Archives of Suicide Research
ISSN: 1381-1118 (Print) 1543-6136 (Online) Journal homepage: http://www.tandfonline.com/loi/usui20
Clinical Features, Psychiatric Assessment and Longitudinal Outcome of Suicide Attempters Admitted to a Tertiary Emergency Hospital Alcinéia Donizeti Ferreira, Alcion Sponholz-Jr MD, PhD, Célia Mantovani, Antônio Pazin-Filho, Afonso Dinis Costa Passos, Neury José Botega & Cristina Marta Del-Ben To cite this article: Alcinéia Donizeti Ferreira, Alcion Sponholz-Jr MD, PhD, Célia Mantovani, Antônio Pazin-Filho, Afonso Dinis Costa Passos, Neury José Botega & Cristina Marta DelBen (2015): Clinical Features, Psychiatric Assessment and Longitudinal Outcome of Suicide Attempters Admitted to a Tertiary Emergency Hospital, Archives of Suicide Research, DOI: 10.1080/13811118.2015.1004491 To link to this article: http://dx.doi.org/10.1080/13811118.2015.1004491
Accepted online: 11 May 2015.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=usui20 Download by: [University of Nebraska, Lincoln]
Date: 04 October 2015, At: 18:24
Clinical Features, Psychiatric Assessment and Longitudinal Outcome of Suicide Attempters Admitted to a Tertiary Emergency Hospital Alcinéia Donizeti Ferreira1, Alcion Sponholz-Jr MD, PhD1, Célia Mantovani1, Antônio Pazin-Filho1, Afonso Dinis Costa Passos2, Neury José Botega3, Cristina Marta Del-Ben1
Downloaded by [University of Nebraska, Lincoln] at 18:24 04 October 2015
1
Emergency Hospital of the Medical School of Ribeirão Preto, Division of Psychiatry, Department of Neuroscience and Behavior, Medical School of Ribeirão Preto, University of São Paulo, Brazil, Ribeirão Preto, Brazil, 2 Department of Social Medicine, Medical School of Ribeirão Preto, University of São Paulo, Brazil, Ribeirão Preto, Brazil, 3 Department of Medical Psychology and Psychiatry, Faculty of Medical Sciences, University of Campinas, Brazil, Campinas, Brazil Corresponding Author: Alcion Sponholz-Jr MD, PhD, Emergency Hospital of the Medical School of Ribeirão Preto, Division of Psychiatry, Department of Neuroscience and Behavior, Medical School of Ribeirão Preto, University of São Paulo, Brazil, Avenida Bandeirantes 3900, Ribeirão Preto 14048-900, Brazil. Email: [email protected]
Abstract Objective: Characterize admissions to an emergency hospital due to suicide attempts and verify outcomes in two years. Method: Data were collected from medical records and were analyzed using descriptive statistics and logistic regression. Results: The sample consisted of 412 patients (58.7% women; mean age=32.6 years old, SD=14.3). Self-poisoning was the most frequent method (84.0%), and they were diagnosed mainly as depressive (40.3%) and borderline personality disorders (19.1%). Previous suicide attempts and current psychiatric treatment were reported by, respectively, 32.0% and 28.4%. Fifteen patients (3.6%, 9 males) died during hospitalization. At discharge, 79.3% were referred to community-based psychiatric services. Being male (OR = 2.11; 95% CI = 1.25-3.55), using violent methods (i.e. 1
hanging, firearms and knives) (OR = 1.96; 95% CI = 1.02-3.75) and psychiatric treatment history (OR = 2.58; 95% CI = 1.53-4.36) were predictors for psychiatric hospitalization. Of 258 patients followed for 2 years, 10 (3.9%) died (3 suicide), and 24 (9.3%) undertook new suicide attempts. Patients with a history of psychiatric treatment had higher risks of new suicide attempts (OR=2.46, 95% CI = 1.07-5.65).
Downloaded by [University of Nebraska, Lincoln] at 18:24 04 October 2015
Conclusions: Suicide attempters admitted to emergency hospitals exhibit severe psychiatric disorders, and despite interventions, they continue to present high risks for suicide attempts and death.
KEYWORDS: Suicide attempt, Suicide, Emergency room, Emergency Psychiatry
INTRODUCTION Suicide is associated with multiple risk factors, and a prior history of suicide attempts is a strong predictor of death by suicide (Gunnell & Frankel, 1994; Haukka, Suominen, Partonen, & Lönnqvist, 2008). After an episode of deliberate self-harm, the risk of death by suicide in the subsequent year varies from 0.5% to 2.0%, and it increases to more than 5% after nine years (Owens, Horrocks, & House, 2002). The World Health Organization (WHO) estimates that by 2020, more than 1.5 million people will commit suicide (WHO, 2003), and a significantly greater number of individuals will most likely attempt suicide because attempts can be up to 40 times more frequent than the act itself (Schmidtke et al., 1996).
2
Many people who attempt suicide require medical attention, and contact with health services is an opportunity for suicide risk detection and a referral for specialized treatment (Fleischmann et al., 2008). This is particularly relevant in emergency settings, in which a significant portion of suicide attempters receives first care aid (Jo et al., 2011). However, the routines regarding the psychiatric assessment of suicide attempters can vary
Downloaded by [University of Nebraska, Lincoln] at 18:24 04 October 2015
considerably from one emergency center to another. For instance, a survey of 223 Californian emergency departments found that less than half of the services reported the availability of at least one mental health professional for the assessment of suicide attempters, and only one-quarter had the possibility of a psychiatric admission to their own hospitals (Baraff, Janowicz, & Asarnow, 2006). In low- and middle-income countries (LAMIC), the situation can be even worse. A study conducted in emergency rooms in eight LAMIC showed that in half of the emergency services studied less than one-third of the suicide attempters were referred to health services for further evaluation and follow-up (Fleischmann et al., 2005).
Until recently, suicide was not viewed in Brazil as a public health problem, as it was most likely obscured by the high mortality rates for homicide and traffic accidents in the country. However, a recent study showed that from 1998 to 2008, the total number of deaths due to suicide in Brazil rose from 6.985 to 9.328, representing an increase of 33.5% (Waiselfisz, 2011). These numbers might be even greater in light of underreporting and the poor quality of information contained in the death certificates found in the some areas of the country (Lovisi, Santos, Legay, Abelha, & Valencia, 2009). Despite these understatements, suicide is the third leading external cause of death in Brazil.
3
Moreover, nearly 20% of deaths due to external causes (a total of 143.256 in 2010, http://tabnet.datasus.gov.br/cgi/idb2012/matriz.htm) are recorded based only on the mechanism of death and not on the intention (i.e., “falls and drowning”), making it even more difficult to ascertain the real numbers of deaths by suicide in the country (Bertolote,
Downloaded by [University of Nebraska, Lincoln] at 18:24 04 October 2015
Botega, & de Leo, 2011).
Considering the paucity of data regarding suicide in LAMIC and the heterogeneity of the health care of suicide attempters, we sought a better understanding of the profile of suicide attempters in LAMIC, as well as of the medical care provided for this condition. Therefore, the aims of this study were to characterize the persons admitted to a tertiary referral emergency hospital in the southeast of Brazil due to suicide attempts and to verify the outcomes of these patients in the years following their admission. Specifically, we sought to: a) delineate the sociodemographic and clinical profiles of suicide attempters admitted to referral emergency hospitals over a period of two years, considering eventual differences between genders, b) verify the existence of possible predictors of decision-making regarding the discharge disposition after a suicide attempt, and c) assess the possible predictors of the occurrence of new serious suicide attempts in the 2 years following the suicide attempts.
METHODS Study Design And Setting This is a retrospective cohort study conducted at the Emergency Hospital of the Ribeirão Preto Medical School of the University of São Paulo, Brazil. It is the main tertiary
4
emergency hospital of a catchment area composed of 26 municipalities, containing an estimated population of 1,300,000 inhabitants and located in the southeast of the country. Ribeirão Preto is the main city of the region, with 600,000 inhabitants and a per capita gross domestic product of approximately US$14,000 (IBGE, 2010). This hospital accounts for 51% of the emergency visits in the region, receiving mainly cases of high
Downloaded by [University of Nebraska, Lincoln] at 18:24 04 October 2015
complexity (Adolfi Júnior et al., 2010). Referrals to this emergency hospital follow local and regional emergency medical regulations, which take into account the principles of hierarchy and the complexity of the service network of the Brazilian Health System (Sistema Único de Saúde, SUS). This emergency unit has an emergency room (ER) where the patients are initially admitted mainly by the internal medicine team or the surgical team, according to their supposed diagnosis established by the regulatory system. The patients are evaluated and if they need to be observed or start treatment, this emergency unit has 169 beds, which work as intermediate beds until the patient needs are confirmed and a treatment plan can be determined.
Several medical specialties work together in the emergency room, among them is psychiatry. According to the clinical routines of the hospital, all patients admitted due to a suicide attempt, regardless of the clinic of admission, should be submitted to a psychiatric assessment. The psychiatric evaluation basically consists of verifying the maintenance of suicidal ideation, the identification of any psychiatric conditions underlying the suicide attempt, early intervention in the emergency context, and a referral to psychiatric care at one of the outpatient or inpatient mental health services available in the region.
5
Selection Of Participants The study population consisted of all patients admitted to the emergency unit, from 1 January 2006 to 31 December 2007, with a diagnosis of "intentional self-inflicted injury" and coded as X60 to X84, according to the tenth edition of International Classification of Diseases (ICD 10) (WHO, 1993). We chose to use these diagnostic categories as a way of
Downloaded by [University of Nebraska, Lincoln] at 18:24 04 October 2015
sorting the cases, as there is not a specific code for a suicide attempt in the ICD 10. This strategy also allowed for a broad variety of cases, avoiding losses due to a lack of recording of suicide attempts in the medical files.
The local ethical committee approved the study (protocol number: 13437/2008).
Data Collection And Outcomes Data were collected from medical records, according to protocols already applied in the Brazilian population, as part of the SUPRE-MISS study (Bertolote et al., 2005; Fleischmann et al., 2005; Fleischmann et al., 2008). The variables of interest were: demographic data; methods of suicide attempts; specialty of admission; length of stay; completion of the psychiatric assessment; psychiatric diagnosis; occurrence of previous suicide attempts; current psychiatric community-based care; and psychiatric referral at the time of discharge from the emergency unit (community-based treatment vs. partial or full psychiatric hospitalization). Data were extracted by a social worker familiarized with the routines of the referral emergency hospital, who were trained by two senior psychiatrists regarding the possibilities of register in the medical records of the relevant information for the collection of the variable of interest.
6
The psychiatric diagnosis was defined as the diagnosis recorded in the medical files as the main diagnosis, not including information on co-morbidities. According to the routines of the service, senior psychiatrists, based on the clinical history elaborated by medical residents, defined the psychiatric diagnosis. These senior psychiatrists had a systematic training in the application of operational diagnostic criteria, and can achieve
Downloaded by [University of Nebraska, Lincoln] at 18:24 04 October 2015
good reliability indexes of the diagnosis performed under indirect supervision (Del-Ben et al., 2005).
The discharge disposition from the emergency hospital was categorized according to the need for continuity of care in a protected environment immediately after discharge from the emergency room, including both partial and full psychiatric hospitalization. All patients referred to partial hospitalization and the majority of the patients referred to full hospitalization agreed with this proposal. According to Brazilian laws, in the case of involuntary admission the consent was obtained from a relative who became legally responsible for the admission.
To analyze the outcomes after discharge from the emergency unit, we considered only patients living in the main city of the region (Ribeirão Preto). This strategy was adopted for two reasons: a) the differences between the main city in the region and other cities regarding the availability of mental health services, and b) the unfeasibility of acquiring information concerning the possible occurrence of death among patients from other municipalities. New admissions to the emergency hospital because of a new suicide attempt in the 2 years following the index admission were assessed by querying the
7
hospital database. The occurrence of deaths was checked in the Mortality Information System of the municipality of Ribeirão Preto.
Statistical Analysis Data were analyzed with the SPSS software package, version 16.0. For the exploratory
Downloaded by [University of Nebraska, Lincoln] at 18:24 04 October 2015
analysis and comparison between genders regarding demographic features, qualitative variables were analyzed using the chi-square test or Fisher's exact test, and quantitative variables were evaluated using the t test. Values of p < 0.05 were considered statistically significant.
To explore the decision-making process with regards to discharge disposition, an immediate referral to psychiatric hospitalization (partial or full) at the time of discharge from the emergency hospital was established as the main outcome, and sex, age, ethnicity, education, marital status, occupational status, methods used in the attempted suicide, previous suicidal attempts, current psychiatric treatment, main psychiatric diagnosis and length of stay were the predictor variables. Initially, we calculated odds ratios (ORs) and confidence intervals (95% CI) of the variables of interest, and logistic regression analyses were then conducted. The variables that reached statistical significance (p 0.05). There was a higher proportion of men
9
(54.7%), in comparison with women (22.3%), who were employed (p
ISSN: 1381-1118 (Print) 1543-6136 (Online) Journal homepage: http://www.tandfonline.com/loi/usui20
Clinical Features, Psychiatric Assessment and Longitudinal Outcome of Suicide Attempters Admitted to a Tertiary Emergency Hospital Alcinéia Donizeti Ferreira, Alcion Sponholz-Jr MD, PhD, Célia Mantovani, Antônio Pazin-Filho, Afonso Dinis Costa Passos, Neury José Botega & Cristina Marta Del-Ben To cite this article: Alcinéia Donizeti Ferreira, Alcion Sponholz-Jr MD, PhD, Célia Mantovani, Antônio Pazin-Filho, Afonso Dinis Costa Passos, Neury José Botega & Cristina Marta DelBen (2015): Clinical Features, Psychiatric Assessment and Longitudinal Outcome of Suicide Attempters Admitted to a Tertiary Emergency Hospital, Archives of Suicide Research, DOI: 10.1080/13811118.2015.1004491 To link to this article: http://dx.doi.org/10.1080/13811118.2015.1004491
Accepted online: 11 May 2015.
Submit your article to this journal
Article views: 44
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=usui20 Download by: [University of Nebraska, Lincoln]
Date: 04 October 2015, At: 18:24
Clinical Features, Psychiatric Assessment and Longitudinal Outcome of Suicide Attempters Admitted to a Tertiary Emergency Hospital Alcinéia Donizeti Ferreira1, Alcion Sponholz-Jr MD, PhD1, Célia Mantovani1, Antônio Pazin-Filho1, Afonso Dinis Costa Passos2, Neury José Botega3, Cristina Marta Del-Ben1
Downloaded by [University of Nebraska, Lincoln] at 18:24 04 October 2015
1
Emergency Hospital of the Medical School of Ribeirão Preto, Division of Psychiatry, Department of Neuroscience and Behavior, Medical School of Ribeirão Preto, University of São Paulo, Brazil, Ribeirão Preto, Brazil, 2 Department of Social Medicine, Medical School of Ribeirão Preto, University of São Paulo, Brazil, Ribeirão Preto, Brazil, 3 Department of Medical Psychology and Psychiatry, Faculty of Medical Sciences, University of Campinas, Brazil, Campinas, Brazil Corresponding Author: Alcion Sponholz-Jr MD, PhD, Emergency Hospital of the Medical School of Ribeirão Preto, Division of Psychiatry, Department of Neuroscience and Behavior, Medical School of Ribeirão Preto, University of São Paulo, Brazil, Avenida Bandeirantes 3900, Ribeirão Preto 14048-900, Brazil. Email: [email protected]
Abstract Objective: Characterize admissions to an emergency hospital due to suicide attempts and verify outcomes in two years. Method: Data were collected from medical records and were analyzed using descriptive statistics and logistic regression. Results: The sample consisted of 412 patients (58.7% women; mean age=32.6 years old, SD=14.3). Self-poisoning was the most frequent method (84.0%), and they were diagnosed mainly as depressive (40.3%) and borderline personality disorders (19.1%). Previous suicide attempts and current psychiatric treatment were reported by, respectively, 32.0% and 28.4%. Fifteen patients (3.6%, 9 males) died during hospitalization. At discharge, 79.3% were referred to community-based psychiatric services. Being male (OR = 2.11; 95% CI = 1.25-3.55), using violent methods (i.e. 1
hanging, firearms and knives) (OR = 1.96; 95% CI = 1.02-3.75) and psychiatric treatment history (OR = 2.58; 95% CI = 1.53-4.36) were predictors for psychiatric hospitalization. Of 258 patients followed for 2 years, 10 (3.9%) died (3 suicide), and 24 (9.3%) undertook new suicide attempts. Patients with a history of psychiatric treatment had higher risks of new suicide attempts (OR=2.46, 95% CI = 1.07-5.65).
Downloaded by [University of Nebraska, Lincoln] at 18:24 04 October 2015
Conclusions: Suicide attempters admitted to emergency hospitals exhibit severe psychiatric disorders, and despite interventions, they continue to present high risks for suicide attempts and death.
KEYWORDS: Suicide attempt, Suicide, Emergency room, Emergency Psychiatry
INTRODUCTION Suicide is associated with multiple risk factors, and a prior history of suicide attempts is a strong predictor of death by suicide (Gunnell & Frankel, 1994; Haukka, Suominen, Partonen, & Lönnqvist, 2008). After an episode of deliberate self-harm, the risk of death by suicide in the subsequent year varies from 0.5% to 2.0%, and it increases to more than 5% after nine years (Owens, Horrocks, & House, 2002). The World Health Organization (WHO) estimates that by 2020, more than 1.5 million people will commit suicide (WHO, 2003), and a significantly greater number of individuals will most likely attempt suicide because attempts can be up to 40 times more frequent than the act itself (Schmidtke et al., 1996).
2
Many people who attempt suicide require medical attention, and contact with health services is an opportunity for suicide risk detection and a referral for specialized treatment (Fleischmann et al., 2008). This is particularly relevant in emergency settings, in which a significant portion of suicide attempters receives first care aid (Jo et al., 2011). However, the routines regarding the psychiatric assessment of suicide attempters can vary
Downloaded by [University of Nebraska, Lincoln] at 18:24 04 October 2015
considerably from one emergency center to another. For instance, a survey of 223 Californian emergency departments found that less than half of the services reported the availability of at least one mental health professional for the assessment of suicide attempters, and only one-quarter had the possibility of a psychiatric admission to their own hospitals (Baraff, Janowicz, & Asarnow, 2006). In low- and middle-income countries (LAMIC), the situation can be even worse. A study conducted in emergency rooms in eight LAMIC showed that in half of the emergency services studied less than one-third of the suicide attempters were referred to health services for further evaluation and follow-up (Fleischmann et al., 2005).
Until recently, suicide was not viewed in Brazil as a public health problem, as it was most likely obscured by the high mortality rates for homicide and traffic accidents in the country. However, a recent study showed that from 1998 to 2008, the total number of deaths due to suicide in Brazil rose from 6.985 to 9.328, representing an increase of 33.5% (Waiselfisz, 2011). These numbers might be even greater in light of underreporting and the poor quality of information contained in the death certificates found in the some areas of the country (Lovisi, Santos, Legay, Abelha, & Valencia, 2009). Despite these understatements, suicide is the third leading external cause of death in Brazil.
3
Moreover, nearly 20% of deaths due to external causes (a total of 143.256 in 2010, http://tabnet.datasus.gov.br/cgi/idb2012/matriz.htm) are recorded based only on the mechanism of death and not on the intention (i.e., “falls and drowning”), making it even more difficult to ascertain the real numbers of deaths by suicide in the country (Bertolote,
Downloaded by [University of Nebraska, Lincoln] at 18:24 04 October 2015
Botega, & de Leo, 2011).
Considering the paucity of data regarding suicide in LAMIC and the heterogeneity of the health care of suicide attempters, we sought a better understanding of the profile of suicide attempters in LAMIC, as well as of the medical care provided for this condition. Therefore, the aims of this study were to characterize the persons admitted to a tertiary referral emergency hospital in the southeast of Brazil due to suicide attempts and to verify the outcomes of these patients in the years following their admission. Specifically, we sought to: a) delineate the sociodemographic and clinical profiles of suicide attempters admitted to referral emergency hospitals over a period of two years, considering eventual differences between genders, b) verify the existence of possible predictors of decision-making regarding the discharge disposition after a suicide attempt, and c) assess the possible predictors of the occurrence of new serious suicide attempts in the 2 years following the suicide attempts.
METHODS Study Design And Setting This is a retrospective cohort study conducted at the Emergency Hospital of the Ribeirão Preto Medical School of the University of São Paulo, Brazil. It is the main tertiary
4
emergency hospital of a catchment area composed of 26 municipalities, containing an estimated population of 1,300,000 inhabitants and located in the southeast of the country. Ribeirão Preto is the main city of the region, with 600,000 inhabitants and a per capita gross domestic product of approximately US$14,000 (IBGE, 2010). This hospital accounts for 51% of the emergency visits in the region, receiving mainly cases of high
Downloaded by [University of Nebraska, Lincoln] at 18:24 04 October 2015
complexity (Adolfi Júnior et al., 2010). Referrals to this emergency hospital follow local and regional emergency medical regulations, which take into account the principles of hierarchy and the complexity of the service network of the Brazilian Health System (Sistema Único de Saúde, SUS). This emergency unit has an emergency room (ER) where the patients are initially admitted mainly by the internal medicine team or the surgical team, according to their supposed diagnosis established by the regulatory system. The patients are evaluated and if they need to be observed or start treatment, this emergency unit has 169 beds, which work as intermediate beds until the patient needs are confirmed and a treatment plan can be determined.
Several medical specialties work together in the emergency room, among them is psychiatry. According to the clinical routines of the hospital, all patients admitted due to a suicide attempt, regardless of the clinic of admission, should be submitted to a psychiatric assessment. The psychiatric evaluation basically consists of verifying the maintenance of suicidal ideation, the identification of any psychiatric conditions underlying the suicide attempt, early intervention in the emergency context, and a referral to psychiatric care at one of the outpatient or inpatient mental health services available in the region.
5
Selection Of Participants The study population consisted of all patients admitted to the emergency unit, from 1 January 2006 to 31 December 2007, with a diagnosis of "intentional self-inflicted injury" and coded as X60 to X84, according to the tenth edition of International Classification of Diseases (ICD 10) (WHO, 1993). We chose to use these diagnostic categories as a way of
Downloaded by [University of Nebraska, Lincoln] at 18:24 04 October 2015
sorting the cases, as there is not a specific code for a suicide attempt in the ICD 10. This strategy also allowed for a broad variety of cases, avoiding losses due to a lack of recording of suicide attempts in the medical files.
The local ethical committee approved the study (protocol number: 13437/2008).
Data Collection And Outcomes Data were collected from medical records, according to protocols already applied in the Brazilian population, as part of the SUPRE-MISS study (Bertolote et al., 2005; Fleischmann et al., 2005; Fleischmann et al., 2008). The variables of interest were: demographic data; methods of suicide attempts; specialty of admission; length of stay; completion of the psychiatric assessment; psychiatric diagnosis; occurrence of previous suicide attempts; current psychiatric community-based care; and psychiatric referral at the time of discharge from the emergency unit (community-based treatment vs. partial or full psychiatric hospitalization). Data were extracted by a social worker familiarized with the routines of the referral emergency hospital, who were trained by two senior psychiatrists regarding the possibilities of register in the medical records of the relevant information for the collection of the variable of interest.
6
The psychiatric diagnosis was defined as the diagnosis recorded in the medical files as the main diagnosis, not including information on co-morbidities. According to the routines of the service, senior psychiatrists, based on the clinical history elaborated by medical residents, defined the psychiatric diagnosis. These senior psychiatrists had a systematic training in the application of operational diagnostic criteria, and can achieve
Downloaded by [University of Nebraska, Lincoln] at 18:24 04 October 2015
good reliability indexes of the diagnosis performed under indirect supervision (Del-Ben et al., 2005).
The discharge disposition from the emergency hospital was categorized according to the need for continuity of care in a protected environment immediately after discharge from the emergency room, including both partial and full psychiatric hospitalization. All patients referred to partial hospitalization and the majority of the patients referred to full hospitalization agreed with this proposal. According to Brazilian laws, in the case of involuntary admission the consent was obtained from a relative who became legally responsible for the admission.
To analyze the outcomes after discharge from the emergency unit, we considered only patients living in the main city of the region (Ribeirão Preto). This strategy was adopted for two reasons: a) the differences between the main city in the region and other cities regarding the availability of mental health services, and b) the unfeasibility of acquiring information concerning the possible occurrence of death among patients from other municipalities. New admissions to the emergency hospital because of a new suicide attempt in the 2 years following the index admission were assessed by querying the
7
hospital database. The occurrence of deaths was checked in the Mortality Information System of the municipality of Ribeirão Preto.
Statistical Analysis Data were analyzed with the SPSS software package, version 16.0. For the exploratory
Downloaded by [University of Nebraska, Lincoln] at 18:24 04 October 2015
analysis and comparison between genders regarding demographic features, qualitative variables were analyzed using the chi-square test or Fisher's exact test, and quantitative variables were evaluated using the t test. Values of p < 0.05 were considered statistically significant.
To explore the decision-making process with regards to discharge disposition, an immediate referral to psychiatric hospitalization (partial or full) at the time of discharge from the emergency hospital was established as the main outcome, and sex, age, ethnicity, education, marital status, occupational status, methods used in the attempted suicide, previous suicidal attempts, current psychiatric treatment, main psychiatric diagnosis and length of stay were the predictor variables. Initially, we calculated odds ratios (ORs) and confidence intervals (95% CI) of the variables of interest, and logistic regression analyses were then conducted. The variables that reached statistical significance (p 0.05). There was a higher proportion of men
9
(54.7%), in comparison with women (22.3%), who were employed (p
