Available online at www.sciencedirect.com

General Hospital Psychiatry 32 (2010) 549–555

Emergency Psychiatry in the General HospitalThe emergency room is the interface between community and health care institution. Whether through outreach or in-hospital service, the psychiatrist in the general

hospital must have specialized skill and knowledge to attend the increased numbers of mentally ill, substance abusers, homeless individuals, and those with greater

acuity and comorbidity than previously known. This Special Sectionwill address those overlapping aspects of psychiatric,medicine, neurology, psychopharmacology,

and psychology of essential interest to the psychiatrist who provides emergency consultation and treatment to the general hospital population.

Comparison of patients with and without mental disorders treated forsuicide attempts in the emergency departments of four general

hospitals in Shenyang, China☆,☆☆

Bo Bi, M.D., Ph.D.a, Jianhua Tong, M.D.b, Li Liu, M.D.a, Shengnan Wei, M.D.a,Haiyan Li, M.D.a, Jinglin Hou, M.D.a, Shanyong Tan, M.D.a, Xu Chen, M.D.a,

Wei Chen, M.D.a, Xiaoju Jia, M.D.a, Ying Liu, M.D.a, Guanghui Dong, M.D., Ph.D.c,Xiaoxia Qin, M.D.a,⁎, Michael R. Phillips, M.D., Ph.D.d

aDepartment of Psychiatry, First Affiliated Hospital, China Medical University, Shenyang, Liaoning 110001, PR ChinabDepartment of Scientific Research, First Affiliated Hospital, China Medical University, Shenyang 110001, PR China

cStatistics Center, School of Public Health, China Medical University, Shenyang 110001, ChinadShanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 110001, China

Received 30 January 2010; accepted 8 June 2010

Abstract

Objective: Compare the sociodemographic and psychological characteristics of suicide attempters admitted to emergency departments ofgeneral hospitals in China that do and do not meet diagnostic criteria for mental disorders.Methods: The Structured Clinical Interview for DSM-IV, the Suicide Ideation Scale, the Hamilton Depression Rating Scale and a quality oflife measure were administered to 239 consecutive suicide attempters who were treated in the emergency departments of four randomlyselected general hospitals in Shenyang.Results: Among the enrolled subjects, 166 (69.5%) met diagnostic criteria for a current mental disorder. Among these 166 subjects, 62.7%had mood disorders, 14.5% had anxiety disorders, 10.8% had psychotic disorders and 3.6% had substance use disorders. The 73 suicideattempters without a mental disorder were younger, had higher levels of impulsiveness and were more likely to have ideas about beingrescued. Multivariate logistic regression analysis identified the following independent predictors of having a current psychiatric disorder inthe suicide attempters: female gender (OR=3.67, 95% CI=1.23–10.91), more than 6 years of formal education (OR=1.19, 95%CI=1.04–1.36), a higher score on the suicide ideation scale (OR=1.01, 95% CI=1.00–1.03), a higher score on Hamilton depression ratingscale (OR=1.26, 95% CI=1.16–1.37) and a lower score on the quality of life scale (OR=0.75, 95% CI=0.63–0.90).Conclusion: The prevalence of psychiatric disorders in suicide attempters in emergency departments of urban China is lower than thatreported in most western countries. Suicide attempters with and without mental illnesses are distinct on a number of important dimensions.Mental health assessment and appropriate discharge planning for patients treated in emergency departments for suicide attempts are crucialcomponents of comprehensive suicide prevention efforts.© 2010 Elsevier Inc. All rights reserved.

Keywords: Attempted suicide; General hospital; Emergency department; Psychiatric disorders

☆ The sponsor did not participate in the design of the project, in theconduct of the study or in the preparation of the manuscript.

☆☆ None of the authors have a conflict of interest.⁎ Corresponding author. Tel.: +86 24 8328 2184.E-mail address: qinxiaoxia@vip.sina.com (X. Qin).

0163-8343/$ – see front matter © 2010 Elsevier Inc. All rights reserved.doi:10.1016/j.genhosppsych.2010.06.003

1. Introduction

Suicide in China is an urgent public health problem. Onthe basis of analyses completed by the World HealthOrganization, the combined category of neuropsychiatric

550 B. Bi et al. / General Hospital Psychiatry 32 (2010) 549–555

conditions and suicide accounted for more than 20% of thetotal burden of illness in China in 2004 [1,2]. Nonfatalsuicidal behaviors are important because they are among themost powerful predictors of subsequent suicide deaths [3–6].Previous studies report substantial overlap in the character-istics of persons who make medically serious suicideattempts and those who die of suicide [7,8].

Although the etiology of suicide is not well understood,numerous studies have shown that the presence of mentaldisorders is one of the strongest risk factors for suicideattempts and deaths [9]. Recent studies suggest that mentaldisorders are equally predictive of suicidal behavior in deve-loped and developing countries, but the strongest predictorsof suicide attempts in developed countries were mooddisorders, whereas in developing countries impulse-control,substance use, and posttraumatic stress disorders were mostpredictive [10]. In China, a national case-control psycho-logical autopsy study reported an overall rate of mentaldisorders among completed suicides of 63%, which is muchlower than the rate of 90% reported in psychological autopsystudies from other countries [11,12]. The prevalence ofmental disorders among suicide attempters in China isuncertain because few of the studies of suicide attempts inemergency departments have employed well-defined diag-nostic criteria for mental disorders. There are, moreover, fewcomparisons of the attempters who do and do not havemental illnesses.

Identifying the prevalence of mental disorders amongsuicide attempters and the similarities and differencesbetween attempters with and without mental disorders is acrucial step to developing targeted strategies for treatinghigh-risk patients. The purpose of the current study is toidentify the prevalence of mental disorders in suicideattempters treated in general hospital emergency rooms inChina and to compare the characteristics of suicideattempters with and without a current mental illness.

2. Methods

2.1. Designs and setting

Individuals treated for suicide attempts (reported by thepatient or family members) in the emergency departments of4 tertiary-level general hospitals in Shenyang (a city with apopulation of 6.9 million residents), Liaoning Province, innortheastern China were enrolled in the study. The hospitalswere randomly selected from all tertiary general hospitalslocated in Shenyang using a random number table. Allindividuals who came to the emergency rooms after havingmade a suicide attempt were identified and approached by atrained research assistant. Subjects who were 15 years of ageor older, who were able to understand the study procedures,who had at least one contact persons (to enable follow-up),and who provided written informed consent were enrolled.The study was approved by the Institutional Review Boardof the China Medical University.

2.2. Subjects and assessment

During the enrollment period, from June 2007 to January2008, 403 suicide attempt episodes were treated at thetarget emergency rooms. In 366 instances the individualsmet criteria for inclusion in the study, but seven of the caseswere repeat attempts during the enrollment period so onlythe first episode was considered. Among the 359 differentpatients, 29 were not approached by the research team(primarily because they left the emergency room before theresearchers could arrive), 90 refused to participate, 1 didnot provide all of the data needed for analysis, and 239(59.3%) completed the full evaluation. There were nostatistical differences by gender (P=.715), age (P=.971) oryears of education (P=.069) between the included andexcluded patients.

The 239 individuals and their accompanying familymembers were independently interviewed by two trainedresearchers. The comprehensive suicide attempt interviewschedule used includes several components that took 2 hoursto complete: (1) a detailed structured questionnaire assessedthe patients sociodemographic characteristics (age, gender,employment status, marital status, residence, annual incomeof family, educational level, religious beliefs), the char-acteristics of the attempt (method of self-harm, alcohol useat the time of the episode, reported motive, time consideredsuicide before acting, suicide note, help-seeking prior toattempt) and self-reports of prior attempts or of suicidalhistory among family members or associates; (2) the Beck19-item Scale for Suicide Ideation [13] evaluates theintensity of patients' attitudes, behaviors, and plans tocommit suicide. Each item consists of three options graded0-2 according to the intensity of the suicidality; (3) the24-item Hamilton Depression Rating Scale [14,15]; (4) aquality of life rating scale covering the month prior to theattempt. Respondents assess six characteristics of theattempter (physical health, psychological health, economiccircumstances, work, family relationships and relationshipswith no family associates) on a scale of 1 (very poor) to 5(excellent). (5) Psychiatric diagnosis was made according tothe Diagnostic and Statistical Manual of Mental Disorders,fourth edition, as assessed by the Structured ClinicalInterview for DSM-IV Axis I Disorders (SCID). The Chinesetranslation of the SCID has been shown to be reliable andvalid [12,16–19]. This version of the SCID allowed for theinclusion of “not otherwise specified” (NOS) categories ofillness for subjects who had clinically significant symptomscombined with social dysfunction but did not meet fullcriteria of a specific disorder (which is fairly common inChina), and for the recording of multiple diagnoses rankedaccording to clinical importance. The six psychiatricresearchers who participated in the study attended a4-week training course in the use of the SCID; theirinterrater reliability at the end of training using 16 tapedinterviews of different types of patients was excellent(intraclass correlation coefficient=0.95).

Table 1Socio-demographic characteristics of suicide attempters

Crude frequency and %Based on results of SCID exam (n=239)

P

Without anypsychiatric disordersn %

With psychiatricdisordersn %

Age group15–24 34 (46.6) 46 (27.7) .03*5–44 31 (42.5) 90 (54.2)45–59 5 (6.8) 22 (13.3)60+ 3 (4.1) 8 (4.8)Total mean age(in years)

29.86±14.29 33.69±13.69 .05*

Mean age for female 30.36±12.88 33.08±12.74 .18Mean age for male 28.06±18.90 35.83±16.61 .14GenderFemale 57 (78.1) 129 (77.7) .95Male 16 (21.9) 37 (22.3)Marital statusNever married 29 (39.7) 61 (36.7) .04*Married 33 (45.2) 72 (43.4)Cohabitation 10 (13.7) 12 (7.2)Divorced/separated 0 (0) 13 (7.8)Widowed 1 (1.4) 8 (4.8)Employment statusEmployment 47 (64.4) 85 (51.2) .01*Unemployment 11 (15.1) 55 (33.1)Student 12 (16.4) 16 (9.6)Housewife 3 (4.1) 10 (6.0)Living situationSolitary 1 (1.4) 18 (11.5) .02*Shared accommodation 10 (13.7) 16 (10.3)Living with family 51 (69.9) 120 (76.9)Cohabitation 11 (15.1) 2 (1.3)

551B. Bi et al. / General Hospital Psychiatry 32 (2010) 549–555

2.3. Data analysis

The sociodemographic and clinical characteristics ofsuicide attempters with and without a DSM-IV illness werecompared. To examine the mean differences in the studyvariables i.e. age, gender, employment status, marital status,residence, self-reported past history of self-harm, any familyhistory of suicide, impulsive suicide attempts between thetwo groups, we used a frequency distribution, Student's ttest, chi-square test and Fisher's Exact test with the assistanceof a computer statistical package called SPSS for WindowsVersion 11.5 (SPSS, Chicago, IL, USA). The critical level ofstatistical significance was set at 0.05 and the analysis wastwo-tailed. A logistic regression model examined factorsassociated with a psychiatric diagnosis among suicideattempters, with presence of a psychiatric diagnosis as thedependent variable. Independent variables in the modelincluded age; years of education (dichotomized as b6 of ≥6years); gender; religious beliefs and previous episodes ofsuicide attempts, self-rescue, suicide notes, funeral arrange-ments, the suicide ideation, depression and the life quality.First, we entered all eleven variables into unconditionallogistic regression analyses. The significant independentpredictors from the analyses were then selected for possibleuse in the model. We tested forward (conditional) inclusionof variables in the logistic regression equation. Our modelincluded eleven predictors and based on complete data 239suicide attempts. Statistical significance in the logisticregression model was assessed using the Wald statistic andthe 95% confidence intervals were computed using theGaussian approximation to the log likelihood of the rate [20].

Annual income of familyLow (≤10 000) 10 (13.7) 35 (21.1) .24Medium(10 001–50 000)

44 (60.3) 82 (49.4)

High (N50 000) 19 (26.0) 49 (29.5)Educational levelElementary school 44 (60.3) 89 (53.6) .20High school 22 (30.1) 46 (27.7)College 7 (9.6) 31 (18.7)Religious beliefsNo 68 (93.2) 151 (91.0) .57Yes 5 (6.8) 15 (9.0)

3. Results

3.1. Sociodemographic characteristics of suicide attempters

A comparison of demographic characteristics for eachgroup is shown in Table 1. Of the 239 patients, 186(77.8%) were female and 53 (22.2%) male. The majoritywere Han ethnic group (n=222, 92.9%). Attempted suicidewas by self-poisoning in 220 cases (92.1%).Fifty-eightpatients (24.3%) had a history of previous suicide attempts.The mean age of the patients who had attempted suicidewas 32.5 years (S.D.=14.0).

The patients with and without psychiatric disorders weresimilar in terms of gender, educational level, religious beliefsand annual family income but were different in terms of age,marital status, employment status and living situation.Compared to attempters without a mental illness those witha mental illness were older, more likely to be divorced orwidowed, more likely to be unemployed andmore likely to beliving alone.

3.2. Characteristics of the suicide attempters

The most common method of attempted suicide wasself-poisoning in both the groups with and without

psychiatric disorders (92.2% and 91.8%, respectively) andthe majority of patients who overdosed used psychotropicdrugs (Table 2). No significant difference was observedbetween the two groups. Histories of a previous suicideattempts were not statistically significant between groups(P=.12). A positive family history of suicide attempts wasalso not significantly different between groups (P=.26).There were no significant differences between the twogroups in their alcohol use at the time of the episode or upto 12 h before. There were also no significant differencesbetween the two groups in writing a suicide note andmaking funeral arrangements.

Those without psychiatric diagnoses had significantlymore self-rescue ideation compared to the psychiatric group

Table 2Clinical characteristics of the suicide attempters

Characteristics Without anypsychiatric disorders

With psychiatricdisorders

P

N % N %

Method of suicide attemptsSelf-poisoning 67 (91.8) 153 (92.2) .83Self-injury 5 (6.8) 12 (7.2)Other 1 (1.4) 1 (0.6)

Previous episodes of suicide attemptsNo 60 (82.2) 121 (72.9) .12Yes 13 (17.8) 45 (27.1)

Family history of suicide attemptsNo 72 (98.6) 159 (95.8) .26Yes 1 (1.4) 7 (4.2)

Alcohol use at the time of the episode or up to 12 h beforeNo 66 (90.4) 145 (87.3) .50Yes 7 (9.6) 21 (12.7)

Self-rescueNo 61 (83.6) 160 (96.4) .001*Yes 12 (16.4) 6 (3.6)

Impulsive suicide attemptsNo 31 (42.5) 101 (60.8) .001*Yes 42 (57.5) 65 (39.2)

Motive of suicide attemptDeceased pain and burden 30 (41.1) 101 (60.8) .008*Threatened others 33 (43.8) 41 (24.7)Other 10 (15.1) 22 (14.5)

Suicide noteNo 68 (93.2) 148 (89.2) .34Yes 5 (6.8) 18 (10.8)

Funeral arrangementsNo 71 (97.3) 161 (97.0) .91Yes 2 (2.7) 5 (3.0)

Seeking for helpNo 56 (76.7) 132 (79.5) .63Yes 17 (23.3) 34 (20.5)

Score on SIS 13.84±19.45 39.99±19.84 .001*Score on HAMA 8.44±5.77 24.34±11.08 .001*Score on life quality 20.06±2.50 16.78±2.84 .001*

SIS, Suicide intent scale; HAMD, Hamilton depression scale.

able 3sychiatric disorders of suicide attempts in emergency department of 4eneral hospitals in Shenyang, China (primary diagnose considered)

Man(N=37)

Woman(N=129)

P

N % N %

ny Axis I diagnoses .01*Mood disorders 23 62.2 81 62.8 .94Major depression 10 27.0 44 34.1Dysthymia 1 2.7 4 3.1Depression disorder NOS 10 27.0 32 24.8Depression due to GMC 1 2.7 1 0.8Depression due to substance 1 2.7 0 0.0Anxiety disorders 2 5.4 24 18.6 .09Specific phobia 0 0.0 1 0.8Posttraumatic stress disorder 0 0.0 1 0.8Anxiety disorder NOS 2 5.4 21 16.3Psychotic disorders 7 18.9 11 8.5 .07Schizophrenia 2 5.4 6 4.7Schizophreniform disorder 1 2.7 0 0.0Schizoaffective disorder 0 0.0 2 1.6Brief psychotic disorder 0 0.0 1 0.8Psychotic disorder dueto substance

3 8.1 0 0.0

Psychotic disorder NOS 1 2.7 2 1.6Substance-related disorders 4 10.8 2 1.6 .03*Somatoform disorders 1 2.7 1 0.8 .93Adjustment disorders 0 0.0 11 8.5 .02*

MC, general medicine condition.

Table 4Result of logistic regression analysis: 73 suicide attempts withoutpsychiatric disorders and 166 suicide attempts with psychiatric disordersas a dependent variable

Independents Significance Odds ratio (95%CI)

Continuous variablesScore on SIS 0.02 1.01 (1.00-1.03)Score on HAMA 0.01 1.26 (1.16-1.37)Score on life quality 0.01 0.75 (0.63-0.90)Dichotomous variablesGender 0.02 3.67 (1.23-10.91)Educational years0–6 years 0.01 1.19 (1.04-1.36)N6 years

552 B. Bi et al. / General Hospital Psychiatry 32 (2010) 549–555

(16.4% and 3.6%, P=.001). Compared to the suicide attemptswith mental disorder group, the group without mentaldisorders manifested more aggressive/impulsive traits, asreflected by taking actions to suicide in less than 2 h (P=.001).Comparing the motives for suicide attempts of the two groupsrevealed a difference that was statistically significant(P=.008). The patients with mental disorders are more likelyto decrease the pain and the burden and those without mentaldisorders are more likely to threaten others. The resultsindicated that suicide attempters with psychiatric disordershad significantly greater intensity of suicidal ideation at thetime of the interview (P=.001). The clinicians' ratings ofdepression, using the Hamilton depression scale, weresignificantly higher for suicide attempters with psychiatricdisorders than for suicide attempters without psychiatricdisorders (P=.001). Score on life quality was greater insuicide attempters without psychiatric disorders than insuicide attempters with psychiatric disorders (P=.001).

TPg

A

G

3.3. Prevalence of mental disorder in suicide attempters

One hundred and sixty-six subjects (69.5%) met thecriteria for an axis I disorder (Table 3). There weresignificant differences in the rates of any diagnoses betweenmen and women (P=.01). Mood disorder was the mostcommon psychiatric diagnosis in both groups (62.2%among men and 62.8% among women), followed bypsychotic disorders, substance-related disorders and anxietydisorders among men. Among women, substance-abuserelated disorders were less common than in men and anxietydisorders are more common than in men. Male patients weresignificantly more likely to suffer from substance-relateddisorders (P=.03). No significant gender difference was

553B. Bi et al. / General Hospital Psychiatry 32 (2010) 549–555

found in the prevalence of anxiety disorders. The mostcommon anxiety disorder was anxiety NOS (16.3% vs.5.4% respectively). Adjustment disorders were present in 11patients (8.5%), with all female patients (P=.02).

3.4. Result of logistic regression analysis

A logistic regression model examined factors associatedwith a psychiatric diagnosis among suicide attempters, withpresence of a psychiatric diagnosis as the dependent variable.Multivariate logistic regression analysis identified thefollowing independent predictors of having a currentpsychiatric disorder in the suicide attempters: female gender(OR=3.67, 95%CI=1.23–10.91), more than 6 years of formaleducation (OR=1.19, 95% CI=1.04–1.36), a higher score onthe suicide ideation scale (OR=1.01, 95% CI=1.00–1.03),a higher score onHamilton depression rating scale (OR=1.26,95% CI=1.16–1.37) and a lower score on the quality of lifescale (OR=0.75, 95% CI=0.63-0.90) (Table 4).

4. Discussion

To the best of our knowledge, this is one of the few studiesabout the psychiatric assessment of suicide attempts inemergency department of general hospitals yet available inmainland China. The sample is representative of emergencyoutpatients at general hospitals in a large urbanmunicipality innorthern China, the diagnosiswas based on the administrationof SCID by trained researcher who had excellent inter-raterreliability, the assessment of mental illness was based onclinical structured interview and standardized instrumentsrather than on psychological autopsy study, and rigorousquality control measures were enforced throughout the study.There are, however, some limitations that should beconsidered when interpreting the results.

The emergency department is a busy and sometimeschaotic environment; thus, many emergency physicians maynot have time to fully screen patients for mental healthissues. As a result, the mental health concerns of emergencydepartment patients are often not recognized or addressedproperly [21,22]. In China, most patients with suicideattempts could not receive a psychiatric assessment. Therate of psychiatric disorders found in this study suggests thatthe assessment of suicide attempts should include carefulscreening for psychiatric symptoms.

4.1. Main findings

The present study investigated the socio-demographiccharacteristics, the clinical characteristics and DSM-IVAxis I diagnoses of suicide attempters admitted toemergency department of general hospitals. The proportionof females was much higher than that of males and themain method was ingestion of psychoactive drugs. Otherfactors included history of prior attempts and use ofalcohol at the time of attempts, and the most frequentmental disorders were mood disorders. These results are

similar to prior studies [23–27] and also indicate thatsignificant differences in demographic and clinical vari-ables exist between patients with and without psychiatricdisorders who attempt suicide. Most suicide attempts ofpatients without psychiatric disorders included adolescents,manifesting impulsive traits, and were associated withwanting to threaten others and make others feel guilty,having significant more self-rescue ideation and wanting toget help. The finding was in contrast to that of Zhang et al[28], who did not find the differences between the suicideswith and without psychiatric diagnoses. However, sampleand method differences may not account for the findings,as the Zhang et al study used the sample of completedsuicide and the method of case-control psychologicalautopsy study.

4.2. Differences of suicide attempters with and withoutmental disorders

Among the social demographic parameters considered, aninfluential one associated with attempted suicide was age. Amajority of suicide attemptors without mental disorders inthis study were between the ages of 15 and 24 years and thelarger proportion of suicide attemptors with mental disorderswere between the ages of 25 and 44 years. The rates ofpsychiatric disorder of youth suicide attempts and adultsuicide attempts (57.5% vs. 75.5%) found in this study isconsistent with the Chinese psychological autopsy study(45% vs. 66%) [29]. However, these are different from thosereported in western countries where among adolescents whocompleted suicide, more than 90%suffered from associatedpsychiatric disorders at the time of their death [30]. Mooddisorders, anxiety disorders, substance abuse and disruptivedisorders convey the highest risk for suicide and the presenceof multiple disorders is associated with especially elevatedrisks [31]. These data suggest that in China youth suicideattempts have a lower prevalence of mental disorders. Thosewho are at the stage of physiological and psychologicaltransformation from childhood to adulthood are probablymay not be equipped to cope with these psychosocialchallenges [32].

4.3. Current psychiatric diagnosis of suicide attempters

Our findings that 69.5% of the patients who attemptedsuicide had psychiatric disorders are lower than the ratefound in a study of Japanese suicide attempters that alsoused DSM-IV Axis I diagnoses criteria. In their study,81% of attempted suicide cases had an axis I diagnosisand mood disorders were also the most common [33]. Therate of mental disorders among suicide attempters in thecurrent study was much lower than those documented inprior studies among clinical samples and those dying bysuicide in western developed countries [34,35]. Ourfinding of a lower rate of mental disorders among suicideattempters is consistent with a Chinese study indicatingthat of 326 people who had carried out serious but non-

554 B. Bi et al. / General Hospital Psychiatry 32 (2010) 549–555

fatal acts of self harm in China, only 40% had adiagnosable mental illness, and 35%reported that theyfirst considered harming themselves 10 minutes or lessbefore making the attempt [36,37]. The current study alsofound that 44.8% suicide attempters had impulsive andaggressive traits, as reflected in taking actions to suicide inless than 2 h. Our finding is also consistent with severalrecent studies that suggest that mental disorders are lessimportant in the occurrence of suicidal behaviors indeveloping countries relative to developed countries[10,38]. According to Nock et al., although several con-sistent risk factors for suicidality emerged cross-nationally,an exception was that mood disorders were the strongestdiagnostic predictors in developed countries while im-pulse-control disorders were the strongest predictors indeveloping countries [39]. The reason for the difference inthe importance of impulse-control disorders betweendeveloped and developing countries is unclear and awaitsfurther examination.

4.4. Predictor of suicide attempters with mental disorder

Multivariate analysis indicated that the key factorsassociated with a psychiatric diagnosis among suicideattempters in emergency departments were female gender,lower level of education, suicidal ideation, depressivesymptoms and lower life quality. Scores on Hamilton Ratingscale for depression may be associated with psychiatricdisorders and increase the likelihood of suicidal acts when anindividual is feeling hopeless because of depression or otherdisorders and is facing seemingly insurmountable problems.The data also suggests that the increasing suicidal ideationquestionnaire scores were associated with the currentpsychiatric disorder of suicide attempters [40]. If the mentalhealth services are limited, this could be particularlyimportant for maximally facilitating the next steps: recog-nition of mental disorders and treatment engagement.

4.5. Limitation

One limitation of the present study is that the findingsare based on a relatively small sample in one regionalhospital, raising the question of whether the results can begeneralized. The second is that we had limited data onsuicide attempters who did not participate in our study.The third is that our study cohort was limited to an urban-based population. Different outcomes may be expected in arural-based population. Thus, a multicentre study focusingon multiple sites is required to demonstrate current trendsin attempted suicide in China. The fourth is that our studyonly assessed Axis I diagnoses. We did not assess Axis Idiagnoses and may have underestimated this comorbidity.Despite these limitations, the present study providesevidence helpful in understanding the characteristics ofnonfatal suicide attempters in China and has implicationsfor prevention.

4.6. Conclusion

This study is a comprehensive evaluation of consecutivepatients admitted to hospitals because of medical injurysustained due to a suicide attempt. Suicide attempters withand without mental illnesses are distinct on a number ofimportant dimensions. Mental health assessment andappropriate discharge planning for patients treated inemergency departments for suicide attempts are crucialcomponents of comprehensive suicide prevention efforts.

Acknowledgments

This project was part of the “Small Grants Program toImprove the Quality and Implementation of SuicideResearch in China” which was supported by the ChinaMedical Board of New York (grant number 05-813) andcoordinated by Professor Michael Phillips of the ShanghaiJiao Tong University School of Medicine. We would like tothank the four participating hospitals in Shenyang for theiractive support of the project; Wang Zhiqing, Jiang Chunlingfrom the Beijing Suicide Research and Prevention Center atthe Beijing Hui Long Guan Hospital for their assistance incoordinating the project.

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