, P = 1 .ooo

Percentage figures refer to cases for which information was available ( > 88% for each item)

risk of suicide and further self-harm was divided into two categories, namely high and lowlmoderate. Management was considered to be ‘high risk’ if the individual was referred to specialist services such as a drug misuse team or mental health services, or if they were admitted as an in-patient (this would normally lead to psychiatric assessment). Management was considered to be ‘low risk’ if there was referral only to the general practitioner or no follow-up.

Results

Assessment forms were collected on 909 individuals aged 16 years or over during a 6-month study period between 1 September 1997 and 28 February 1998. The item on alcohol use was completed in 751 cases (83%). In total, 187 subjects (25%) were high alcohol users. No assessment forms were completed for a further 275 deliberate self-harm patients known to have been seen by mental health services during the study period. Many of these cases appear to have been referred directly to mental health

services without assessment in the accident and emergency department because they were already under the care of mental health services.

High alcohol users had a higher rate of many of the main risk factors for suicide (see Table 1). Of 16 risk factors selected for study (from previous literature), 7 risk factors were more common in high alcohol users, namely male sex, living alone, being unemployed, previous self-harm, previous psychiatric treatment, current suicidal thoughts and current suicidal plans. One risk factor, namely long- term unemployment, was more common in low alcohol users.

Table 2 shows that high alcohol users were more likely to be assessed as being at higher risk of suicide and of further self-harm. They were also more likely to receive ‘high-risk’ clinical management. However, Table 3 shows that when all variables associated with ‘high-risk’ management were entered into a multiple logistic regression, the main predictors were male sex, trying to avoid discovery, current suicidal thoughts, current suici- dal plans and high medical risk, but not high alcohol consumption.

Table 2. Estimated risk and clinical management of high and low alcohol users following self-harm

High alcohol users n 1%)”

Low alcohol users n 1%)”

Chi-square test (df = 1 in all cases)

High estimated risk of suicide High estimated risk of further self-harm ‘High-risk’ clinical management

113 (63) 151 (83) 146 (82)

268 (49) 340 (62) 366 (68)

x2 = 9 64, P = 0.002

x 2 = l l 6. P=OOOl x2=21 9. P<O.OOl

aThere were 187 high alcohol users and 564 low alcohol users Percentages are based on the number of forms on which the item listed was completed (>95% for each item)

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Suicide risk in heavy drinkers

Table 3 Main predictors of 'high-risk clinical management following self-harm (multiple regression)

High-risk clinical management

(n=609) n 1%)"

Low-risk clinical management

n ( % l a (n=222)

Odds ratio (95% confidence

interval)

Male Tried to avoid discoven/ Current suicidal thoughts Current suicidal plans High medical risk

294 (48%) 110 (21%) 331 (65%) 186 (37%) 331 (60%)

80 (36%) 8 (4%)

7 (3%) 62 (29%)

41 (20%)

1 62 (1 05-2 50) 2 91 (1 30-6 55) 3 30 (2 01-5 43) 5 29 (2 09-13 40) 2 60 (1 69-3 98)

a Percentages are based on the numbers of forms on which the item listed was completed (>87% for each item)

Discussion

This is a rare positive result on risk assessment. Previous studies, including those involving Manchester hospitals, have shown that risk assess- ment following DSH is poorly conducted (5 ,6) , and it is possible that in this study the assessment forms themselves assisted clinical decision-making by providing a check-list of risk factors. Our results show that the high suicide risk in habitual heavy drinkers is reflected in their clinical assessment and management. However, it is not alcohol use itself but the risk factors that are found in high alcohol users, namely current suicidal thoughts and plans and male sex, which appear to determine these judgements. Training in risk assessment for trainee doctors in accident and emergency departments should emphasize alcohol as an independent risk factor for further deliberate self-harm and future suicide.

Acknowledgements The MASSH project is funded by Manchester Health Authority, South Manchester University Hospitals NHS

Trust, Central Manchester Healthcare NHS Trust, North Manchester Healthcare NHS Trust and The Mental Health Services of Salford NHS Trust. We are grateful to the trainee doctors who completed the assessment forms.

References

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2. HAWTON K, FAGG J, PLATT S, HAWKINS M. Factors associated with suicide after parasuicide in young people. Br Med J 1993;306: 1641 -1644.

3. BECK AT, STEER RA. Clinical predictors of eventual suicide: a 5- to 10-year prospective study of suicide attempters. J Affect Disord 1989;17:203-209.

4. FARRELL M, LEWIS G. Discrimination on the grounds of diagnosis. Br J Addict 1990;85:883-890.

5. KAPUR N, HOUSE A, CREED F, FELDMAN E, FRIEDMAN T, GUTHRIE E. Management of deliberate self-poisoning in adults in four teaching hospitals: descriptive study. Br Med J

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