The factors affecting rehabilitation to society of emergency department based post-suicidal care program recipients

1. Introduction

In 2019, South Korea maintained its position from 2018 as the country with the highest suicide rate (24.6 per 100,000 population) among the Organization for Economic Cooperation and Development (OECD) countries. Despite the declining suicide rates among OECD countries with high suicide rates, the suicide rate in Korea has been consistently on the rise [1].

People who have attempted suicide belong to a high-risk group with more than 10-fold higher risk of suicide than the general population [2]. The experts unanimously agree that high-risk individuals require aggressive management in emergency medical facilities. Nevertheless, only 8% of the estimated 40,000 people brought to the emergency department (ED) after a suicide attempt receive counselling and treatment, whereas the remaining 92% are discharged without any measures. Aggressive suicide prevention programmes are essential to effectively address the issue of suicide among individuals with high suicidal ideation as well as appropriate post-attempt management for suicide attempters to prevent another suicide attempt.

Finland and Japan—two countries that outranked South Korea in terms of suicide rates until the early 2000s—have managed to reduce their suicide rates and have achieved a lower suicide rate than Korea since implementing national suicide countermeasures [3]. Moreover, Denmark managed to reduce its suicide reattempt rate from 34% in 2002 to 14% in 2004 after implementing a post-attempt management programme for suicide attempters. In Korea, a post-attempt management project for suicide attempters launched in Dongdaemun-gu has reduced the number of suicide attempters from 106 in 2010 to 82 in 2011. In addition to these results, many studies have shown that post-attempt management of suicide attempters is effective in preventing another suicide attempt [4, 5, 6, 7, 8, 9, 10].

In South Korea, the ED-based Post-Attempt Care Programme was launched in 2013, and by 2021, 76 hospitals have adopted this initiative. This project aims to establish a support system for emotional recovery, rehabilitation and prevention of reattempts for individuals presented to the ED following suicide attempts. However, the ultimate goal of this programme extends beyond preventing suicide reattempts and deaths. It strives to facilitate reintegration into society by providing mental and psychological therapies and social welfare services. Despite the importance of post-attempt management, existing research has primarily focused on the characteristics of suicide attempters, with no studies investigating social reintegration and its predictors among individuals subject to ED-based post-attempt care programmes [11, 12, 13].

This study seeks to address this gap by examining the factors influencing the successful social reintegration of suicide attempters who have participated in ED-based post-attempt care programmes. Social reintegration was determined through face-to-face interviews or phone consultations with programme administrators to assess suicide attempters’ current employment status, utilisation of social welfare facilities (rehabilitation services, such as social adaptation and vocational training), and continuation of education.

2. Materials and methods

2.1 Study participants

This is a prospective study of patients in the ED of a university hospital in Seoul after a suicide attempt between 01 March 2018 and 31 October 2020. Our hospital runs an ED-based case management project, and two social workers are assigned to this programme. Individuals who have attempted suicide were first examined and treated for physical injuries in the ED, and then referred to psychiatry and the Loving Life Team. Patients who consented to the Loving Life Team case-management programme and the present study were enrolled (Fig. 1) (IRB No.: 2018-04-007-001).

Fig. 1.Flowchart of patient selection. DAMA: Discharge Against Medical Advice; ED: emergency department.

3. Results

Among patients in the ED for a suicide attempt during the study period, 106 consented to the post-attempt care programme. After excluding one patient with missing data, one duplicate patient, and 18 patients lost to follow-up, 86 patients were enrolled in the study (Fig. 1). The mean age of the study population was 38.3 years, with 15 aged ≤19 years (17.4%), 36 aged 20–39 years (41.9%), 17 aged 40–59 years (19.8%), and 18 aged ≥60 years (20.9%), showing that young adults aged 20–39 years accounted for the highest percentage of suicide attempters. There were more women (n = 51; 59.3%) than men (n = 35; 40.7%). At the initial social reintegration assessment, 63 were identified to have been reintegrated (73.3%), and 23 (26.7%) failed to reintegrate. In the second social reintegration assessment, 69 (80.2%) reintegrated, and 17 (19.8%) failed to reintegrate (Table 1).

Initial social reintegration was significantly associated with living alone (p = 0.002), referral to a mental health welfare centre (p = 0.042), psychiatric hospitalisation history (p = 0.018), and physical medical history (p = 0.042), while it was not significantly associated with sex, education level, marital status, employment status, monthly income, medical insurance, past suicide attempt history, the authenticity of suicide attempt, psychiatric treatment, family histories and the RRRS score. Second, social reintegration was associated with living alone (p < 0.001), initial social reintegration status (p < 0.001), and educational level (p = 0.01). There were no significant differences in referral to a mental health welfare centre (p = 0.543), psychiatric hospitalisation history (p = 0.177), and physical medical history (p = 0.05) (Table 2).

Factors that differed significantly in the univariate analysis were entered into the multivariate logistic regression analysis. Living alone was a significant predictor of initial social reintegration (p = 0.023) (Table 3), whereas initial social reintegration status (p < 0.001) and living alone (p = 0.033) were significant predictors of second social reintegration (p < 0.001) (Table 4).

4. Discussion

This study analysed the predictors of social reintegration among patients in the ED after a suicide attempt. Previous studies on suicide have primarily focused on the characteristics of suicide attempters. However, these studies have only provided evidence for identifying individuals at high risk of suicide, with little practical data for preventing suicide. Furthermore, few studies have examined the recovery and social reintegration of patients brought to the ED after suicide attempts.

Our multivariate logistic regression analysis showed that initial social reintegration status was a significant predictor of the second social reintegration of suicide attempters. In other words, the initial social reintegration status can determine whether an individual can achieve social reintegration at a later time point, suggesting that the quick social reintegration of suicide attempters can be long-term and definitive. Therefore, in the early stages, it is essential to aggressively address suicide attempters to facilitate their quick social return and ensure favourable long-term outcomes.

Additionally, living alone increased the odds of both initial and secondary social reintegration. This finding contradicts the general expectation that living with someone who can provide social and emotional support lowers the odds of suicide attempts or increases the odds of social reintegration. Previous studies have reported that suicide attempts among adolescents and young adults are influenced by impaired or severed family relationships, such as conflicts with parents [16, 17]. Furthermore, in terms of marital status, the number of married male suicide attempters has significantly increased over the past decades, with concerns about an increase in the number of male high school graduates, unemployed and married individuals [18]. Most interpersonal conflicts that trigger suicide involve family members, with marital conflict being the most common cause [19]. Thus, living with someone and experiencing conflict with that person can lead to a suicide attempt, and returning home to this person without resolving the conflict may hinder the social reintegration of the person who has attempted suicide. However, it is well known that older adults who live alone have a significantly higher suicide attempt rate [20, 21, 22]. Given these findings, our results may be attributed to the demographic characteristics of our sample, where young adults aged 10–39 years account for nearly 60% of the entire study sample. Therefore, additional research is required to conduct a more accurate assessment of the reasons for suicide attempts.

In our univariate analysis, a history of physical medical issues and educational level were significantly correlated with social reintegration. Previous studies have reported that the severity of physical illness and medical conditions affect suicide attempts, suicidal ideation and referrals to psychiatric treatment [23, 24]. Similarly, our results indicated that experiencing interruptions in daily life due to a physical illness hindered social reintegration. Hence, it is important to assess, treat and facilitate recovery from pre-existing conditions in addition to providing psychiatric assessment and treatment for those who have attempted suicide brought to the ED to promote their social reintegration. Furthermore, the rates of suicidal ideation and suicide attempts were higher among less educated individuals [18]. In our study, the odds of social reintegration decreased with increasing educational level in the univariate analysis, although the association was not significant in the multivariate analysis. These results contradict the previous findings. According to Agerbo [25], high income, high education and married status can increase suicide rates among individuals with a psychiatric history. Furthermore, the incidence rates of suicide attempts and suicidal ideation may be higher among less-educated individuals, but a lower number of suicide attempts among highly educated individuals may indicate more severe medical and social states and fatal suicide attempts. Further research on this topic is required.

This study has several limitations. First, this is a single-centre study conducted at a university hospital in Seoul, Korea. Consequently, the regional characteristics and population composition of the sample do not represent the region or country; thus, the findings cannot be generalised. Second, the sample size is small owing to the single-centre design. Third, we relied on self-report to collect data because of the nature of this topic. Some patients refused to answer some questions, and they might have provided false responses intentionally or otherwise. To address this issue, case managers need to develop good rapport with patients during the initial assessment to increase the reliability of responses and lower the rate of missing responses. Fourth, the follow-up periods of two months and four months are inadequate. Therefore, long-term studies with larger and more diverse populations are needed.

5. Conclusions

This study has several implications, including highlighting the benefits of rapid social reintegration in promoting long-term social reintegration among suicide attempters who consent to ED-based post-attempt care programs. The need for aggressive interventions to promote social reintegration among suicide attempters who live with someone, and the importance of assessing and treating pre-existing medical conditions and their severity, in addition to psychiatric assessment. Therefore, case managers of the Loving Life Team as well as ED and psychiatric providers, should be educated and trained to promote quick social reintegration of patients brought to the ED after a suicide attempt. Furthermore, for suicide attempters who live with someone else, it may be more effective to include cohabiting individuals in counselling and therapy sessions. Based on our findings and subsequent research, it is essential to explore measures to help those who have attempted suicide successfully reintegrate into society beyond simply lowering the suicide rate.

Availability of data and materials

There are ethical restrictions on sharing a dataset because the data contain potentially identifying information. Loving Life team can be contacted for data access via e-mail (s8250@paik.ac.kr) or by calling 82-10-8497-7119.

Author contributions

HJK—performed the authored, analyzed the data, prepared tables, authored and reviewed drafts of the paper. JWC—reviewed drafts of the paper, designed and wrote the first manuscript. All authors approved the final draft.

Ethics approval and consent to participate

This study was approved by the institutional review board (IRB) of Inje University Sanggye Paik hospital (IRB No.: 2018-04-007-001). We acquired the informed consent for the patients or their guardians for data collection.

Acknowledgment

Thanks for Young-ho Shin (Sanggye Paik Hospital’s case management team) for their data management support.

Funding

This work was supported by the 2023 Inje University research grant (20230137).

Conflict of interest

The authors declare no conflict of interest.