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Management in Primary Care at the Time of a Suicide Attempt and Its Impact on Care Post-Suicide Attempt: an Observational Study

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Management in Primary Care at the Time of a Suicide Attempt and Its Impact on Care Post-Suicide Attempt: an Observational Study Younes et al. BMC Family Practice (2020) 21:55 https://doi.org/10.1186/s12875-020-01126-9 RESEARCH ARTICLE Open Access Management in primary care at the time of a suicide attempt and its impact on care post-suicide attempt: an observational study in the French GP sentinel surveillance system Nadia Younes1,2,3*, Mathieu Rivière4,5, Frédéric Urbain3, Romain Pons4,5, Thomas Hanslik4,5, Louise Rossignol4, Christine Chan Chee6 and Thierry Blanchon4 Abstract Background: We aimed to describe primary care management at the time of a suicide attempt (SA) and after the SA. Methods: An observational (cross-sectional) study was conducted among 166 sentinel GPs within France (a non- gatekeeping country) between 2013 and 2017 for all GP’s patients who attempted suicide. Measurements: frequency of patients 1) managed by the GP at the time of the SA, 2) addressed to an emergency department (ED), 3) without care at the time of the SA, and 4) managed by the GP after the SA and factors associated with GP management at the time of and after the SA. Results: Three hundred twenty-one SAs were reported, of which N = 95 (29.6%) were managed by the GP at the time of the SA, N = (70.5%) were referred to an ED, and N = (27.4%) remained at home. Forty-eight (14.9%) patients did not receive any care at the time of the SA and 178 (55.4%) were managed directly by an ED. GPs were more likely to be involved in management of the patient at the time of the SA if they were younger (39.2% for patients < 34 years old; 22.9% for those 35 to 54 years old, and 30.3% for those more than 55 years old p = 0.02) or the SA involved a firearm or self-cutting (51.9%) versus those involving drugs (23.7%); p = 0.006). After the SA, GPs managed 174 patients (54.2%), more often (60%) when they provided care at home at the time of the SA, p = 0.04; 1.87 [1.07; 3.35]. No other factor was associated with management by GPs after the SA. (Continued on next page) * Correspondence: [email protected] 1EA 40-47 Université Versailles Saint-Quentin-en-Yvelines, F-78047 Guyancourt, France 2Versailles Hospital, Academic Unit of Psychiatry, 177 Rue de Versailles, 78157 Le Chesnay, Cedex, France Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Younes et al. BMC Family Practice (2020) 21:55 Page 2 of 9 (Continued from previous page) Conclusions: The study faced limitations: data were not available for patients managed solely by specialists during their SA and results may not be generalisable to countries with a stronger gatekeeping system. We concluded that GPs are involved in the management of patients at the time of a SA for a third of patients. EDs are the major provider of care at that time. Half patients consulted GPs after the SA and connections between GPs and ED upon discharge should be improved. Keywords: Suicide prevention, General practice, Suicide attempts, Management of the suicide attempt, Post-suicide attempt care Background gatekeeping countries (as in Belgium, France, Germany, Suicidal behaviour has been identified as a major public Canada and Switzerland) where patients may have direct health issue worldwide [1]. In France, 195,000 suicide at- access to specialists [19]. The Belgian Network of Senti- tempts (SA) [2, 3] and 10,000 suicides (incidence rate nel General Practices reported several characteristics of 18.0/100,000 inhabitants) [4] are reported per year. This SA encountered between 2013 and 2016 (n = 245), in- is among the highest incidence rates in Europe. cluding one information about GP informant of suicide GPs play a central role in suicide prevention and the attempt (n = 241) and established that GP was on site as management of suicidal patients. Suicidal behaviours are first caregiver following the SA for N = 46 patients frequent in primary care: 2.4 to 8% of primary care pa- (19.1%) [20]. The first aim of our study was to describe tients have suicidal thoughts [5, 6] and a GP encounters further, in another non-gatekeeping country, the role of one to six SAs in a working year [7, 8] and loses a pa- GPs as first caregiver following the SA (how often, for tient by suicide every four to 7 years [7, 9]. Among pa- which patients, and their management: how often GPs tients with depressive disorders, 10.4% attempted suicide refer patients to the hospital, how often they give care in during the last 5 years [10]. At least half of patients who place of the hospital). died by suicide and two thirds of those who attempted The aftercare of a SA is challenging, because of the suicide visited a GP in the preceding months, challen- high risk of subsequent suicide or all-cause mortality ging the GPs’ recognition and management of suicidal [21] and morbidity. Two of 10 patients repeat a SA dur- patients [11–13]. According to Milner’s systematic re- ing the first 5 years [22]. Active contact and follow-up view and meta-analysis, suicide prevention in primary has been shown to be effective in preventing a repeat care produced equivocal results [14]. One point has not SA in the first 12 months (n = 5319; pooled RR = 0.83; yet been investigated: the involvement of primary-care 95% CI: 0.71 to 0.97). However, the effect at 24 months professionals at the time of the SA. The role of emer- was not confirmed in EDs [23]. Studies conducted gency departments (EDs) has been more explored. A among patients registered in a general hospital in the systematic review estimated that mental or behavioural- UK for SA have reported the central role of primary health disorders accounted for 4% of ED attendance and, care (gatekeeping system): approximately 30 to 40% among these, a third due to self-harm or suicidal idea- consulted their GP in the week following a SA and 25 tion [15]. In standard practice in the ED, those who at- to 50% in the following month. Among them, 58% dis- tempt suicide are either hospitalized or sent home after cussed the SA during the first consultation [7, 11, 24]. treatment and evaluation by a mental-health profes- The rate of mental health treatment does not exceed sional, with some variability in the organization accord- 30–50%, with a higher rate if the appointment was ing to country and setting [14–17]. We found few data booked with a mental health professional before dis- on prehospital or primary care. A South-African study charge [25]. A recent study conducted in Canada a explored the attitudes of 130 prehospital providers (not non-gatekeeping country, reported a more limited role including GPs) on transport decision in the management of primary care and a high frequency of patients with- of SA patients who refuse care. They reported a critical out any care: among 23,140 individuals attending EDs lack of training and certain negative attitudes and diffi- for self-harm in a Canadian hospital, 10.7% consulted a culties [18]. For primary care, the position of GPs (pa- GP for a mental-health visit within 1 month, 17.1% a tients’ expectations and GPs’ task performance regarding psychiatrist, 3.6% both, and 68.6% had no care [22]. mental health care, role of others health actors) varies The role of primary care needs to be explored further. between health care systems. In more gatekeeping coun- We aimed to describe how often and for which patients tries (as in Netherlands, Spain and the United Kingdom GPs provide aftercare following a SA and whether the for example), a patient cannot consult a medical special- role of GPs as first caregiver following the SA is associ- ist directly and GPs’ task could be different than in non- ated with more aftercare by the GP. Younes et al. BMC Family Practice (2020) 21:55 Page 3 of 9 The objective of the present study is to describe pri- seen while they are on duty or seen by other caregivers mary care management 1) at the time of a SA and 2) (mainly EDs) who belong to the GPs patient base. SAs after the SA. are defined, from the WHO/EURO para-suicide defin- ition of “suicidal acts of self-inflicted injury or self- Methods poisoning with drugs in excess of the generally recog- Population and procedure nized therapeutic dose, excluding non-suicidal self- We studied “suicidal” patients from the French General injury or self-poisoning” [28, 29].
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