Title: Implementation of evidence‐based intervention for suicidal patients admitted to the emergency department: Implications from our real‐world experience of assertive case management
Abstract: Psychiatry and Clinical NeurosciencesVolume 75, Issue 3 p. 108-109 Letters to the EditorFree Access Implementation of evidence-based intervention for suicidal patients admitted to the emergency department: Implications from our real-world experience of assertive case management Kazuya Okamura MD, Corresponding Author Kazuya Okamura MD [email protected] orcid.org/0000-0002-4665-4849 Department of Psychiatry, Nara Medical University School of Medicine, Nara, Japan Correspondence: Email: [email protected] for more papers by this authorTakashi Komori MD, Takashi Komori MD Department of Psychiatry, Nara Medical University School of Medicine, Nara, JapanSearch for more papers by this authorMai Sugimoto BA, Mai Sugimoto BA Psychiatric Medical Center, Nara Medical University Hospital, Nara, JapanSearch for more papers by this authorYoshitaka Kawashima PhD, Yoshitaka Kawashima PhD orcid.org/0000-0001-8250-3004 Clinical Psychology Course, Department of Psycho-Social Studies, School of Arts and Letters, Meiji University, Tokyo, Japan Department of Neuropsychopharmacology, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, JapanSearch for more papers by this authorMitsuhiko Yamada MD, PhD, Mitsuhiko Yamada MD, PhD orcid.org/0000-0002-5649-2310 Department of Neuropsychopharmacology, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, JapanSearch for more papers by this authorToshifumi Kishimoto MD, PhD, Toshifumi Kishimoto MD, PhD Department of Psychiatry, Nara Medical University School of Medicine, Nara, JapanSearch for more papers by this author Kazuya Okamura MD, Corresponding Author Kazuya Okamura MD [email protected] orcid.org/0000-0002-4665-4849 Department of Psychiatry, Nara Medical University School of Medicine, Nara, Japan Correspondence: Email: [email protected] for more papers by this authorTakashi Komori MD, Takashi Komori MD Department of Psychiatry, Nara Medical University School of Medicine, Nara, JapanSearch for more papers by this authorMai Sugimoto BA, Mai Sugimoto BA Psychiatric Medical Center, Nara Medical University Hospital, Nara, JapanSearch for more papers by this authorYoshitaka Kawashima PhD, Yoshitaka Kawashima PhD orcid.org/0000-0001-8250-3004 Clinical Psychology Course, Department of Psycho-Social Studies, School of Arts and Letters, Meiji University, Tokyo, Japan Department of Neuropsychopharmacology, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, JapanSearch for more papers by this authorMitsuhiko Yamada MD, PhD, Mitsuhiko Yamada MD, PhD orcid.org/0000-0002-5649-2310 Department of Neuropsychopharmacology, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, JapanSearch for more papers by this authorToshifumi Kishimoto MD, PhD, Toshifumi Kishimoto MD, PhD Department of Psychiatry, Nara Medical University School of Medicine, Nara, JapanSearch for more papers by this author First published: 20 November 2020 https://doi.org/10.1111/pcn.13175Citations: 1AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Most suicidal patients are suffering from psychiatric disorders.1 It is widely recognized that patients admitted to emergency departments (ED) for suicidal behavior have high risk of repeated suicide attempt and suicide deaths.2, 3 In 2016, the assertive case management for suicide attempters, which had been developed for the ACTION-J study,4 was adopted by the National Health Insurance System in Japan.5 Here, we report our real-world experience of this management for the first time. This case report was prepared in accordance with procedures specified by the Ethics Committee of Nara Medical University. Written informed consent was obtained from the patient, and her anonymity has been preserved. Our patient was a 25-year-old traditional craftswoman, who lived alone, distantly from her parents. She was a hard worker and her job required delicate techniques. As she had gotten used to her job, her workload had increased. Gradually, insomnia and dysphoria appeared, which made it difficult for her to concentrate on the job. She experienced anxiety, self-accusation, and suicide ideation, and began drinking alcohol heavily to ease her distress. One day, after drinking, she slit her wrist deeply and was transferred to our hospital. Her injury was serious, and an emergency physician performed surgery to repair the flexor tendon rupture of the left flexor carpi radialis muscle and median nerve injury. Then, the doctor consulted our psychiatric department. The patient told us at the bedside that suicide was the only option for her. Her symptoms fulfilled the DSM-5 criteria of major depressive disorder. She needed hospitalization and standard psychiatric therapy for depression, including antidepressants. After the crisis intervention, the case manager (CM) assessed her risk factors of suicide systematically and filled out the Assessment and Planning Sheet (Table 1) in accordance with the program standards.5 Her risk factors included exhaustion from her job that required great concentration, no one to turn to for advice, and problematic drinking. She had had no previous connection with social resources or welfare services. To reduce these risks, with the support of the psychiatrist and the CM, she took a temporary leave of absence and applied for invalidity benefits. She could not perform her daily activities by herself. Therefore, the CM asked her parents to support her briefly until her recovery. Then, her parents decided to live near her. In addition to the standard psychoeducation, discussion of the patient's problematic drinking was emphasized. She was discharged 1 month later. She continued her absences from work due to the need for rehabilitation. Case management was provided once a month for 6 months. Two months later, she felt impatient to return to work. She still felt the urge to injure herself sometimes. The CM supported her to participate in a return-to-work program offered by our hospital. In this program, she learned to work again in a step-by-step manner under the advice of the staff. Her impatience was gradually relieved, and she could suppress problematic drinking and self-harm. As the patient completed the program, the CM supported her to talk with her parents about her life plan. Finally, she decided to move into her parents' home (500 km away), and obtained a new job there. Table 1. Assessment and Planning Sheet for Patient A (the first interview) Assessment results Implementation plan Risk of suicide: Risk of suicide: She has suicide ideation and feels strong anxiety and impatience. She drank large amounts of alcohol and then went on to make a destructive suicide attempt. And, she has a lot of risk factors of suicide as listed below. Therefore, she is at increased risk of suicide. She needs psychiatric hospitalization. And she needs antidepressant therapy, recuperation, and suspension from work. Adherence to medical treatment: Adherence to medical treatment: Psychiatric problems: Depressive state, insomnia, self-accusation, suicide ideation, anxiety, and impatience Physical complications: The flexor tendon rupture of left flexor carpi radialis muscle and median nerve injury The doctor–patient relationship is not bad, but the patient is not able to express herself enough. Because she has never had psychiatric treatment, psychoeducation is necessary for her in order to understand her psychological symptoms and to continue her treatment. Psychosocial factors: Psychosocial factors: Her risk factors of suicide are as follows: Daily life difficulties Lack of consulters and a solitary life Exhaustion from her job that required a lot of concentration and strict instruction Problematic drinking Anxiety, impatience and helplessness Suicide ideation Mental disorder Her protective factor of suicide is as follows: The good relationship with her family As regards the difficulty of her job, she needs a temporary leave of absence and to receive the 'invalidity benefit.' As regards a lack of consulters, we should ask for her parents' cooperation. As regards her alcohol problems, we should educate her about alcohol. Utilization of resources for help: Utilization of resources for help: She does not have any social support resources. She has parental support, but she cannot consult her parents due to her anxiety. We ask for the cooperation of her boss and the personnel department in her company. We consider introducing a return-to-work program, offered by our hospital. We discuss her ongoing support with her parents. The patient had never been supported by mental health professionals before visiting our hospital, suggesting that the ED is one of the first contact points for these patients. Therefore, strong supportive relationships with the CM are crucial for better adherence to the services among suicidal patients, who are extremely poor at seeking help. The repetition of the suicide attempt tends to occur quickly,6 and suicidal patients often do not receive adequate mental health-care management after their discharge.7-9 On the other hand, we successfully prevented a repeat suicide attempt for more than 6 months. The ED should be recognized as an important and practical opportunity to provide assertive case management for suicide attempters. As a lack of fidelity to the standards contributes to poor results, an official education program has been developed and is currently run by the Japanese Association for Suicide Prevention.10 The CM must have specialized knowledge and experience in social work to conduct the assertive case management properly, and participation in the official education program is mandated to the medical staff to claim medical costs. The authors had participated in this education program, and are now serving as training staff for this program. We recently published The HOPE Program Standards in English, a guide to the program's start-up, practical implementation, and monitoring, with clearly defined minimum requirements.5 We believe that successful implementation of evidence-based intervention and demonstrated improvements in patient outcomes are best accomplished by close adherence to the program standards. Acknowledgments We would like to thank Editage (www.editage.com) for English-language editing. We would like to thank Professor Chiaki Kawanishi from Sapporo Medical University for useful discussions. Disclosure statement The authors declare no conflicts of interest. References 1Kawashima Y, Yonemoto N, Inagaki M, Yamada M. Prevalence of suicide attempters in emergency departments in Japan: A systematic review and meta-analysis. J. Affect. Disord. 2014; 163: 33– 39. CrossrefPubMedWeb of Science®Google Scholar 2Fedyszyn IE, Erlangsen A, Hjorthøj C, Madsen T, Nordentoft M. Repeated suicide attempts and suicide among individuals with a first emergency department contact for attempted suicide: A prospective, nationwide, Danish register-based study. J. Clin. Psychiatry 2016; 77: 832– 840. CrossrefPubMedWeb of Science®Google Scholar 3Nordentoft M, Mortensen PB, Pedersen CB. Absolute risk of suicide after first hospital contact in mental disorder. Arch. Gen. Psychiatry 2011; 68: 1058– 1064. CrossrefPubMedWeb of Science®Google Scholar 4Kawanishi C, Aruga T, Ishizuka N et al. 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