The finding:
The investigators used a national dataset to analyze the effect of a prior psychiatric consultation on subsequent self-harm attempts among 6 South Korean hospitals. Among 2144 patients who presented with repeat self-harm, having had a psychiatric consultation during a prior emergency department (ED) visit was associated with lower mortality (2.5% v 5.8%) on follow-up. This improved mortality is attributed to use of less lethal means including lower rates of hanging (4.6% v 45%) or jumping from heights (1.5% v 15.0%). The authors suggest that the fatality of subsequent suicide attempt is a valuable outcome that captures the effect of active treatment more than a binary reports of self-harm or not, or suicide or no.

Strength and weaknesses:
Data capture was impressive and deliberative: the study utilizes a national dataset, which includes 58 clinical variables specific to the self-harm episode collected by an assigned coordinator at each hospital and reviewed by a quality assurance committee. Thus, description of self-harm was more rigorous than similar studies using only ICD-10 codes or chief complaints. Few data were missing, although there is no description of how missing data might affect the findings. The selected population of patients—ie, who are presenting with a second episode of self-harm—might limit generalizability somewhat, but recurrent ED visits are common, especially among patients with psychiatric illness. The most significant limitation is in the study’s outcome. The authors cannot speak to whether psychiatric consultation reduced the risk of subsequent self-harm or even mortality; the significance of the finding rests on the presumption that selection of less lethal means was due to psychiatric intervention. Because prior means were not examined as a confounder in multivariable analyses, there is a significant risk of bias. Patients often re-use the same lethal means, and those who used lethal means during the first ED visit are not alive for the second and thus not in this study. The study did not include details on the nature of psychiatric intervention provided, eg, hospitalization or crisis planning.

Relevance:
EDs are most often the first point of contact for patients after self-harm, but it remains unclear how best to reduce recurrent self-harm and adverse outcomes. This study suggests that psychiatric consultation that includes lethal means counselling is a life-saving intervention. The notion that lower lethality attempts are a positive outcome relative to higher lethality attempts after ED discharge is novel but may be difficult to capture absent the resource-intensive methodology described in this study.

Type of study (EBM guide):
Cohort study

The finding:
The COVID-19 pandemic has wrought challenges for mental health systems. One measure of the burden of illness and challenges of care delivery is the pandemic’s effect on ED utilization. The investigators examined the volume and nature of presentations at 2 hospitals in the UK. While overall ED volume decreased over 40% from 2019 to 2020, the number of self-harm presentations increased both proportionally (by 10%) and in absolute numbers. This increase is largely accounted for by overdoses rather than other means. Medical hospitalization rates for these self-harm episodes also increased (from 39% to 58%), suggesting more severe attempts.

Strength and weaknesses:
The authors used data from multiple hospitals and use concrete, easily interpretable outcomes such as medical hospitalization to ascertain morbidity. Data were available not only from the ED but also from subsequent medical stays, when patients may have been seen by a C-L team outside the ED. Demographic data were also examined to assess whether particular subgroups appears at risk, although the analysis is under-powered to detect any such trends. The use of ED visits is valuable but limited. Many nonfatal overdoses occur at home, and the patients do not present for care. Data from poison centers and crisis lines will be invaluable for trying to develop a more complete picture of the mental health consequences of COVID-19.

Relevance:
There is an increasingly clear picture of the impact of COVID-19 and the related public health response on emergency psychiatric utilization. While overall ED volumes appear to have decreased, mental health visits to the ED have persisted or even increased in some areas. Among those mental health ED visits there are higher rates of hospitalization and other sequelae of more serious illness. The reasons for these trends are undoubtedly complex and relate to many factors including the availability of outpatient services, widespread social isolation, and economic stressors. If the pandemic persists well into 2021 as seems likely, behavioral health systems will need to re-consider how to structure crisis systems, surveillance, and intensive outpatient services in a way that can address the growing public health burden.

Type of study (EBM guide):
cohort study