One-year follow- up to suicide attempted patients in the Emergency Department of a private hospital using Whatsapp.

ABSTRACT

Suicide as a global public health issue shows fluctuating rates with a tendency to increase. Public health strategies aimed to reduce suicide attempt and retry are the main alternative. Objective: establish the incidence of suicidal retry, opportunity for care and adherence to treatment in the follow-up of patients treated for suicide attempt in the emergency room of a private University hospital. Methods and participants: a descriptive prospective cohort study in patients ?18 years of age with a low-risk suicide attempt assigned to outpatient psychiatric treatment and followed up through WhatsApp application for one year after discharge. Results: the prevalence of suicide attempt in patients who consulted the emergency room was 0.38%. Of 164 patients with a suicide attempt, 33 were low risk. With a median age of 23 IR (25-75): 19-33 years, 87.8% (n: 29) were women, 42.4% (n: 22) with secondary school level and 63.6% (n: 21) with middle socioeconomic stratum. 24.2% (n: 8). The accumulate incidence of retry was 36,3% (n: 12), more frequently in the first month. The earlier attention by psychiatry was after two weeks of discharge. The follow-up adherence was of 45,4%. Conclusions: the accumulated incidence for retry was high. The opportunity for outpatient psychiatric care and adherence to follow up were low. Despite the different methods used until now, monitoring suicidal behavior remains difficult. It is necessary research that explore alternatives for community and social intervention.

Key words: Suicide attempt, follow-up studies, mobile applications, Emergency Service, public health.

INTRODUCTION

Suicide is a public health issue worldwide. Data shows fluctuations with a tendency to high rates, despite efforts in prevention and intervention(1). With more than 800,000 annual suicides, it is the second leading cause of death among people aged between 15 and 39, with a consequent loss of 20 million years of life due to premature death(2,3). In U.S.A. suicide rate in adults increased to 30%, compared to the previous decade(1). In our country, a 2018 report, of the National Institute of Legal Medicine and Forensic Sciences, pointed out that the rate has increased: 5.93 per 100,000 inhabitants.(4)

Suicidal behavior comprises a series of events (ideation, planning, attempt, consummation) that form over time and leads to death. It affects people without distinction of age or condition, and has devastating consequences for the individual, the family and the community(5). Suicide attempts are estimated to be the most important predictor of completed suicide; before reaching that point, 40% of the people had attempted to do so.(6)

In Colombia, local research has pointed out certain risk factors: depression, anxiety, drug addiction, being between 20 and 39 years old, being a man, being single and unemployed; as well as suffering from mental illnesses, chronic or terminal illnesses(4). Women display a higher rate of suicide attempts, while in men the completed suicide is much higher, they express little suicidal ideation and use more lethal

means.(5,7)

We can find certain family factors such as low cohesion, dysfunction, abuse, conflicts, history of suicides, sexual violence, and environmental factors such as behavioral patterns, interpersonal and economic factors. Therefore, protective elements such as positive attitudes, adequate stress coping techniques, family support and social participation are

important.(5,8)

The connection between suicide and impulsive and violent behaviors began to be studied approximately four decades ago by Plutchik and Van Praag(9,10). In addition to psychometric associations, neurobiological links were identified on a neurotransmission level(9). These researches led to the elaboration of the three well-known Plutchik scales: Violence Risk Scale, Suicide Risk Scale and Impulsivity Scale.(10)

Recent studies point to impulsivity as a promising phenotype underlying suicidal and self-injurious behavior. They are based on neurocognitive models of impulsivity that affect decision making. Since cognitive and motor inhibitory control mature in early adulthood, self-injury behaviors is more frequent in young people.(11,12)

Considering that suicide is preventable, technological tools can be developed to intervene in different moments of the sequence of suicidal behavior: suicidal ideation (thoughts, plans) on a community and primary health care (PHC) level, suicide attempt in the emergency services or psychiatric wards and outpatient treatment with follow-ups and social risk

management.

Public health strategies aimed at reducing suicidal attempts and re-attempts, have become the main way of dealing with suicide. Thus, in this scenario, the use of different tools that promote a dialogue with a suicidal patient, acquire a relevant role. Previous, health surveillance methods were by telephone and postal service, educational pamphlets, with heterogeneous results in different studies; both a decrease and an increase in reattempts rates have been found(13), and greater benefits have been reported in contact interventions. The use of mobile technologies has increased due to its remarkable potential in monitoring and accompanying

patients.(14)

During the last decade, there has been an increase in the use of Smartphones and technological devices such as computers and tablets, becoming key tools for patients and health personnel. Social apps have extended their use to health care, estimating that in 2018 50% of the more than 3.4 billion mobile device users had downloaded these apps. Some of them serve as self-care strategies, or can be used for evaluation, clinical decision making and treatment(15). These apps offer communication options that include text messages, agendas, schedules, activities and reminders, as well as the possibility of synchronizing televideo meetings.(16)

In a recent review, the feasibility to use these apps and text messaging in health interventions was verified. Although there is not enough information to make definitive conclusions, it is promising to know that these tools have shown to be able to reduce stress, anxiety and depression, and improved patient adherence, allowing them to have a leading role in their own care, within an approach that provides confidence and security(17). In young populations, active interventions conducted by health personnel who obtain feedback on the treatment has shown positive results in terms of the reduction and remission of

symptoms.(5)

Along this line, the Psychiatry service of the Hospital Infantil Universitario de San José (HIUSJ) introduced, an outpatient follow-up via instant messaging through WhatsApp, within its clinical guide for the management of patients with suicidal behavior in October 2018. Based on this fact, the present study aims to identify follow-up and prevention strategies that benefit this population.

INSTRUMENTS AND METHODOLOGY

INSTRUMENTS AND METHODOLOGY

This is an observational study with a prospective descriptive cohort type, analyzing the follow-up of suicidal patients who received care in the emergency department (ED) of HIUSJ with instructions to receive outpatient treatment, for 12 months after discharge.

Telemonitoring Program by WhatsApp

The Psychiatry service of theHIUSJ has implemented WhatsApp telemonitoring follow-up in their suicidal behavior follow-up. This strategy was intended for patients who are receiving an outpatient treatment through the System of Epidemiological Surveillance of Suicidal Behavior (SISVECOS) of the District Health Secretariat of Bogotá, which provides psychosocial support for the transformation of the social environment of the cases captured through it.(18)

Population

Cohort of all the patients who consulted the emergency department of the HIUSJ hospital due to suicide attempt (ICD-10: X60 to X84), during the period between November 1, 2018 and October 30, 2019, who were discharged and agreed to enter the WhatsApp remote monitoring

program.

Inclusion criteria

Patients admitted to the Emergency Department with a diagnosis of attempted suicide, aged ?18, and that after psychiatry evaluation, were appointed to outpatient treatment, agreed to enter the study by signing the consent form and the use of data privacy, with the ability to handle a smartphone and having a data plan or internet service at home.

Exclusion criteria

patients who required hospitalization due to the severity of suicidal risk, those who had limited knowledge on the use of smartphones, or those in a condition of imprisonment or deprivation of

liberty.

Instruments

SAD PERSONS: Is a scale that uses a short acronym based on ten main risk factors, to assess the probability of a suicide attempt. For the present study, a cut-off point of ? 4 points was used for outpatient treatment.(19)

PLUTCHIK Scale is a self-applied scale to assess impulsive behaviors. It consists of 15 items that refer to the patient’s tendency to do things without thinking or impulsively, revealing a lack of control over certain behaviors such as: ability to plan (3 items), control of emotional states (3 items), appetite control, sexual and money management behaviors (3 items); control of other behaviors (6 items).

The score uses frequency scale from 0 to 3 (never, sometimes, often, always). Items 4, 6, 11, and 15 are scored in reverse. For the present study, ? 20 score was considered high impulsivity, according to the Spanish

validation.(10)

Follow-up

The study patients were included in an Excel database and their follow-ups were automatically scheduled in Google Calendar connected to a Smartphone exclusively programmed for the purpose. Pre-established reminder messages were sent by WhatsApp on the first and third day, first and second week, first, third, sixth, ninth and twelfth months of discharge. The responses were saved on an Excel sheet. The information was periodically reviewed independently by a second researcher.

Outcomes:

The outcomes analyzed in the population were: Suicide reattempt is defined as a potentially harmful self-inflicted behavior without fatal outcome, with evidence of forethought during the follow-up time. Adherence, referred to as the response to follow-up within the established times. Care Timeline refers to the moment in which the patient had a first psychiatric consultation after being discharged from the emergency

room.

Statistical measures:

The description of the qualitative variables was carried out by absolute and relative frequencies and for the quantitative variables, medians with inter-quartile ranges were used, due to the size of the study population and the distribution of the data. STATA 13 software was used for this

analysis.

In those subjects who completed the 12-month follow-up, three main outcomes were assessed: suicidal reattempt tendency, adherence and care timeline.

This study was approved by the Ethics Committee of the Hospital de San José, according to resolution 8430 of 1993.

RESULTS

Regarding clinical variables, 75.7% (n: 25) of the patients had no previous suicide attempts, nor mental illness, 66.6% (n: 22). The most frequent comorbid mental disorder in this population was depressive disorder 24,2% (n: 8). Most patients 84.8% (n: 28) denied the use of psychoactive substances and 93.9% did not report chronic disease.

In the assessment of suicidal risk with the SAD PERSONS scale, the most frequent score was three points 39.3% (n: 13), which corresponds to a low risk. 21.3% (n:7) of the patients showed signs of impulsivity (?20 points on the Plutchik

Scale).

The follow-ups were conducted through WhatsApp according to the aforementioned schedule. Only one patient responded to all of the follow-ups and did reattempt against her life. According to evidence, responses to follow-ups, decreased in about 70% after 6 months (Fig 1). Of the 297 follow-ups performed, there was a response of 45.4% (n: 135) cases.

Suicide reattempt had its highest occurrence during the second week. The cumulative incidence of suicidal reattempt was 36.3% (n: 12). One patient reattempted three times, and two patients reattempted twice. Most of these situations occurred during the first and sixth follow-up months. (Fig. 2)

For 8 patients (24.24%), the earliest opportunity for outpatient psychiatric care was two weeks after discharge. None of them reported having been followed up by the District Health Secretary throughout the whole study.

DISCUSSION

In the present study, the prevalence of suicide attempts in the emergency department is similar to the one reported by Larkin and Doshi (0.4%).(20,21)

As in other studies, suicide attempt rate was higher in females 63% (n: 104). There has been an increase in suicide attempts in younger women using more lethal methods. This limits the prevention of suicidal behavior.(7,22)

Suicide attempts were more frequent in middle class people, with high school education and without a current affective relationship, (strata 3 and 4). Other researchers such as Kuehn, have mentioned similar data, such as a 40% increase in suicide rates within working class, and the need to include an integrated approach aimed at individual, interpersonal and social risks in prevention programs. Goldman more recently has pointed out state and trait genetic risks, which contribute to the complexity and establish the equifinality of suicidal behavior.(22,24)

The cumulative prevalence of suicidal reattempt was high if we compare it with studies such as the one by Knipe, in Sri Lanka, that showed a 3.1% estimated risk of suicide reattempts during the following 12 months.(25)

In the present study, the highest occurrence of reattempts was during the first month, with an 87.5%,. This is considered a high risk situation in studies such as the one carried out by by Hunt.(26)

However, the response rate and adherence to follow-ups was very low, presented intermittent responses, and eventually decreased in six months. Therefore, it was not possible to obtain conclusive data regarding suicidal behavior of participants. Barely 24,2% (n: 8) reported having attended the psychiatric outpatient clinic two weeks after discharge. Without being able to specify the causes, this illustrates that health care does no provide timely care for these patients and apparently shows there is little interest in them, However, as Bruffaerts points out, it is probably due to the fact that patients do not perceive treatment as a necessity, which proves that there is still little understanding of their emotional problems, the acceptance of diagnoses and treatments.(27)

These issues have also been recorded in other studies, where failure to continue with follow-ups and and an increase of low adherence progressed(28,29). Among the possible causes of this phenomenon, the following stand out: women considered follow-ups more useful then men(17), the stigma and self-stigma related to mental disorders, result in patients tending to hide their symptoms and to be reluctant to collaborate, in addition to the methodological difficulties.(30)

The implementation of interventions aimed at reducing the number of suicide cases and reattempts, has focused on improving patients follow-ups after being discharged from psychiatric hospitalization and emergency services. In this study, WhatsApp application was used due to its acceptance and widespread use, being a simple, effective and economical means, which in recent years has positioned itself as and popular tool.(31,32)

The first reports on suicidal patient follow-ups, were described by Motto in 2001, who used the postal service, to keep in touch with his patients for five years after hospital discharge, thus observing a decrease in suicide(33). In other cases, phone calls where the patient was in contact with the medical professional, were implemented, and showed a decrease in attempts during follow-ups.(34)

Currently, mobile health technologies (mHealt) are a tool to monitor suicidal patients. This type of brief contact interventions aim to display a non-intrusive concern for the patient and an availability to help them, thus implementing personalized, adaptable and transposable health interventions(35). A recent meta-analysis evaluated different methods of telemonitoring suicidal behavior, including 14 independent studies; with a total of 3,356 participants, only five remote monitoring programs were developed specifically to self-control suicidal ideation, and one aimed to control self-harm. The analysis showed that these interventions were associated with a significant reduction in suicidal behavior score.(29)

On the other hand, implementing measures to strengthen the permanence of the participants in the study, and integrating digital applications in the treatment of suicidal behavior requires the combination of the professionals in charge, patient acceptance, adequacy of design and use principles, accessibility, digital literacy(36), as well as family and social support networks to optimize the response to follow-ups.(37)

Future research should overcome these limitations and increase knowledge about follow-up services for the prevention of suicidal behavior.(32)

Technological tools would be useful to address the increased demand for consultations, reducing costs and barriers and an effective alternative to overwhelmed emergency services. Without a doubt, in the current situation, this is a challenge. COVID-19 has set off alarms regarding the importance of mental health and the importance of strengthening suicide prevention measures during and especially after the pandemic, since a greater impact on mental health and suicidal behavior is expected.(38,39)

Regarding the strengths of this study, in first place, it has allowed the implementation of a follow-up system for patients with suicidal behavior in the HIUSJ, with accessibility, low costs and outpatient management. Second, it is the first WhatsApp telemonitoring study of patients with suicidal patients in Colombia.

Regarding the limitations of the study, the data collected by patient self-reports may have biases, due to the aforementioned reasons such as the self-stigma of suicidal behavior. The poor response to follow-ups and the low adherence of patients reduced the quality of the data in some

variables.

CONCLUSION

Future research is needed to explore other social and community intervention alternatives that allow overcoming the isolation that the stigma and self-stigma of the suicide attempt impose.

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