Factors associated with the non-assessment of self-harm patients attending an Accident and Emergency Department: results of a national study.

BACKGROUND: Psychosocial assessment of self-harm patients by mental health service staff is an important aspect of their care. Nevertheless, in England around half of those attending a general hospital following a self-harm episode do not receive such an assessment. We have investigated the reasons for this and the characteristics of patients associated with self-discharge or planned discharge without a psychosocial assessment.
METHOD: 8-week audits of self-harm attendances were carried out in 32 Accident and Emergency Departments in England. Where a specialist psychosocial assessment by mental health services was not carried out, information on the reason for this was requested. Due to incomplete data 10 of the 32 hospitals were excluded from analysis.
RESULTS: There were 2780 self-harm attendances at the 22 hospitals. Psychosocial assessments were carried out on 59% of episodes. Among those not assessed, 57% discharged themselves and the remainder were discharged by hospital staff. In multivariable models, being male, taking illegal drugs/alcohol, attendance out of office hours and not being admitted to a hospital bed were associated with an increased risk of self-discharge. Younger subjects were more likely to self-discharge, but this association was explained by age-related admission patterns. Young age (<45 years), no previous self-harm and not being admitted were associated with an increased likelihood of discharge by hospital staff without a psychosocial assessment. The apparent increased risk of discharge without an assessment for those who self-lacerated was attenuated after allowing for their lower admissions rates. LIMITATIONS: Missing data from 10 hospitals led to their exclusion from analysis. Only the primary reason for discharge was reported on the audit forms.
CONCLUSIONS: Those at elevated risk of suicide--older patients and those with a history of self-harm--were the least likely to be discharged by hospital staff without a psychosocial assessment. However, males (at increased risk of suicide compared with females), those who had taken illegal drugs or/and alcohol and those attending 'out of hours' were more likely to self-discharge. Services need to be modified and evaluated, based on further information about why such individuals are not currently engaging in services.