What happens when patients go to the Emergency Department after Deliberate Self-Harm?

Mark Olfson, M.D., M.P.H.

Mark Olfson, M.D., M.P.H.

Dr. Mark Olfson, an AFSP Distinguished Investigator from Columbia University, has been investigating what happens to people who visit the hospital Emergency Department (ED) for deliberate self-harm, i.e. suicide attempt or non-suicidal self-injury. The first paper from this grant was published in Archives of General Psychiatry and presents data about the use of mental health assessments and follow-up outpatient care. The findings highlight the lack of attention to mental health assessment and subsequent referral after deliberate self-harm.

Over 90% of men and women who deliberately harm themselves meet the criteria for a mental disorder diagnosis at the time of their self-harm. Despite this, Dr. Olfson found that only one-half of patients received mental health assessments prior to being discharged. Through a retrospective longitudinal cohort analysis of the 2006 Medicaid Analytic Extract, Dr. Olfson analyzed over 4,400 cases of Medicaid patients who were discharged from the emergency department following an incidence of deliberate self-harm. Only half received a mental health assessment, and a similar percentage received outpatient care within the 30 days following the discharge.

Individuals who had recently received mental health treatment were most likely to receive follow-up mental health care, though it seems likely that a portion of this group represents individuals who were currently receiving care and thus were not driven by emergency department referrals. Individuals seen in the ED and diagnosed with depression were also more likely to have been seen in an outpatient setting after their ED visit. Key differences in the rates of follow-up treatment indicated that African Americans and Hispanics were less likely to have been seen in an outpatient clinic in the 30 days after visiting the ED, even when they may have received evaluations. One group in which we might expect to find a focus in mental health assessment, i.e. individuals using highly lethal self-harm methods, showed no significant association with evaluation and follow-up care. This is potentially of greatest concern since these highly lethal methods put individuals at the greatest risk for completed suicide.

One of the key limitations of the study reported by Dr. Olfson is that the data used did not indicate whether the deliberate self-harm had occurred with or without suicidal intent. Nonetheless, the frontline position of emergency departments offers a unique opportunity to provide lifesaving referrals for mental health care to individuals suffering enough to engage in self-harm behavior. The fact that many of the study’s individuals did not receive mental health assessments or follow-up care represents a missed opportunity to provide emergency mental health services to patients who deliberately harm themselves.

Dr. Mark Olfson is a Professor of Clinical Psychiatry at the College of Physicians and Surgeons, Columbia University, Co-Director of the AHRQ Center for Education and Research on Mental Health Therapeutics and the Scientific Director of Columbia University Teen Screen. Click here to read more about Dr. Olfson's Distinguished Investigator Grant.

Related Publications

  • Bridge, J. A., Marcus, S. C., & Olfson, M. (2012). Outpatient care of young people after emergency treatment of deliberate self-harm. Journal of the American Academy of Child & Adolescent Psychiatry, 51(2), 213-222.e211. 
  • Marcus, S. C., Bridge, J. A., & Olfson, M. (2012). Payment source and emergency management of deliberate self-harm. American Journal of Public Health, 102(6), 1145-1153. 
  • Olfson, M., Marcus, S. C., & Bridge, J. A. (2012). Emergency treatment of deliberate self-harm. Arch Gen Psychiatry, 69(1), 80-88. 
  • Olfson, M., Marcus, S. C., & Bridge, J. A. (2014). FOcusing suicide prevention on periods of high risk. JAMA. doi: 10.1001/jama.2014.501