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Telephone consultations - a medico-legal minefield?
- Ruth V Reed (30 May 2006)
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Age Matters
- Jill Manthorpe, Steve Iliffe (5 June 2006)
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Re: Age Matters
- Guillaume C VAIVA (7 June 2006)
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So not much effect then....
- Simon Hatcher (16 June 2006)
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Ruth V Reed, Senior House Officer, Psychiatry Camden and Islington Mental Health and Social Care NHS Trust, NW3 2QZ
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Telephone contact one month following a suicide attempt may well have some benefit in reducing further attempts, but I wonder how many health professionals would be willing to do this. Telephone assessments are notoriously unreliable for many forms of doctor-patient consultation and surely even more so in this situation – unknown patients, possibly in an ongoing life-crisis, a significant proportion of whom will fulfil the criteria for emotionally unstable personality disorder and whose actions may be inherently unpredictable. It would have been useful to know whether the researchers had predefined criteria for risk stratification and how they decided upon the appropriate course of action for each patient. Without clear guidelines of this sort, clinicians would be entering a medico-legal minefield by undertaking such assessments, where they may be held responsible for clinical judgements made in the absence of many observation-based elements vital to a comprehensive mental state examination. Competing interests: None declared |
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Jill Manthorpe, Professor of Social Work Social Care Workforce Research Unit, King's Colege London, Steve Iliffe
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Positive findings that contact with people who have tried to take their own lives is effective may encourage professionals that there is something that can help people in such distress in an otherwise bleak situation. Guillaume Vaiva and colleagues have provided substantial support for co-ordinated responses in primary care to reduce the risk of further attempts. National suicide prevention strategies show that there are groups for whom interventions may be particularly valuable. Older people still make up a large proportion of those who take their own lives and their intent is often firm. Research on suicide prevention needs to consider responses to older people rather than apply age cut offs. This habit runs the risk of limiting our knowledge about what older people would find helpful, means that we have to hypothesise that what works for adults of working age will work for older people, and creates separate streams of ‘evidence informed’ practice. Is it time for research that excludes older people to be more explicit about why? Jill Manthorpe Professor of Social Work Social Care Workforce Research Unit King’s College London London SE1 9NN Email: jillmanthorpe@kcl.ac.uk Steve Iliffe Reader in General Practice Royal Free Hospital Medical School Rowland Hill Street London NW3 Email: s.iliffe@pcps.ucl.ac.uk Competing interests: None declared |
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Guillaume C VAIVA, professor of psychiatry 59037 LILLE cedex
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We agree with professor Jill Manthorpe. Neverless, only suicide attempters discharged from hospitalization were included in this study. In France, all suicide attempters older than 65 years should be hospitalized : it's our guidelines. Guillaume Vaiva Competing interests: None declared |
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Simon Hatcher, Senior lecturer in psychiatry University of Auckland, Auckland 1
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The paper by Vaiva et al is an admirable attempt to use a brief intervention after self posioning - one phone call at four weeks or three months - to reduce the repetition rate after about a year. However several questions arise from this study. Firstly the rationale behind thinking that a single phone call would make a difference at one month or three months is obscure. We know that most repetitions of self harm occur in the month after the index attempt when individuals are in crisis. An intervention that would make more clinical sense would be a phone call within 48 hours of the index attempt. Secondly it is hard to undertand the authors power calculation as we are not told on what outcome it is powered (repetition? adverse events?) or any of the other usual parameters of a power calculation. This is important as the study essentially showed no difference between the different interventions and it is essential to know if the study was big enough to stand a good chance of detecting a difference. Next is the issue of the representativeness of the study sample. Only about one in five of eligible patients were recruited. Were they different in any important ways, apart from age, from those who were not recruited? I also note that nearly a quarter of patients who were contacted in the intervention groups had a DSM IV diagnosis of somatisation disorder - a remarkably large number which if true would make this a very unusual population. Then there are the results. It is unclear as to how many people had reattempted suicide - in table 2, 103 people report reattempting yet in the text the numbers add up to 91. Why the discrepancy? Also we are not told how many episodes occured in each group which may be important as the study may have had an effect on this outcome. In the analysis of those who were contactable there is no significant difference between the three groups using a chi-squared test with two degrees of freedom. However comparing the individual groups with each other there is a statistically significant difference between those who received a telephone call at one month and controls but no difference between the two telephone groups or between the telephone call at three months and the control group. So how to make sense of these results? Probably telephoning people at a month after they have self poisoned doesn't make much difference to repetition compared to treatment as usual. Any differences observed are probably due to confounding factors, for example people who are easy to contact by phone probably have more resources and are more stable (both geographically and emotionally) than those who cannot be contacted so are less likely to self-harm. The lesson for clinical practice is that when people who self harm are seen in the general hospital, clinicians should be assiduous in getting at least three telephone numbers and two addresses from them. This should help in avoiding the one in four people lost to follow-up found in this study. Competing interests: None declared |
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