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Psychiatric intervention and repeated admission to emergency centres due to drug overdose

Published online by Cambridge University Press:  02 January 2018

Akiko Kanehara
Affiliation:
Department of Youth Mental Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Hayato Yamana
Affiliation:
Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
Hideo Yasunaga
Affiliation:
Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
Hiroki Matsui
Affiliation:
Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
Shuntaro Ando
Affiliation:
Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
Tsuyoshi Okamura
Affiliation:
Department of Neuropsychiatry, The University of Tokyo Hospital, Tokyo, Japan
Yousuke Kumakura
Affiliation:
Department of Neuropsychiatry, The University of Tokyo Hospital, Tokyo, Japan
Kiyohide Fushimi
Affiliation:
Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
Kiyoto Kasai
Affiliation:
Department of Neuropsychiatry, The University of Tokyo Hospital, Tokyo, Japan
Corresponding
E-mail address:
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Abstract

Background

Repeated drug overdose is a major risk factor for suicide. Data are lacking on the effect of psychiatric intervention on preventing repeated drug overdose.

Aims

To investigate whether psychiatric intervention was associated with reduced readmission to emergency centres due to drug overdose.

Method

Using a Japanese national in-patient database, we identified patients who were first admitted to emergency centres for drug overdose in 2010–2012. We used propensity score matching for patient and hospital factors to compare readmission rates between intervention (patients undergoing psychosocial assessment) and unexposed groups.

Results

Of 29 564 eligible patients, 13 035 underwent psychiatric intervention. In the propensity-matched 7938 pairs, 1304 patients were readmitted because of drug overdose. Readmission rate was lower in the intervention than in the unexposed group (7.3% v. 9.1% respectively, P<0.001).

Conclusions

Psychiatric intervention was associated with reduced readmission in patients who had taken a drug overdose.

Type
Research Article
Creative Commons
Creative Common License - CCCreative Common License - BYCreative Common License - NCCreative Common License - ND
This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Copyright
Copyright © The Royal College of Psychiatrists 2015

Self-harm, with or without suicidal intent, substantially increases the risk of future suicide Reference Brådvik, Mattisson, Bogren and Nettelbladt1,Reference Crandall, Fullerton-Gleason, Aguero and LaValley2 and is known to be the strongest predictor of completed suicide. Reference Haukka, Suominen, Partonen and Lönnqvist3Reference Owens, Horrocks and House7 Furthermore, repetition of self-harm is common: Reference Zahl and Hawton8,Reference Gunnell, Bennewith, Peters, Stocks and Sharp9 16% of patients who self-harmed were found to repeat a similar episode within 1 year. Reference Owens, Horrocks and House7 Repetition of self-harm increases the risk of completed suicide. Reference Zahl and Hawton8 One study found overdose to be the most prevalent type of suicide attempt that required admission, Reference Runeson, Tidemalm, Dahlin, Lichtenstein and Långström10 and approximately 80% of self-harm episodes have been reported to involve overdose. Reference Horrocks, Price, House and Owens11 It is therefore necessary to prevent the repetition of self-harm by drug overdose. According to clinical guidelines on the management of self-harm published in 2004, it is recommended that every patient presenting to hospital with self-harm should undergo a psychosocial assessment by specialists before being discharged. 12,13 Despite this recommendation, some studies have found that many patients, especially those with repeated self-harm, Reference Hickey, Hawton, Fagg and Weitzel14 did not actually receive such assessments. Reference Hughes and Kosky15Reference Okumura, Shimizu, Ishikawa, Matsuda, Fushimi and Ito18 That would suggest that the guideline has not been widely used – possibly because it was not based on firm evidence. There is a lack of data on the influence of psychosocial assessments on preventing repetition of self-harm. Some studies have suggested that such assessments do have an influence, but they were based on a small sample size Reference Hickey, Hawton, Fagg and Weitzel14,Reference Kapur, House, Dodgson, May and Creed19Reference Kapur, Cooper, Hiroeh, May, Appleby and House21 or on a small number of highly advanced institutions. Reference Kapur, Murphy, Cooper, Bergen, Hawton and Simkin17,Reference Bergen, Hawton, Waters, Cooper and Kapur22,Reference Kapur, Steeg, Webb, Haigh, Bergen and Hawton23 The present study focused on patients with drug overdose who were admitted to emergency centres. Using a national in-patient database in Japan, it aimed to investigate whether psychiatric intervention before discharge was associated with reduced patient readmissions with drug overdose.

Method

Data source

The Diagnosis Procedure Combination (DPC) database is a national in-patient database in Japan that includes administrative claims data and detailed patient data. Reference Yasunaga, Horiguchi, Kuwabara, Matsuda, Fushimi and Hashimoto24 As of 2012, the database included the data of approximately 7 million in-patients from more than 1000 hospitals in Japan, representing around 50% of all acute care in-patient admissions. The database consists of the following information: unique hospital identifiers; age and gender main diagnoses, comorbidities present on admission, and complications that occurred after admission recorded with text data in Japanese and using ICD-10 25 codes; procedures; and discharge status. The responsible physicians are obliged to record the diagnoses with reference to medical charts on discharge. For the main diagnosis, the physicians have to enter only one ICD code.

This study was approved by the Ethical Committee, Faculty of Medicine, The University of Tokyo (approval No. 3501). Because of the anonymous nature of the data, informed consent was not required.

Participant selection and data

We identified patients with a diagnosis of drug poisoning (ICD-10 codes: T360–T509) who were discharged from participating hospitals between 1 July 2010 and 31 March 2013 (33 months in total). We included patients aged 12 years or older with a first episode of drug overdose and who visited a hospital with at least one full-time psychiatrist during the study period. We excluded patients who died during admission to hospital.

We identified psychiatric intervention by means of procedure codes for ‘interview for assessment and/or psychotherapy by a psychiatrist’, coded using the Japanese Procedure Codes defined under the fee schedule of the national health insurance system. We divided the patients into two groups: (a) those who received a psychiatric intervention – the psychiatric intervention group; and (b) those who did not – the unexposed group.

Based on the protocol of Quan et al, we converted ICD-10 codes of comorbidities that were present on admission into scores for each patient to calculate the Charlson comorbidity index (CCI). Reference Quan, Sundararajan, Halfon, Fong, Burnand and Luthi26 This index is used to predict mortality by classifying or weighting comorbidities to assess disease burden and case mix. Hospital volume was defined as the number of patients with the diagnosis of drug overdose annually at each hospital; it was classified into three categories (low, medium and high volume), with approximately equal numbers of patients in each group.

Outcome

The primary outcome was readmission to the same hospital due to repeated drug overdose.

Statistical analyses

We conducted one-to-one matching between the psychiatric intervention group and unexposed group based on the estimated propensity score of each patient. Reference D'Agostino27 This approach avoided treatment selection bias, which is inherent in observational data analysis. In this approach, every patient in the intervention group was matched with a patient in the unexposed group based on the estimated propensity score, the probability of undergoing the intervention calculated using the observed potential confounders. The matched patients constituted two groups with similar characteristics, which resembled a randomised experiment-like situation. To estimate the propensity score, we fitted a logistic regression model with receipt of the psychiatric intervention as the outcome variable and the following as independent variables: age; gender; ICD-based information on toxic agents (non-opioid analgesics, anti-pyretics and anti-rheumatics [T39]; anti-epileptic, sedative, hypnotic and anti-Parkinsonian drugs [T42]; other psychotropic drugs [T43]; other drugs [T36–38, T41, T44–T49]; and unspecified drugs [T50]); ICD-based diagnoses of mental disorders (schizophrenia [F2]; mood disorders [F3]; organic mental disorders [F0]; mental disorders due to psychoactive substance use [F1]; disorders of personality and behaviour [F6]; and other mental disorder); Japan Coma Scale Reference Ohta, Kikuchi, Hashi and Kudo28 on admission; CCI; tracheal intubation; haemodialysis; type of hospital (academic or non-academic); hospital volume category and fiscal year of discharge. The C-statistic was calculated to evaluate the goodness of fit.

We conducted one-to-one matching between the psychiatric intervention and unexposed groups using nearest-neighbour matching within a calliper. One unexposed patient with the closest propensity score was selected for each intervention patient – provided that the difference in propensity score was within a certain amount (a calliper). We set a calliper as 0.20 of the standard deviation of the estimated propensity scores to achieve good balance between the intervention and unexposed groups. We used standardised differences to compare the prevalence of characteristics between the two groups. Reference Austin29 An absolute standardised difference of >10 has been suggested as signifying meaningful imbalance. Reference Austin29 We performed a chi-squared test to compare the proportions of readmission between the psychiatric intervention and unexposed groups among the propensity-matched patients. Logistic regression analysis for readmission was performed to calculate the odds ratio and 95% confidence interval (CI) of the psychiatric intervention group with respect to the unexposed group. We performed subgroup analysis on propensity-matched patients by age group. The threshold for significance was P<0.05. All statistical analyses were conducted using IBM SPSS Statistics, version 22.0 (IBM SPSS, Armonk, New York, USA).

Results

We identified 29 564 eligible patients from 368 hospitals during the study period; they comprised the psychiatric intervention group (n=13 035; 44.1%) and unexposed group (n=16 529; 55.9%). In total, 1961 patients (6.6%) required repeated admission due to drug overdose. Using one-to-one propensity score matching, we obtained 7938 pairs of the psychiatric intervention and unexposed groups. The C-statistic for goodness of fit was 0.768. Table 1 shows the demographic characteristics of all patients (n=29 564) and the propensity score-matched patients (n=15 876). Patients in the psychiatric intervention group were more likely to have the following characteristics: be younger and female; have schizophrenia, mood disorder, or personality or behaviour disorders; take psychotropic drugs during their overdose episode; have a worse consciousness level; undergo tracheal intubation and haemodialysis; and be discharged after 2012. Academic hospitals and higher volume hospitals were more likely to perform psychiatric interventions. After propensity score matching, the patient distributions were closely balanced between the two groups.

Table 1 Demographic and clinical characteristics of the psychiatric intervention and unexposed groups

All patients Propensity-matched patients
Unexposed group (n=16 529) Psychiatric intervention group (n=13 035) Absolute standardised difference Unexposed group (n=7938) Psychiatric intervention group (n=7938) Absolute standardised difference
n % n % n % n %
Female 10 944 66.2 9310 71.4 11.2 5620 70.8 5576 70.2 1.3
Age, years
 12–19 1044 6.3 884 6.8 2.0 550 6.9 523 6.6 1.2
 20–29 3401 20.6 3181 24.4 9.1 1978 24.9 1877 23.6 3.0
 30–39 3293 19.9 3315 25.4 13.2 1955 24.6 1934 24.4 0.5
 40–49 2651 16.0 2564 19.7 9.7 1559 19.6 1558 19.6 0.0
 50–59 1468 8.9 1343 10.3 4.8 786 9.9 791 10.0 0.3
 60–69 1389 8.4 874 6.7 6.4 530 6.7 567 7.1 1.6
 70–79 1441 8.7 548 4.2 18.4 358 4.6 400 5.0 1.9
 80–89 1442 8.7 289 2.2 28.9 198 2.5 254 3.2 4.2
 ≥90 400 2.4 37 0.3 18.3 24 0.3 34 0.4 1.7
Toxic agent
 Non-opioid analgesics, anti-pyretics and anti-rheumatics 651 3.9 730 5.6 8.0 383 4.8 365 4.6 0.9
 Anti-epileptic, sedative-hypnotic and anti-Parkinsonism drugs 4685 28.3 4109 31.5 7.0 2423 30.5 2469 31.1 1.3
 Other psychotropic drugs 1172 7.1 1186 9.1 7.3 701 8.8 697 8.8 0.0
 Other drugs 2113 12.8 273 2.1 41.6 143 1.8 234 2.9 7.3
 Unspecified drugs 7908 47.8 6737 51.7 7.8 4288 54.0 4173 52.6 2.8
Classification of mental disorder
 Schizophrenia 1394 8.4 2210 17.0 26.0 1133 14.3 1154 14.5 0.6
 Mood disorders 3845 23.3 5484 42.1 40.9 3006 37.9 3070 38.7 1.6
 Organic mental disorders 260 1.6 178 1.4 1.6 114 1.4 127 1.6 1.6
 Mental disorders due to psychoactive substance use 451 2.7 351 2.7 0.0 260 3.3 271 3.4 0.6
 Disorders of personality and behaviour 261 1.6 461 3.5 12.1 210 2.6 217 2.7 0.6
 Other mental disorder 1190 7.2 2042 15.7 26.9 1012 12.7 990 12.5 0.6
 Not known 9128 55.2 2309 17.7 84.6 2203 27.8 2109 26.6 2.7
Level of consciousness on admission
 Alert 5299 32.1 2909 22.3 22.2 1983 25.0 1949 24.6 0.9
 Dull 3746 22.7 3280 25.2 5.9 1886 23.8 1919 24.2 0.9
 Somnolence 3416 20.7 2963 22.7 4.9 1846 23.3 1850 23.3 0.0
 Coma 4068 24.6 3883 29.8 11.7 2223 28.0 2220 28.0 0.0
Charlson comorbidity index
 0 12 251 74.1 11 200 85.9 29.8 6775 85.3 6640 83.6 4.7
 1 2524 15.3 1352 10.4 14.7 859 10.8 929 11.7 2.8
 2 994 6.0 327 2.5 17.4 215 2.7 247 3.1 2.4
 ≥3 760 4.6 156 1.2 20.4 89 1.1 122 1.5 3.5
Tracheal intubation 1019 6.2 2130 16.3 32.4 787 9.9 816 10.3 1.3
Haemodialysis 203 1.2 249 1.9 5.7 97 1.2 111 1.4 1.8
Academic hospital 5532 33.5 6328 48.5 30.9 3269 41.2 3248 40.9 0.6
Hospital volume groups, per year
 Low (≤38) 6673 40.4 3240 24.9 33.5 2491 31.4 2444 30.8 1.3
 Medium (39–84) 5529 33.5 4216 32.3 2.6 2651 33.4 2688 33.9 1.1
 High (≥85) 4327 26.2 5579 42.8 35.5 2796 35.2 2806 35.3 0.2
Fiscal year of discharge
 2010 5825 35.2 3290 25.2 21.9 2454 30.9 2419 30.5 0.9
 2011 5693 34.4 5002 38.4 8.3 2959 37.3 2949 37.2 0.2
 2012 5011 30.3 4743 36.4 13.0 2525 31.8 2570 32.4 1.3

Table 2 shows the proportion of readmissions due to drug overdose in each subgroup in the propensity score-matched groups. In the matched patients, 1304 patients (8.2%) required repeated admission due to drug overdose. Patients who were younger females, had personality disorders and took other psychotropic drugs during their overdose episode were more likely to be readmitted as a result of drug overdose. Patients who were admitted to higher volume hospitals or discharged before 2011 were also more likely to be readmitted.

Table 2 Proportions of readmission due to overdose in each subgroup in the propensity-matched patients (n=15 876)

No. of patients Readmission %
Total 15 876 1304 8.2
Female 11 196 1032 9.2
Age, years
 12–19 1073 91 8.5
 20–29 3855 358 9.3
 30–39 3889 389 10.0
 40–49 3117 278 8.9
 50–59 1577 109 6.9
 60–69 1097 52 4.7
 70–79 758 20 2.6
 ≥80 510 7 1.4
Toxic agent
 Non-opioid analgesics, anti-pyretics and anti-rheumatics 748 35 4.7
 Anti-epileptic, sedative-hypnotic and anti-Parkinsonism drugs 4892 395 8.1
 Other psychotropic drugs 1398 121 8.7
 Other drugs 377 19 5.0
 Unspecified drugs 8461 734 8.7
Classification of mental disorder
 Schizophrenia 2287 206 9.0
 Mood disorders 6076 507 8.3
 Organic mental disorders 241 10 4.1
 Mental disorders due to psychoactive substance use 531 28 5.3
 Disorders of personality and behaviour 427 57 13.3
 Other mental disorders 2002 154 7.7
 Not known 4312 342 7.9
Level of consciousness on admission
 Alert 3932 334 8.5
 Dull 3805 318 8.4
 Somnolence 3696 317 8.6
 Coma 4443 335 7.5
Charlson comorbidity index
 0 13,415 1164 8.7
 1 1788 103 5.8
 2 462 27 5.8
 ≥3 211 10 4.7
Tracheal intubation 1603 98 6.1
Haemodialysis 208 12 5.8
Academic hospital 6517 529 8.1
Hospital volume groups, per year
 Low (≤38) 4935 358 7.3
 Medium (39–84) 5339 463 8.7
 High (≥85) 5602 483 8.6
Fiscal year of discharge
 2010 4873 572 11.7
 2011 5908 507 8.6
 2012 5095 225 4.4

The propensity score-matched analysis showed a significant difference in readmission due to drug overdose between the psychiatric intervention and unexposed groups (7.3% v. 9.1% respectively; P<0.001). Logistic regression analysis showed that the psychiatric intervention group had a significantly lower proportion of readmission through drug overdose than the unexposed group (adjusted odds ratio 0.79; 95% CI 0.71–0.89; P<0.001; Table 3). Subgroup analysis showed that psychiatric intervention was significantly associated with lower readmission in two age groups – patients in their 20s and 40s (Table 4).

Table 3 Proportions of readmission due to overdose in the propensity-matched group (n=15 876)

Unexposed group (n=7938) Psychiatric intervention group (n=7938)
n % n % P Odds ratio (95% CI)
722 9.1 582 7.3 <0.001 0.79 (0.71–0.89)

Table 4 Subgroup analysis with proportions of readmission due to overdose in the psychiatric intervention group (n=7938)

Unexposed group Intervention group
Age, years No. of patients Readmission % No. of patients Readmission % P Odds ratio (95% confidence interval)
Total 7938 722 9.1 7938 582 7.3 <0.001 0.79 (0.71–0.89)
12–19 550 47 8.5 523 44 8.4 1.000 0.98 (0.64–1.51)
20–29 1978 204 10.3 1877 154 8.2 0.026 0.78 (0.62–0.97)
30–39 1955 205 10.5 1934 184 9.5 0.336 0.90 (0.73–1.11)
40–49 1559 164 10.5 1558 114 7.3 0.002 0.67 (0.52–0.86)
50–59 786 62 7.9 791 47 5.9 0.137 0.74 (0.50–1.09)
60–69 530 28 5.3 567 24 4.2 0.478 0.79 (0.45–1.39)
≥70 580 12 2.1 688 15 2.2 1.000 1.06 (0.49–2.27)

Discussion

Using a national in-patient database in Japan, this study compared repeated admission due to drug overdose between a psychiatric intervention and an unexposed group. Only 44% of the admitted patients underwent psychiatric intervention. A propensity-matched analysis demonstrated that the proportion of repeated admission through drug overdose was lower in the psychiatric intervention than in the unexposed group. Although not statistically significant for some age groups, the results were consistent across the various age groups. Psychiatric intervention was associated with lower readmission in younger subgroups, which is consistent with the findings of other reports. Reference Kawanishi, Aruga, Ishizuka, Yonemoto, Otsuka and Kamijo30,Reference Erlangsen, Lind, Stuart, Qin, Stenager and Larsen31

Several studies have investigated the effect of psychiatric intervention before discharge on preventing repetition of self-harm. However, the generalisability of those reports was limited because they were based on small sample sizes Reference Hickey, Hawton, Fagg and Weitzel14,Reference Kapur, House, Dodgson, May and Creed19Reference Kapur, Cooper, Hiroeh, May, Appleby and House21 or were restricted to data from highly advanced institutions with specialist self-harm teams. Reference Kapur, Murphy, Cooper, Bergen, Hawton and Simkin17,Reference Bergen, Hawton, Waters, Cooper and Kapur22,Reference Kapur, Steeg, Webb, Haigh, Bergen and Hawton23 One strength of the present study was the that it was representative of the general in-patient population, being based on nationwide data from various types of hospitals.

Previous investigations have shown mixed results on the effect of psychiatric intervention. Reference Kapur, Murphy, Cooper, Bergen, Hawton and Simkin17 Most of those studies adopted a conventional regression model, which failed to adjust for patient backgrounds and hospital factors. Our study included various factors that could affect the probability of undergoing psychiatric intervention. Those key factors enabled us to conduct a propensity score analysis, which further reduced selection bias when estimating intervention effects from observational data. The model used in the matching method exhibited good discriminating ability in estimating receipt of psychiatric intervention (area under the receiving operating characteristic curve 0.768; 95% CI 0.763–0.773).

The proportion of readmission within 1 year (4.4%) was lower than the proportions of repeated self-harm (16%) reported in one systematic review. Reference Owens, Horrocks and House7 A recent systematic review of brief contact interventions also found a higher rate of repeated self-harm (intervention 9.8%; unexposed 11.1%). Reference Milner, Carter, Pirkis, Robinson and Spittal32 The reviewed studies identified repeated episodes using various methods such as the use of catchment areas for including patients, follow-up interviews and checking medical records. In the present study, we were able to identify only same-hospital readmission due to overdose, and this was a potential source of underestimation.

Our findings suggest that psychiatric intervention following admission due to drug overdose was associated with reduced readmission. Clinical guidelines from the National Institute for Health and Care Excellence in 2004 12 and Royal College of Psychiatrists in 2004 13 recommend that a psychosocial assessment by a trained mental health specialist be carried out for all patients who self-harm. In the present study, interventions by psychiatrists were associated with reduced risk of readmission, which suggests that such interventions are effective. However, because we were unable to assess the effect of intervention by other specialists, our findings may not apply to hospitals without consultation liaison services provided by psychiatrists.

The intervention in the present study included two aspects – assessment and psychotherapy. Because the DPC database lacked information regarding classification of the performed intervention, we were unable to distinguish between assessment and psychotherapy; likewise, we could not identify which elements of the intervention were effective. In the context of brief hospital admission, however, we assume that the intervention reflected the effects of assessment.

Several limitations of this study warrant consideration. First, the database we used did not include the severity of mental disorder, which may have influenced the probability of undergoing psychiatric intervention. Second, the recorded diagnoses in administrative claims databases are less well validated than those based on prospective cohorts or registries. Third, a large proportion of unspecified drugs may have caused confounding bias and led to underestimating the true effect of the intervention.

In conclusion, our study demonstrated that psychiatric intervention by psychiatrists before discharge was associated with reduced risk of repeated admission to emergency centres. These findings indicate the importance of psychiatric intervention for drug overdose patients admitted to emergency centres in preventing repeated admission.

Funding

This study was supported by a grant from the Ministry of Health, Labour and Welfare, Japan (Research on Policy Planning and Evaluation Grant No. H26-Policy-011).

Footnotes

Declaration of interest

None.

References

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Figure 0

Table 1 Demographic and clinical characteristics of the psychiatric intervention and unexposed groups

Figure 1

Table 2 Proportions of readmission due to overdose in each subgroup in the propensity-matched patients (n=15 876)

Figure 2

Table 3 Proportions of readmission due to overdose in the propensity-matched group (n=15 876)

Figure 3

Table 4 Subgroup analysis with proportions of readmission due to overdose in the psychiatric intervention group (n=7938)

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