Do individuals follow up with mental health services after a suicide attempt? Findings from the assertive management of attempted suicide service, Bengaluru, India.

OBJECTIVE: There is limited information from India on whether individuals follow up with mental health services after a suicide attempt. The objective of this study was to determine follow-up rates after a suicide attempt with mental health services of those individuals treated as part of the assertive management of attempted suicide service in a general hospital in Bengaluru, India.
MATERIALS AND METHODS: Records from 284 persons from January 2016 to December 2016 were analyzed to ascertain their follow-up rates with mental health services after a suicide attempt.
RESULTS: After discharge, 25% individuals followed up on a single occasion with mental health services. Individuals with a psychiatric diagnosis were significantly more likely to follow up with mental health services as compared to those without a psychiatric diagnosis (P < 0.011, odds ratio: 2.875, confidence interval at 95%: 1.276-6.481). 90.8% were contacted through telephone as part of aftercare.
CONCLUSIONS: Most individuals in India, especially those without a psychiatric diagnosis, do not follow up with mental health services after a suicide attempt. Periodic telephonic contacts are a useful aftercare strategy to reach out to this high-risk population. Limitation of this study is that findings are from an urban general hospital setting. Copyright:

BACKGROUND

Individuals with a previous suicide attempt are at high risk of repeat attempts as well as death.[1] However, most individuals with high suicide risk do not always access care from or follow up with mental health services.[2]

World Health Organization World Mental Health surveys showed that only 17% of persons with suicidal behaviors in low- and middle-income countries like India had received mental health care as compared to 56% of respondents in high-income countries.[3] Studies across the years and from different countries have similarly shown that individuals seeking help from general hospitals for medical complications arising from suicide attempts were not always seen by mental health services.[45]

Suicide rates in India are among the highest in the world.[6] The National Mental Health Survey in India showed a prevalence rate of 6.4% of suicide risk in the population sample.[7] A study on persons with suicide attempts attending medical emergency of a tertiary general hospital in a North Indian city showed that almost half of these individuals had a psychiatric diagnosis.[8] In a record review of medically stabilized individuals who had attempted suicide and were treated in a crisis intervention center in a tertiary general hospital in South India, the authors noted that personality traits like hostility were predictive of suicidal intent.[9]

Findings from a large multisite study showed that brief interventions along with aftercare delivered to individuals after a suicide attempt significantly improved outcomes compared to treatment as usual.[10] While a randomized controlled trial in India showed similar results, information from India on whether individuals follow up with mental health services after a suicide attempt is sparse.[11] It is in this background that we report on follow-up rates of individuals treated in a general hospital setting after a suicide attempt with mental health services in Bengaluru, India.

MATERIALS AND METHODS

The setting of this service was a Medical College Hospital in Bengaluru, India, with a general hospital psychiatry unit. Before January 2016, individuals with suicide attempts admitted in various clinical wards in the study site for medical complications were seen by psychiatry after referral from treating team. An internal audit revealed that a significant number of these individuals were discharged without being seen by psychiatry. Hence, in January 2016, the assertive management of attempted suicide (AMAS) service was set up in the study site to ensure that individuals admitted for treatment of medical complications resulting from suicide attempts were assertively provided mental health care even before a formal psychiatry referral. Refer to Figure 1 for delivery of mental health care through AMAS.

Figure 1

Flowchart showing the delivery of mental healthcare through assertive management of attempted suicide

The AMAS was primarily co-ordinated by a service manager (SM) who was a qualified general staff nurse. SM was trained in diagnostic interviewing, use of M.I.N.I. 5.0 and basic counseling using live demonstrations and didactic training by a psychiatrist. Other psychiatrists then independently assessed and confirmed the quality of SM's work through the process of observation. This assessment was done before initiation of AMAS. SM's work performance with respect to diagnostic interviewing and counseling was monitored on a constant basis subsequently by several psychiatrists over duration of 6 months. Feedback over SM's work performance was also taken at multiple intervals from consultants from clinical departments like emergency and general medicine where persons with suicide attempts were admitted for treatment of medical complications.

As part of AMAS, SM identified patients with suicide attempts admitted in medical wards from admission registers in the emergency. The SM established contact with the patient and the caregiver and sensitized them for the need for psychiatric evaluation. The SM then performed a detailed intake which included a semi-structured sociodemographic pro forma and also used the M.I.N.I. 5.0 to determine a preliminary psychiatric diagnosis. After the intake, the SM ensured that a psychiatric consultant evaluated the individual. The psychiatric consultant established the presence/absence of a psychiatric diagnosis according to ICD 10 guidelines and associated contextual factors. The psychiatrist formulated an individualized treatment plan depending on the patient's condition. SM ensured the implementation of this treatment plan simultaneously along with medical management by liaising between psychiatry and medical departments. While there were always concerted efforts made to transfer the patient to psychiatry once the medical complications were addressed, most patients got discharged against medical advice without inpatient psychiatric care due to financial and other logistic reasons. Taking cognizance of this before discharge, SM counseled individuals and caregivers about symptoms of mental illness and emotional distress, encouraged adherence with prescribed treatment plan and regular follow-up with mental health services.

The SM typically evaluated around 2–5 patients/day. The SM was a single individual and worked from Monday to Saturday between 9:00 am and 5:00 pm. The SM's primary responsibility was to coordinate the delivery of essential mental health care to individuals with medically suicide attempts and to ensure that these individuals are seen by mental health professionals. The actual mental health treatment was delivered by a multidisciplinary team that involved a psychiatrist, psychiatric social worker and clinical psychologist. The SM was primarily dedicated only for AMAS and typically did not carry out any clinical responsibilities other than those pertaining to AMAS.

After discharge, SM contacted individuals and caregivers through phone calls to check in on them. In the course of the phone call, SM reiterated need for adherence to treatment and follow-up with mental health services. The first phone call was within the 1stweek of discharge, the next phone call 2 weeks after the previous call, and subsequently, the patient was followed up on phone monthly for 6 months. Thus, each patient would receive around 7 phone calls over 6 months. As part of the efforts to reach out to the individual and/or caregiver, SM made at least two attempts over a period of 2 separate days. SM documented all the variables, treatment plan, and details of phone calls in separate case registers for AMAS.

Details of study objectives, methods, and statistical analysis

The primary objective of this study was to determine the follow-up rates with mental health services of individuals seen by AMAS within 6 months after a suicide attempt. Follow-up for the purposes of this study was defined as follow-up documented in case records of AMAS by the individual on at least one occasion with any mental health services. All individuals seen by AMAS were encouraged to follow up with mental health services in the study site itself. Those already under psychiatric treatment from other centers before their attempts were encouraged to continue follow-up with their original mental health services. Those individuals residing at a considerable distance from the study site and referred for medical complications, were encouraged to seek help from mental health services closer to their residence or the study site depending on the individuals' preferences.

The secondary objective was to assess for significant differences between two groups of individuals: those who followed up and those who did not follow up even once with mental health services. The variables analyzed included age, gender, religion, education levels, marital status, type of employment, past history of suicide attempts, and psychiatric diagnosis. While the initial psychiatric diagnosis as part of the intake was made according to M.I.N.I. 5.0 by SM, the final psychiatric diagnosis recorded was made by treating psychiatrist according to clinical interview on the basis of ICD-10 guidelines. The details of in-person follow-up, whether the individual/caregiver answered the phone calls and number of phone calls received, were also obtained from case records of AMAS.

We received approval from Institutional Ethics Committee to report findings from case records of AMAS (IEC no: 224/2016). We performed the analysis using SPSS 16 (version 16.0, IL, Chicago, USA). As part of the analysis, we initially assessed continuous data for normal distribution using Shapiro–Wilk test. As the continuous data (“age of individual,” “number of deaths due to suicide,” and “number of phone-calls answered”) was not in normal distribution, we performed comparisons using Mann–Whitney tests for independent samples. We used Chi-square test with Fisher's correction where applicable for categorical variables and binomial logistic regression to determine significant predictors of follow-up with mental health services after a suicide attempt.

RESULTS

We studied records of 300 individuals treated as part of the AMAS from January 2016 to December 2016. Sixteen were excluded due to reasons of death in the ward or immediately after discharge from medical complications, revision of suicidal attempt to accidental self-harm, and inadequate data due to individuals and family refusing all medical care.

There was no significant difference between median ages of those individuals who followed up with mental health services after a suicide attempt and those who did not (median age in those who followed up: 26, median age in those who did not follow up: 27; Mann–Whitney U: 6958, P = 0.313). Seven individuals from the study population died by suicide within a year of discharge (median = 2 in those who followed up, median = 5 in those who did not follow up, Mann–Whitney U: 4945.0, P = 0.997).

Follow-up rate of individuals with mental health care services on at least one occasion within 6 months after the attempt was 25%. There were no significant differences between those who followed up and those who did not with respect to sociodemographic variables and past history of suicide attempt [Table 1]. It was observed that 29% of individuals with a psychiatric diagnosis followed up with mental health services as compared to 12% of individuals without a psychiatric diagnosis (χ2= 6.885, P = 0.009).

Table 1

Comparison of sociodemographic variables between those who followed up and those who did not

Sociodemographic variables	Followed up once (n=71; 25%)	Did not follow up at all (n=213; 75%)	χ2	Significance*
Gender
Men	31 (26.05)	88 (73.94)	0.121	0.728
Woman	40 (24.24)	125 (75.75)
Marital status
Single	29 (25.21)	86 (74.78)	0.005	0.944
Marrieda	42 (24.85)	127 (75.14)
Education levels
7th grade and below	9 (16.07)	47 (83.92)	3.348	0.188
8th grade to diploma/Grade 12	35 (25.73)	101 (74.26)
Graduation	27 (29.34)	65 (70.65)
Occupation
Unemployed	15 (21.12)	26 (12.20)	13.033	0.071
Homemaker	11 (15.49)	54 (25.35)
Farmer	3 (4.22)	9 (4.22)
Self-employed	3 (4.22)	25 (11.73)
Unskilled	3 (4.22)	13 (4.57)
Skilled	13 (18.30)	33 (15.49)
Professional	13 (18.30)	40 (18.77)
Student	10 (14.08)	13 (6.10)
Religion
Hindu	61 (25.4)	179 (74.6)	0.162	0.922
Christian	7 (23.3)	23 (76.7)
Muslim	3 (21.4)	11 (78.6)
Past suicide attempt
No past attempt	52 (23)	174 (77)	2.34	0.126
Past attempt present	19 (32.8)	39 (67.2)

*P<0.05 is considered as significant

We performed a binomial logistic regression to ascertain whether the presence of psychiatric diagnosis predicted follow-up with mental health services and adjusted for confounders that could potentially affect follow-up such as age, sex, marital status, and past history of suicide attempt. The results showed that individuals with a suicide attempt with a psychiatric diagnosis were significantly more likely to follow-up on at least one occasion with mental health services as compared to individuals without a psychiatric diagnosis (P < 0.011, odds ratio: 2.875, confidence interval at 95%: 1.276–6.481). In the group of individuals with psychiatric diagnoses, nearly half of the group of those with diagnoses of bipolar disorder and obsessive–compulsive disorder and psychoses (44%) followed up with mental health services on at least one occasion while follow-up rates were the least in those with substance use disorders [Table 2].

Table 2

Comparison of follow-up rates across various groups of diagnosis with mental health services

Presence of psychiatric diagnosis	Followed up once (n=71; 25%)	Did not follow up at all (n=213; 75%)	χ2	Significance
No diagnosis	8 (12.5)	56 (87.5)	12.073	0.017*
Adjustment disorder, depression, and anxiety	46 (29.67)	109 (70.32)
Substance use	5 (16.12)	26 (83.87)
Bipolar, OCD, and psychoses	8 (44.44)	10 (55.55)
Personality disorder	4 (25)	12 (75)

*P<0.05 is considered as significant. Diagnoses are grouped according to severity of symptoms. OCD – Obsessive compulsive disorder

90.8% of the individuals were contacted at least once by phone during the same period. There were no significant differences in the number of calls answered by individual/caregiver between those with a psychiatric diagnosis and those without a psychiatric diagnosis (median of number of calls in those with a psychiatric diagnosis = 6, median number of calls in those without a psychiatric diagnosis = 5, Mann–Whitney U = 6837, P = 0.720).

DISCUSSION

Our study showed that 25% of those who attempted suicide followed up with mental health services at 6 months. These findings are similar to those from a community study in Mexico City that showed 1-year prevalence rate of mental health service use was 21% among adolescents with suicide attempt.[12] Another study from China showed that only 6.8% of those who attempted suicide sought help from professional mental health services.[13] A study from USA showed that Asian Americans with suicidal ideation were less likely to seek help from professional mental health sources as compared to other ethnic groups.[14] These findings indicate that help-seeking patterns in persons with suicidal behaviors in India as well as other low- and middle-income countries need to be studied systematically to achieve greater understanding of such low use of professional mental health services.

Most individuals who attempt suicide have mental illnesses.[15] However, in India and other developing countries, a significant proportion of those who attempt suicide do not qualify for a psychiatric diagnosis.[8916] Findings from our study show that around 22.5% of individuals do not meet criteria for any psychiatric diagnosis [Table 2] and that these individuals were significantly less likely to never follow-up at all with mental health services. We hypothesize that in certain settings, individuals not meeting criteria for psychiatric disorders might also not perceive their suicidal behaviors and ideation as symptoms of serious mental illness. In such a scenario, they might not access professional mental healthcare services due to a perception that such services might not be of use to them.

Our study also showed that a very low proportion of those with substance use disorders followed up with mental health services after a suicidal attempt [Table 2]. Research from India showed that treatment contact with any kind of health provider for persons with alcohol disorders was 2.8% and for those with depression was 12.75%.[17] Considering that persons with common mental disorders such as substance use disorders and depression do not utilize mental health services optimally in Indian settings, our results lead to the inference that such suboptimal service utilization also extends to individuals with suicide attempts.

A significant proportion of individuals in our study were diagnosed with adjustment disorders, depression, and anxiety disorders [Table 2]. Research from Mumbai has shown a significant association of suicide attempts with stressors.[16] In a community survey from southern India, 50% of the male respondents believed that suicide was a reasonable resolution for certain situations.[18] In a study on influence of stress and depression on suicide related beliefs, Asian origin Americans reported a significant degree of association between perceived stress and suicide related beliefs even in the absence of depression.[19] These studies support the inference that a significant proportion of individuals in our study might have attempted suicide as a reaction to stressors and did not consider their suicidal actions as a medical symptom warranting help from mental health services.

Studies have shown that a significant proportion of individuals with suicidal behaviors do not engage with aftercare for their mental health issues on a regular basis.[20] Our study showed that 90.8% of individuals answered phone calls from mental health services as part of aftercare. Other studies have also showed that telephone contacts can be useful as aftercare in persons at high risk for suicide. In a study conducted on men at high suicide risk in Canada, interventions comprising of telephone support program was perceived more useful and relevant by the participants as compared to interventions comprising of rapid referral to mental health services or information sessions.[21] Telephone-based interventions have also been effective in delaying suicide reattempt in individuals who have attempted suicide.[22] Literature review of studies in suicide prevention suggests that regular active contact with individuals at high suicide risk is protective.[23] Findings from India also support this.[24]

We infer that telephone contacts have the potential to serve as a useful strategy to reach out to individuals after a suicide attempt in India. However, it is to be noted that outcomes of telephone-based programs indicate that beneficial effects are not necessarily persistent over long duration.[25]

Limitations of study and future directions

This study reports on findings from a clinical service located in an urban Medical College Hospital with psychiatry unit in Bengaluru, India. All individuals seen as part of AMAS had medically serious suicide attempts that required at least a day's admission in medical units. The study findings cannot be generalized to individuals with low lethality attempts or those in community settings. The AMAS also did not record details on the income of those affected.

Findings from this study do indicate the need in the future for a systematic inquiry into reasons for individuals not accessing mental health services after a suicide attempt, especially in India. There is also a need for the authors to systematically analyze the longitudinal data from the phone calls as part of the AMAS hereafter.

CONCLUSIONS

Most individuals with suicide attempts, especially those without a psychiatric diagnosis treated in an urban general hospital setting in Bengaluru, India, do not follow up with any mental healthcare services after discharge. Periodic telephonic contacts are a potentially useful after-care strategy to reach out to this population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.