Study: Self-harm patients not receiving mental health evaluations

About half of self-harm patients treated in hospital emergency rooms and discharged did not receive a mental health evaluation before being sent home, according to a recent study.

Mark Olfson, M.D., a psychiatrist at Columbia University and his colleagues examined a year’s worth of Medicaid claims. In 7,355 episodes of deliberate self-harm, 4,595 were discharged without being hospitalized (including more than one visit by some individuals). Of those discharged, 47.5 percent had received a mental health assessment in the emergency department and 52.4 percent received a follow-up outpatient mental health visit within 30 days.

Olfson says adults who present to emergency departments following deliberate self-harm should receive a comprehensive mental health evaluation in addition to an evaluation of their medical health.

“Most adults who self-harm suffer from underlying psychiatric disorders, most commonly depression or a personality disorder often in combination with a substance use disorder,” he says. “Deliberate self-harm is also one of the strongest known risk factors for subsequent suicide. Many have few or weak social supports such as close friends or family members with whom they can confide and who can assist them if suicidal behavior becomes imminent.”

Abigail M. Judge, Ph.D., a licensed psychologist in Massachusetts, says one troubling aspect of the study was that those involved were beneficiaries of the Medicaid program. “These are already a vulnerable population,” she says. “Not only are the evaluations not occurring or maybe needing follow-up, but this is among an already vulnerable population.”

Judge says mental disorders are highly prevalent among adults who self-harm. “Even if there’s a lack of suicidal intent on that occasion, that’s not usually explicit with subsequent risk of suicidal intent. It’s a serious clinical presentation. It’s really incumbent on the clinician to understand what the behavior signifies.”

Emergency department physicians may be unlikely to determine suicidal intent on their own.

“This is a complicated issue even among psychologists and psychiatrists who are studying this,” Judge says. “So for a physician, involving a psychiatric evaluation is really critical, in my opinion.”

“People who are engaging in self-harm are in distress and the nature of that distress and the risk of suicidality needs to be rigorously evaluated.”

Olfson said it’s difficult to determine why such a large number of Medicaid insured adults who self-harm are discharged without a mental health assessment. “However, previous research indicates that many hospital emergency departments, especially those within smaller hospitals, have no access to mental health professionals,” he says. “In addition, surveys of emergency department staff suggest that in some emergency departments, staff tend to minimize the seriousness of self-injurious behavior, particularly when they occur among patients who have made several similar previous visits.”

He says a thorough assessment in the emergency department provides opportunities to engage the patient in care at a time when they may be highly motivated to seek relief from their distress.

Ben Johnson, Ph.D., ABPP, clinical psychologist and director at RICBT Cognitive Behavioral Therapy and Coaching, and a member of the Rhode Island Psychological Association, says it’s important for patients to get a solid referral to outpatient care, whether or not they are suicidal.

“The level of suffering, emotional suffering and disability among patients with self-harm issues is likely high and impulsivity is also likely high, so we need to find ways to streamline the referral to outpatient services and somehow find ways to motivate them to follow-up,” Johnson says. “Regardless of the perceived lethality of the method, it’s still a cry for help that society needs to take seriously and we shouldn’t have to focus on whether or not they were about to kill themselves in order to get motivated to really help them access care and reduce the barriers and stigma for going to psychotherapy.”

Barbara Pearson, Ed.D., a psychologist in Maine who works at a community mental health center and with a dialectical behavior therapy treatment team, says other than suicidal intent, patients with various disorders may self-harm. “Some categories of patients such as Borderline Personality Disorder have a fairly high incidence of this problem. In addition, disorders such as bulimia and anorexia can be life threatening and the emergency room can be an opportunity to identify the problem.”