Psychological Medicine, 1979, 9, 493-500 Printed in Great Britain
Psychiatric symptoms in self-poisoning patients J. G. B. NEWSON-SMITH1 AND S. R. HIRSCH2 From the Department of Psychiatry, Charing Cross Hospital, London
Self-poisoning patients admitted to hospital were studied for persistence of psychiatric symptoms over a 3-month period and evaluated at 3 points in time with the General Health Questionnaire and the Present State Examination. Symptoms were identified which had a high or low prevalence at 3-month follow-up. GHQ and PSE scores correlated at 0-8. The implications of the study are discussed, particularly the earlier need for out-patient help in those who had a moderate or high number of symptoms at initial interview. SYNOPSIS
INTRODUCTION A study of recent and older literature on parasuicide revealed that comparatively little emphasis has been placed on the importance of symptoms and clinical profiles in these patients with relationship to clinical outcome. It is difficult to compare reports by different authors on mental illness in these patients. A major problem is that different diagnostic criteria have been used. Weissman (1974), in a review of studies, found that depression is the most common diagnosis reported accounting for between 35 and 79 % of all who attempt suicide. Another difficulty is that many authors use mental illness and personality disorders as mutually exclusive categories. Vinoda (1966) used the Personal Illness Scale of the Symptom Sign Inventory (SSI, Foulds & Hope, 1968) and found attempted suicides were very similar to psychiatric controls in the amount of symptomatology produced. Philip (1970) used the Personal Illness and Character Disorder Scales on 100 suicide attempters. Twelve per cent showed no signs of personal disturbance, 40 % were personally disturbed and 48 % had character disorders. The overall mean personality profile was similar to that obtained by neurotics. Birtchnell & de Alarc6n (1971) used a modified version of the Zung depression scale and reported similar scores for depressed patients and suicide 1 Address for correspondence: Dr J. G. B. Newson-Smith, Department of Adult Psychiatry, St George's Hospital, London S Wl 7 0QT. 1 Address for reprints: Professor S. R. Hirsch, Charing Cross Hospital, Fulham Palace Road, London W6 8RF.
attempters. The New Haven Study (Weissman, 1974) used standardized depression scales and compared symptom patterns and degree of depression between suicide attempters and outpatients receiving treatment for depression, but these revealed no significant differertces. They found both groups were at least moderately depressed. Morgan et al. (1975) reported on psychiatric findings in deliberate self-harm patients: reactive depression 52%, personality disorder 29%, alcohol abuse 18%, mental illness absent 10%. The Middlesex Hospital Questionnaire for the same group revealed that scores resembled those of psychiatric outpatients and greatly exceeded those of normals both on depression and anxiety. Eastwood et al. (1972) used the General Health Questionnaire (Goldberg, 1972). The mean score for suicide attempters was more than twice the cut-off score for mental illness. The background to this work lies in the use of 2 research instruments as standardized measures of the mental state in a recent study comparing clinical assessment of these patients by psychiatrists and social workers (Newson-Smith & Hirsch, 1979). Early in the course of that study, the high level of neurotic symptoms was noted for the 4 weeks before the act. It was also apparent that 1 week later, many of the symptoms had disappeared without any specific intervention by psychiatric staff (apart from the usual brief assessment interview). The instruments used were the General Health Questionnaire (GHQ) and the ninth edition of the Present State Examination (PSE)
493 0033-2917/79/2828-4100 $01.00 © 1979 Cambridge University Press
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J. G. B. Newson-Smith and S. R. Hirsch
(Wing et al. 1974). The GHQ is a selfadministered questionnaire, which aims to give information about the present mental state, rather than about personality traits or the liability to fall ill in the future. It has been found to discriminate effectively between psychiatric patients and normal controls. The PSE is a semistructured interview which has been used extensively in studies of acutely ill patients and of general population samples, both in the UK and abroad. It was decided to examine the mental state systematically in a series of self-poisoning patients. Three points in time were selected and the 2 instruments used. This study focuses on rapid change in levels of emotional distress by assessing patients at 3 points in time over a 3-month period. It was therefore necessary to assess a normal control group at the same points in time. Despite the existence of considerable cross-sectional normative data on the GHQ, there are no follow-up studies of change in GHQ scores in a normal population. The possibility of random or very short-lived fluctuation of scores in the normal population must be considered when seeking to understand the relevance of change in scores observed in the self-poisoning sample. METHOD
week. They were finally repeated at 3-month follow-up, for the preceding 4 weeks. Hospital employees provided the control group. Heads of departments were circulated for volunteers to fill in a set of 3 GHQ forms, covering the same time intervals (nurses, doctors and social workers were excluded). The GHQ score was calculated by using the non-weighted GHQ scoring method. The cut-off score of 11 was used, above which the score is within the range of probable psychiatric morbidity and the patient is a probable psychiatric 'case'. The neurotic PSE score was calculated by adding the 2 neurotic subscores (non-specific neurotic symptoms and specific neurotic symptoms). The Index of Definition level was based on information gained at the PSE interview and incorporates cut-off points on the basis of symptoms which have been identified as present. Eight degrees of definition are incorporated. At the threshold and definite levels (5-8) disorders are sufficiently well defined to apply the Catego program of clinical classification (Wing et al. 1978). Catego 'diagnoses', syndrome and symptom profiles were obtained from the PSE data. RESULTS One hundred and thirty-one patients were admitted during the time of the study who met the selection criteria for self-poisoning. Eighty-nine per cent of patients available on week days entered the study. (Thirty-nine patients were discharged over weekends precluding research
Selection of subjects This was restricted to those parasuicide patients who had deliberately taken an excess of a substance thought to be harmful and as a result had been admitted to a medical ward for adults or the casualty short-stay ward under medical care. Table 1. Comparison of 51 patients interviewed 3 It is the general policy of the hospital to admit times with 10 patients interviewed twice and 18 all such patients for medical and psychiatric patients interviewed once assessment. Inevitably, a few are discharged 3 interviews 2 interviews 1 interview directly from casualty with or without psy(N = 51) (N - 10) (N = 18) chiatric assessment and these are not included Mean age 3O±13 30±ll 24±6 in the study. The first 3 patients fit for assessment (years ±S.D.) entered the study on any day. The research Sex interviews were independent of routine psyM 4(40%) 19(37%) 11 (61%) F 6(60%) 32(63%) 7(39%) chiatric assessment. 36±14 1st GHQ score 32±16 33±18 The patient was asked to complete the GHQ (mean±s.D.) 18±15 1st PSE score 16±11 17±11 (60-item version) and the PSE was administered. (mean±s.D.) Both covered symptoms in the 4 weeks before the 21±18 18±18 2nd GHQ score overdose. The patient was re-interviewed 1 week (mean±s.D.) 2nd PSE score 9±9 11 ±10 — after the first interview, usually at home. The (mean±s.D.) GHQ and PSE were repeated for the intervening
495
Psychiatric symptoms in self-poisoning patients
assessment. Two non-English-speaking patients were excluded and one acutely disturbed schizophrenic was transferred to another hospital.) Seventy-nine patients were interviewed initially, of these 61 had a second interview (1 week later) and 51 a third interview (3 months later). Table 1 summarizes descriptive statistics for the first 2 interviews. It shows that the differences both in GHQ and PSE scores between patients interviewed 3 times, twice or once, is negligible. Therefore it is unlikely that the results reported will be severely biased by the absence of dropouts, not interviewed on the second or third occasions. Initial levels of PSE and GHQ scores Initial GHQ and PSE scores are surprisingly high. The mean GHQ score is 32, well above the cut-off point of 11. Similarly, the mean PSE score is 16. Almost two thirds of patients are at threshold and above Index of Definition levels, and therefore can be classified into one of the Table 2. Changes in GHQ, PSE, and Index of Definition levels over time Time from overdose
0-2 days I
Mean scores 32±16 GHQ (N = 48)* PSE (N = 51) 16±12 Index of definition (:AT= si) Patients at 31 (61 %) threshold level and above (levels 5-8)
7-9 days II
3 months III
18±18
12±15
20(39%)
11(22%)
9±9
5±6
Complete sets of GHQ scores not obtained on 3 patients.
categories of formal psychiatric illness (Table 2). Ninety per cent are above the cut-off GHQ score of 11. Comparison of scores and levels for the 3 interviews Table 2 shows that the mean GHQ and PSE scores have been approximately halved by the second interview and are approximately one third of their original value at the third interview. Similarly, the Index of Definition levels are reversed at second interview, i.e. 61 % are threshold and above initially and 61 % are below threshold at second interview. Seventy-eight per cent are below threshold at third interview. GHQ scores of patients compared with those of hospital employees Table 3 shows the constant low mean score of 4 obtained for the hospital employees as opposed to the higher but decreasing mean scores for the patients. At any one point in time, 9-11 % of the employees reached a score above 11 (cut-off) as compared with the high proportion of overdose patients at the first interview (90 %) which fell to 31 % at the third interview. This is similar to the findings of Goldberg et al. (1976) that approximately 11 % of a random sample of a general practice population were found on the GHQ to be psychiatrically disturbed. At 3 months the difference in final mean scores is still marked, 12 for the patients and 4 for the employees. The results for the control group support the contention that the 90 % prevalence of high scores (i.e. above 11) in self-poisoners cannot be explained on the basis of random fluctuation in symptom levels. Nor can it be
Table 3. Comparison of self-poisoners and controls Sex (%)
Hospital employees (N = 80) Self-poisoners (W = 48)
Age (% in year range)
M
F
33
67
38
62
< 20
17
Interview Hospital employees Mean GHQ score±s.D. % with scores > 11 Self-poisoners Mean GHQ score±s.D. % with scores > 11
Social class (RG) (%) I
II
III
IV
V
33
0
16
48
29
7
21
0
6
71
6
17
20-35
36-65
56 58
> 65
II
III
4±7 11
4±7 9
4±8 11
32±16 90
18±18 50
12±15 31
/. G. B. Newson-Smith and S. R. Hirsch
496
explained as part of the base rate of undisclosed psychiatric morbidity in the normal population. Correlation between GHQ scores and PSE scores The PSE and GHQ scores were compared using the Pearson product-moment correlation coefficient. Highly significant correlations were obtained for all interviews at 0-78, 0-81 and 0-77 respectively (significance of all, P < 0-0001). Clinical course of neurotic symptoms Table 4 places the patients into categories based on their initial GHQ score, i.e. 0-20, 21-40, 41-60. This enables subsequent scores to be studied with reference to initial scores. Patients in the 0-20 category usually remain at this level. Ninety-three per cent are 'non-cases' (using the GHQ cut-off score of 11) at second interview and 86% at final interview. Only 14% have received any form of psychological treatment at final interview, whether by psychiatrists, general practitioner, social worker, etc., so there is little indication from any point of view that this group was psychiatrically ill. Sixty-three per cent of patients in the 21-40 initial category remain 'cases' at second interview, so 37 % have improved sufficiently to become ' non-cases'. : Fifty per cent are 'cases' at the final interview. The mean GHQ score of 18 is in the 'case' range at final interview. Sixty-nine per cent had received some form of professional psychological help by this time. Seventy-two per cent of patients in the 41-60 Table 4. Changes in clinical indices over time related to initial GHQ scores (N = 48) Initial GHQ scores (interview I) No. of patients Mean GHQ Interview I II III GHQ 'cases'-% with GHQ above 11 Interview I II III Repeat overdose by interview III (3 months) Psychological help by interview III (% treated by social workers or
doctors)
0-20
21-10
41-60
14
16
18
12 3 6
27 20 18
46 28 11
64 7 14 2
100 63 50 4
100 72 28 0
14
69
73
initial category remain as 'cases' at second interview, so only 28 % have improved sufficiently to become 'non-cases'. At final interview only 28 % remain as 'cases'. The mean GHQ score at second interview is 28 but falls to the cutoff score of 11 at third interview. Seventy-three per cent had received some form of professional psychological help by this time. It is interesting that the initial scores do not predict the likelihood of a repeat overdose within the 3-month period. Two patients repeated the act in the low range, 4 in the mid range, and none in the high range. This is consistent with the view that overdosing is a form of behavioural reaction not necessarily related to an illness state or severity of symptoms. Patients in the high GHQ range may have been 'ill' and responded to treatment. The clinical course was similarly studied by reference to the initial Index of Definition level. Patients were divided into 3 categories: i.e. below threshold (1-4), threshold (5) and definite (6-8) levels (see Table 5). Again, it is demonstrated that patients in the low range, i.e. below threshold, generally remain at this low level (85 % at second interview, and 80 % at third interview). Patients at threshold level show improvement at the second interview, i.e. 74 % are below threshold, and this increases to 80 % at the third interview. Patients with definite conditions show less improvement at second interview (19 % below threshold), but at final interview 75 % are below threshold. Diagnostic results Catego classes on patients interviewed 3 times (N = 51) provided 16 definite and 15 borderline diagnoses. Thirty were of depressive disorders (none of depressive psychosis) and 1 of 'other affective psychosis'. Table 6 shows the rank-order frequency of individual Catego syndromes (derived from the PSE interview). 'Worry' is the most common syndrome (84 %) followed by simple depression (73 %). Worry remains in first position at second and third interviews. Simple depression drops to fifth place at both subsequent interviews. Generally the rank-order remains similar in subsequent interviews, although the percentage of patients experiencing individual syndromes drops. This is to be expected from previous examination of neurotic scores. The general
Psychiatric symptoms in self-poisoning patients
497
Table 5. Changes in the number of'cases' {by Index of Definition) as related to initial Index of Definition level (N = 57) Initial level
Below threshold No. (%)
At threshold No. (%)
Definite No. (%)
Total no patients
20 (100)
15 (100)
16 (100)
51
17(85) 2(10) 1(5)
11 (74) 2(13) 2(13)
3(19) 4(25) 9(56)
51
16 (80) 3(15) 1(5) 20 (100)
12 (80) 3(20) 0(0) 15(100)
12 (75) 1(6) 3(19) 16 (100)
Interview I Interview II Below threshold At threshold Definite Interview III Below threshold At threshold Definite Total no. patients
51 51
Table 6. Rank-order frequency of the 10 most common PSE syndromes in this series (N = 51) Prevalence of syndromes at each interview (%) symbol
Syndrome
I
II
III
WO SD TE OD IT IC
Worry Simple depression Tension Somatic features of depression Irritability Loss of interest and concentration Social unease Loss of energy Special features of depression Situational anxiety
84 73 63 59 55 53 51 37 29 28
63 37 44 45 31 43 31 28 22 20
53 24 33 33 26 20 12 14 6 22
su LE ED SA
Table 7. Rank-order frequency of the 10 most common individual PSE symptoms in this series (N = 51) Prevalence at each interview (%) PSE symptom Suicidal plans or acts Subjective feelings of nervous tension Depressed mood Hopelessness Irritability Tension pains Worrying Tiredness or exhaustion Poor concentration Neglect due to brooding
I
II
III
92 75 73 61 55 49 45 45 43 35
22 41 37 33 31 33 28 33 37 14
6 28 24 14 26 26 14 37 18 8
profile is that of minor neurotic illness with depressive features. Table 7 shows the rank-order frequency of the 10 most common individual PSE symptoms (as opposed to syndromes) in this study. Pre33
dictably in the self-poisoning series, suicidal plans or acts are the most common initial symptom, present in 100 % of the series. However, this symptom drops to ninth and tenth places respectively at second and third interviews. Two symptoms which might be expected to be most closely related to suicidal plans or acts are depressed mood and hopelessness. They rank in third and fourth places initially. The symptom 'subjective feelings of nervous tension' is prominent at all interviews. The form of disorder in self-poisoning patients is reflected by a comparison of the frequency of different symptoms of depression between these patients and in-patients and out-patients being treated for depression and community 'cases'. These 'cases' were persons identified in a community sample who were not in treatment but would be regarded as being psychiatrically ill, i.e. a PSE 'case' (see Table 8). Caution must be applied in interpreting these symptom frequencies due to the small number of depressed outPSM
9
498
J. G. B. Newson-Smith and S. R. Hirsch Table 8. Comparison of the frequency of selected PSE symptoms in other series^ and self-poisoners
PSE symptoms
In-pts (N = 55) (%)
Out-pts (N = 14) (%)
Depressed mood Hopelessness Inefficient thinking Self depreciation Pathological guilt Lack of energy Loss of weight Early waking Retardation
100 63 46 38 21 63 46 42 21
100 71 43 36 21 79 71 21
Gen. populn. 'cases' (N = 19) (%)
Selfpoisoners (N = 51) (%)
Significant* differences between self-poisoners and other groups
100 11 22 22 6 28 11 28 —
73 61 31 28 2 37 26 20 0
Less than in-pts and 'cases' More than 'cases' NS NS Less than in-pts Less than out-pts Less than out-pts NS Less than in-pts
7
* Significance tested by 2 x 2 chi-squares with Yates' correction, P < 0-05. t Reproduced by courtesy of Professor J. K. Wing (1976).
patients and community 'cases'. Depression was only rated in 73 % of self-poisoners which compares with 100% in the other series. Selfpoisoners resemble treatment patients in the high prevalence of hopelessness. 'Cases' have a low prevalence. The proportion of overdoses affected by inefficient thinking and self depreciation falls between the higher prevalence in patients in treatment and lower prevalence in 'cases'. The remaining symptoms in Table 8 occurred relatively infrequently in self-poisoners and 'cases' as compared with patients having treatment for depression. The total mean PSE score for the selfpoisoners is 16, as compared with 15 for 'cases', 24 for depressed out-patients and 26 for depressed in-patients. Thus, the symptom frequencies and PSE scores of our self-poisoning patients are in many ways like those of community 'cases'. DISCUSSION The patients are not a consecutive series of all self-poisoners brought to hospital. It could be argued that most samples of self-poisoners are unrepresentative of the total group, many of whom go undisclosed or are dealt with by the general practitioner, leave casualty before being assessed, or discharge themselves prematurely from the wards. There is value, however, in knowing about this group, who are assessable to evaluation and treatment in clinical practice. In this group, the GHQ and PSE (neurotic) scores appear to measure much the same type
of disorder, since the correlation between them is so high. The PSE was generally well tolerated by the patients and took about 40 minutes to administer at first interview. The GHQ takes the patient only a few minutes to complete; however, they showed more resistance to filling in a form than to being interviewed. The 30-item version of the GHQ would probably have been more acceptable to them. The GHQ proves a useful instrument for follow-up work, as it does not require a trained interviewer nor does the patient need to be seen in person. This study has confirmed that the patients experienced a high level of neurotic symptoms before the self-poisoning. The method allowed these symptoms to be measured only retrospectively, i.e. after the overdose. The patients were interviewed as soon as possible after regaining consciousness, and little time was therefore allowed for memory falsification, i.e. to put an unpleasant experience behind them or to search after meaning. The second interview was considered important in gaining information about the mental state for the short interval of 1 week after the overdose. This is usually prior to any psychological treatment and also a time when the risk of repeat overdose is high. The time span covered by this PSE interview and GHQ was different, i.e. 1 week as opposed to 4 weeks (a sub-group of 20 patients were rated at first and final interviews for the previous week in addition to the previous 4 weeks and there was virtually no difference in the PSE ratings). The
499
Psychiatric symptoms in self-poisoning patients
second interview was technically the most difficult to obtain. The timing was considered crucial for comparative purposes. There is little information available about the clinical state at this stage. In normal clinical practice, follow-up is usually more than 1 week later and there is a high nonattendance rate. Many patients were visited more than once to obtain this interview, as they 'forgot' about it. Eighteen patients were lost between first and second interviews. This largely reflects the high numbers of persons, mainly men with alcohol and drug problems, without fixed address, who take overdoses in this part of London. However, results have shown that mean scores at first interview are hardly affected by removing their scores. Overall, we have confirmed our initial impression that the act of self-poisoning can have a cathartic therapeutic effect. This is less likely in patients with high initial levels of symptoms, i.e. 72 % of patients with initial GHQ scores in the range 41-60 are GHQ 'cases' at 1 week, and 81 % of patients with definite initial PSE diagnoses remain as probable and definite 'cases' at 1 week. Nevertheless, we have seen that in some patients there is a dramatic drop in symptoms without psychiatric treatment. It would seem that for them the act itself, its effects on significant others and life circumstances together with hospital care have brought definite relief. Spontaneous remission may also be an important factor. Patients with low initial symptom levels do well psychiatrically and few receive treatment. Most are non-attenders at any psychiatric followup appointment offered. We believe that medically-oriented follow-up is neither effective nor indicated for this group. However, early repetition of the act does occur in this group. We hope that initial screening could detect those patients most at risk and likely to benefit from early socially-oriented help. Patients initially in initial middle and high categories for symptoms and levels show a different picture. At 1 week their symptoms have fallen proportionately less and patients in the high category still have a comparatively greater mean score. This is not so at 3 months. Interestingly, the vast majority in these 2 groups have obtained professional psychological help by the final interview. Our results suggest that more active efforts are needed to help these patients
very soon after the overdose in order to reduce the ensuing psychiatric morbidity. The higher the initial level of symptoms, the greater is the indication for early intervention. We stress that the standard clinic appointment a few weeks hence is neither effective nor appropriate. It may partly explain our present unsuccessful management of the whole problem of repetition of parasuicide. Many follow-up studies of parasuicide patients have relied on rates for repeat parasuicide acts and suicide as criteria for judging the effectiveness of intervention. This is a narrow measure, and our findings have shown a considerable number of patients remain in psychological distress yet do not repeat the act. We argue that they would benefit from early intervention. Study of diagnostic PSE results as opposed to scores has yielded interesting results. The general profile is that of neurotic symptomatology with depressive features resembling 'cases' discovered in the general population more than patients having treatment for depression at a hospital. We have stressed from our results the importance of early help, although in most patients we are not dealing with major psychiatric illness. Further work needs to be done to evaluate the effectiveness of different types of early intervention, both alone and in combination. The main types are those which employ psychotherapeutic and social skills and those employing medication. Antidepressants and minor tranquillizers may have some place in alleviating distress for those with moderate and high levels of initial symptomatology (we have noted the high prevalence of the symptom 'subjective feelings of nervous tension'). The next step may be to look at the relative value of medication and psychotherapeutic help for those patients having moderate or high scores on the GHQ and PSE. We are grateful to the following at Charing Cross Hospital: the Clinical Research Committee for awarding the research fellowship to J. G. B. NewsonSmith, the staff of the Medical School Computer Department and Mr Steven Platt for help in analysing the data. We are also grateful to Professor J. K. Wing for advice and analysis of the PSE data and Dr L. K. Hemsi for reading the manuscript.
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REFERENCES Birtchnell, J. & Alarcon, J. (1971). Depression and attempted suicide: a study of 91 cases seen in a casualty department. British Journal of Psychiatry 118, 289-296. Eastwood, M. R., Henderson, A. S. & Montgomery, I. M. (1972). Personality and parasuicide: methodological problems. The Medical Journal of Australia i, 170-175. Foulds, G. A. & Hope, K.. (1968). Manual of Symptom Sign Inventory (SSI). University of London Press: London. Goldberg, D. (1972). The Detection of Psychiatric Illness by Questionnaire. Oxford University Press: London. Goldberg, D., Kay, C. & Thompson, L. (1976). Psychiatric morbidity in general practice and the community. Psychological Medicine 6, 565-569. Morgan, H. G., Burns-Cox, C. J., Pocock, H. & Pottle, S. (1975). Deliberate self-harm: clinical and socio-economic characteristics of 368 patients. British Journal of Psychiatry 127, 564-574. Newson-Smith, J. G. B. & Hirsch, S. R. (1979). Clinical evaluation of parasuicide: social workers compared to psychiatrists. British Journal of Psychiatry (in the press).
Philip, A. E. (1970). Traits, attitudes and symptoms in a group of attempted suicides. British Journal of Psychiatry 116, 475-482. Vinoda, K. S. (1966). Personality characteristics of attempted suicides. British Journal of Psychiatry 112, 1143-1150. Weissman, M. M. (1974). The epidemiology of suicide attempts 1960-1971. Archives of General Psychiatry 30, 737-746. Wing, J. K. (1976). A technique for studying psychiatric morbidity in in-patient and out-patient series and in general population samples. Psychological Medicine 6, 665-671. Wing, J. K., Cooper, J. E. & Sartorius, N. (1974). The Measurement and Classification of Psychiatric Symptoms. Cambridge University Press: London. Wing, J. K., Mann, S. A., Leff, J. P. & Nixon, J. M. (1978). The concept of a 'case' in psychiatric population surveys. Psychological Medicine 8, 203-217. Zung, W. W. K. (1965). A self-rating depression scale. Archives of General Psychiatry 12, 63-70.
Psychiatric symptoms in self-poisoning patients J. G. B. NEWSON-SMITH1 AND S. R. HIRSCH2 From the Department of Psychiatry, Charing Cross Hospital, London
Self-poisoning patients admitted to hospital were studied for persistence of psychiatric symptoms over a 3-month period and evaluated at 3 points in time with the General Health Questionnaire and the Present State Examination. Symptoms were identified which had a high or low prevalence at 3-month follow-up. GHQ and PSE scores correlated at 0-8. The implications of the study are discussed, particularly the earlier need for out-patient help in those who had a moderate or high number of symptoms at initial interview. SYNOPSIS
INTRODUCTION A study of recent and older literature on parasuicide revealed that comparatively little emphasis has been placed on the importance of symptoms and clinical profiles in these patients with relationship to clinical outcome. It is difficult to compare reports by different authors on mental illness in these patients. A major problem is that different diagnostic criteria have been used. Weissman (1974), in a review of studies, found that depression is the most common diagnosis reported accounting for between 35 and 79 % of all who attempt suicide. Another difficulty is that many authors use mental illness and personality disorders as mutually exclusive categories. Vinoda (1966) used the Personal Illness Scale of the Symptom Sign Inventory (SSI, Foulds & Hope, 1968) and found attempted suicides were very similar to psychiatric controls in the amount of symptomatology produced. Philip (1970) used the Personal Illness and Character Disorder Scales on 100 suicide attempters. Twelve per cent showed no signs of personal disturbance, 40 % were personally disturbed and 48 % had character disorders. The overall mean personality profile was similar to that obtained by neurotics. Birtchnell & de Alarc6n (1971) used a modified version of the Zung depression scale and reported similar scores for depressed patients and suicide 1 Address for correspondence: Dr J. G. B. Newson-Smith, Department of Adult Psychiatry, St George's Hospital, London S Wl 7 0QT. 1 Address for reprints: Professor S. R. Hirsch, Charing Cross Hospital, Fulham Palace Road, London W6 8RF.
attempters. The New Haven Study (Weissman, 1974) used standardized depression scales and compared symptom patterns and degree of depression between suicide attempters and outpatients receiving treatment for depression, but these revealed no significant differertces. They found both groups were at least moderately depressed. Morgan et al. (1975) reported on psychiatric findings in deliberate self-harm patients: reactive depression 52%, personality disorder 29%, alcohol abuse 18%, mental illness absent 10%. The Middlesex Hospital Questionnaire for the same group revealed that scores resembled those of psychiatric outpatients and greatly exceeded those of normals both on depression and anxiety. Eastwood et al. (1972) used the General Health Questionnaire (Goldberg, 1972). The mean score for suicide attempters was more than twice the cut-off score for mental illness. The background to this work lies in the use of 2 research instruments as standardized measures of the mental state in a recent study comparing clinical assessment of these patients by psychiatrists and social workers (Newson-Smith & Hirsch, 1979). Early in the course of that study, the high level of neurotic symptoms was noted for the 4 weeks before the act. It was also apparent that 1 week later, many of the symptoms had disappeared without any specific intervention by psychiatric staff (apart from the usual brief assessment interview). The instruments used were the General Health Questionnaire (GHQ) and the ninth edition of the Present State Examination (PSE)
493 0033-2917/79/2828-4100 $01.00 © 1979 Cambridge University Press
494
J. G. B. Newson-Smith and S. R. Hirsch
(Wing et al. 1974). The GHQ is a selfadministered questionnaire, which aims to give information about the present mental state, rather than about personality traits or the liability to fall ill in the future. It has been found to discriminate effectively between psychiatric patients and normal controls. The PSE is a semistructured interview which has been used extensively in studies of acutely ill patients and of general population samples, both in the UK and abroad. It was decided to examine the mental state systematically in a series of self-poisoning patients. Three points in time were selected and the 2 instruments used. This study focuses on rapid change in levels of emotional distress by assessing patients at 3 points in time over a 3-month period. It was therefore necessary to assess a normal control group at the same points in time. Despite the existence of considerable cross-sectional normative data on the GHQ, there are no follow-up studies of change in GHQ scores in a normal population. The possibility of random or very short-lived fluctuation of scores in the normal population must be considered when seeking to understand the relevance of change in scores observed in the self-poisoning sample. METHOD
week. They were finally repeated at 3-month follow-up, for the preceding 4 weeks. Hospital employees provided the control group. Heads of departments were circulated for volunteers to fill in a set of 3 GHQ forms, covering the same time intervals (nurses, doctors and social workers were excluded). The GHQ score was calculated by using the non-weighted GHQ scoring method. The cut-off score of 11 was used, above which the score is within the range of probable psychiatric morbidity and the patient is a probable psychiatric 'case'. The neurotic PSE score was calculated by adding the 2 neurotic subscores (non-specific neurotic symptoms and specific neurotic symptoms). The Index of Definition level was based on information gained at the PSE interview and incorporates cut-off points on the basis of symptoms which have been identified as present. Eight degrees of definition are incorporated. At the threshold and definite levels (5-8) disorders are sufficiently well defined to apply the Catego program of clinical classification (Wing et al. 1978). Catego 'diagnoses', syndrome and symptom profiles were obtained from the PSE data. RESULTS One hundred and thirty-one patients were admitted during the time of the study who met the selection criteria for self-poisoning. Eighty-nine per cent of patients available on week days entered the study. (Thirty-nine patients were discharged over weekends precluding research
Selection of subjects This was restricted to those parasuicide patients who had deliberately taken an excess of a substance thought to be harmful and as a result had been admitted to a medical ward for adults or the casualty short-stay ward under medical care. Table 1. Comparison of 51 patients interviewed 3 It is the general policy of the hospital to admit times with 10 patients interviewed twice and 18 all such patients for medical and psychiatric patients interviewed once assessment. Inevitably, a few are discharged 3 interviews 2 interviews 1 interview directly from casualty with or without psy(N = 51) (N - 10) (N = 18) chiatric assessment and these are not included Mean age 3O±13 30±ll 24±6 in the study. The first 3 patients fit for assessment (years ±S.D.) entered the study on any day. The research Sex interviews were independent of routine psyM 4(40%) 19(37%) 11 (61%) F 6(60%) 32(63%) 7(39%) chiatric assessment. 36±14 1st GHQ score 32±16 33±18 The patient was asked to complete the GHQ (mean±s.D.) 18±15 1st PSE score 16±11 17±11 (60-item version) and the PSE was administered. (mean±s.D.) Both covered symptoms in the 4 weeks before the 21±18 18±18 2nd GHQ score overdose. The patient was re-interviewed 1 week (mean±s.D.) 2nd PSE score 9±9 11 ±10 — after the first interview, usually at home. The (mean±s.D.) GHQ and PSE were repeated for the intervening
495
Psychiatric symptoms in self-poisoning patients
assessment. Two non-English-speaking patients were excluded and one acutely disturbed schizophrenic was transferred to another hospital.) Seventy-nine patients were interviewed initially, of these 61 had a second interview (1 week later) and 51 a third interview (3 months later). Table 1 summarizes descriptive statistics for the first 2 interviews. It shows that the differences both in GHQ and PSE scores between patients interviewed 3 times, twice or once, is negligible. Therefore it is unlikely that the results reported will be severely biased by the absence of dropouts, not interviewed on the second or third occasions. Initial levels of PSE and GHQ scores Initial GHQ and PSE scores are surprisingly high. The mean GHQ score is 32, well above the cut-off point of 11. Similarly, the mean PSE score is 16. Almost two thirds of patients are at threshold and above Index of Definition levels, and therefore can be classified into one of the Table 2. Changes in GHQ, PSE, and Index of Definition levels over time Time from overdose
0-2 days I
Mean scores 32±16 GHQ (N = 48)* PSE (N = 51) 16±12 Index of definition (:AT= si) Patients at 31 (61 %) threshold level and above (levels 5-8)
7-9 days II
3 months III
18±18
12±15
20(39%)
11(22%)
9±9
5±6
Complete sets of GHQ scores not obtained on 3 patients.
categories of formal psychiatric illness (Table 2). Ninety per cent are above the cut-off GHQ score of 11. Comparison of scores and levels for the 3 interviews Table 2 shows that the mean GHQ and PSE scores have been approximately halved by the second interview and are approximately one third of their original value at the third interview. Similarly, the Index of Definition levels are reversed at second interview, i.e. 61 % are threshold and above initially and 61 % are below threshold at second interview. Seventy-eight per cent are below threshold at third interview. GHQ scores of patients compared with those of hospital employees Table 3 shows the constant low mean score of 4 obtained for the hospital employees as opposed to the higher but decreasing mean scores for the patients. At any one point in time, 9-11 % of the employees reached a score above 11 (cut-off) as compared with the high proportion of overdose patients at the first interview (90 %) which fell to 31 % at the third interview. This is similar to the findings of Goldberg et al. (1976) that approximately 11 % of a random sample of a general practice population were found on the GHQ to be psychiatrically disturbed. At 3 months the difference in final mean scores is still marked, 12 for the patients and 4 for the employees. The results for the control group support the contention that the 90 % prevalence of high scores (i.e. above 11) in self-poisoners cannot be explained on the basis of random fluctuation in symptom levels. Nor can it be
Table 3. Comparison of self-poisoners and controls Sex (%)
Hospital employees (N = 80) Self-poisoners (W = 48)
Age (% in year range)
M
F
33
67
38
62
< 20
17
Interview Hospital employees Mean GHQ score±s.D. % with scores > 11 Self-poisoners Mean GHQ score±s.D. % with scores > 11
Social class (RG) (%) I
II
III
IV
V
33
0
16
48
29
7
21
0
6
71
6
17
20-35
36-65
56 58
> 65
II
III
4±7 11
4±7 9
4±8 11
32±16 90
18±18 50
12±15 31
/. G. B. Newson-Smith and S. R. Hirsch
496
explained as part of the base rate of undisclosed psychiatric morbidity in the normal population. Correlation between GHQ scores and PSE scores The PSE and GHQ scores were compared using the Pearson product-moment correlation coefficient. Highly significant correlations were obtained for all interviews at 0-78, 0-81 and 0-77 respectively (significance of all, P < 0-0001). Clinical course of neurotic symptoms Table 4 places the patients into categories based on their initial GHQ score, i.e. 0-20, 21-40, 41-60. This enables subsequent scores to be studied with reference to initial scores. Patients in the 0-20 category usually remain at this level. Ninety-three per cent are 'non-cases' (using the GHQ cut-off score of 11) at second interview and 86% at final interview. Only 14% have received any form of psychological treatment at final interview, whether by psychiatrists, general practitioner, social worker, etc., so there is little indication from any point of view that this group was psychiatrically ill. Sixty-three per cent of patients in the 21-40 initial category remain 'cases' at second interview, so 37 % have improved sufficiently to become ' non-cases'. : Fifty per cent are 'cases' at the final interview. The mean GHQ score of 18 is in the 'case' range at final interview. Sixty-nine per cent had received some form of professional psychological help by this time. Seventy-two per cent of patients in the 41-60 Table 4. Changes in clinical indices over time related to initial GHQ scores (N = 48) Initial GHQ scores (interview I) No. of patients Mean GHQ Interview I II III GHQ 'cases'-% with GHQ above 11 Interview I II III Repeat overdose by interview III (3 months) Psychological help by interview III (% treated by social workers or
doctors)
0-20
21-10
41-60
14
16
18
12 3 6
27 20 18
46 28 11
64 7 14 2
100 63 50 4
100 72 28 0
14
69
73
initial category remain as 'cases' at second interview, so only 28 % have improved sufficiently to become 'non-cases'. At final interview only 28 % remain as 'cases'. The mean GHQ score at second interview is 28 but falls to the cutoff score of 11 at third interview. Seventy-three per cent had received some form of professional psychological help by this time. It is interesting that the initial scores do not predict the likelihood of a repeat overdose within the 3-month period. Two patients repeated the act in the low range, 4 in the mid range, and none in the high range. This is consistent with the view that overdosing is a form of behavioural reaction not necessarily related to an illness state or severity of symptoms. Patients in the high GHQ range may have been 'ill' and responded to treatment. The clinical course was similarly studied by reference to the initial Index of Definition level. Patients were divided into 3 categories: i.e. below threshold (1-4), threshold (5) and definite (6-8) levels (see Table 5). Again, it is demonstrated that patients in the low range, i.e. below threshold, generally remain at this low level (85 % at second interview, and 80 % at third interview). Patients at threshold level show improvement at the second interview, i.e. 74 % are below threshold, and this increases to 80 % at the third interview. Patients with definite conditions show less improvement at second interview (19 % below threshold), but at final interview 75 % are below threshold. Diagnostic results Catego classes on patients interviewed 3 times (N = 51) provided 16 definite and 15 borderline diagnoses. Thirty were of depressive disorders (none of depressive psychosis) and 1 of 'other affective psychosis'. Table 6 shows the rank-order frequency of individual Catego syndromes (derived from the PSE interview). 'Worry' is the most common syndrome (84 %) followed by simple depression (73 %). Worry remains in first position at second and third interviews. Simple depression drops to fifth place at both subsequent interviews. Generally the rank-order remains similar in subsequent interviews, although the percentage of patients experiencing individual syndromes drops. This is to be expected from previous examination of neurotic scores. The general
Psychiatric symptoms in self-poisoning patients
497
Table 5. Changes in the number of'cases' {by Index of Definition) as related to initial Index of Definition level (N = 57) Initial level
Below threshold No. (%)
At threshold No. (%)
Definite No. (%)
Total no patients
20 (100)
15 (100)
16 (100)
51
17(85) 2(10) 1(5)
11 (74) 2(13) 2(13)
3(19) 4(25) 9(56)
51
16 (80) 3(15) 1(5) 20 (100)
12 (80) 3(20) 0(0) 15(100)
12 (75) 1(6) 3(19) 16 (100)
Interview I Interview II Below threshold At threshold Definite Interview III Below threshold At threshold Definite Total no. patients
51 51
Table 6. Rank-order frequency of the 10 most common PSE syndromes in this series (N = 51) Prevalence of syndromes at each interview (%) symbol
Syndrome
I
II
III
WO SD TE OD IT IC
Worry Simple depression Tension Somatic features of depression Irritability Loss of interest and concentration Social unease Loss of energy Special features of depression Situational anxiety
84 73 63 59 55 53 51 37 29 28
63 37 44 45 31 43 31 28 22 20
53 24 33 33 26 20 12 14 6 22
su LE ED SA
Table 7. Rank-order frequency of the 10 most common individual PSE symptoms in this series (N = 51) Prevalence at each interview (%) PSE symptom Suicidal plans or acts Subjective feelings of nervous tension Depressed mood Hopelessness Irritability Tension pains Worrying Tiredness or exhaustion Poor concentration Neglect due to brooding
I
II
III
92 75 73 61 55 49 45 45 43 35
22 41 37 33 31 33 28 33 37 14
6 28 24 14 26 26 14 37 18 8
profile is that of minor neurotic illness with depressive features. Table 7 shows the rank-order frequency of the 10 most common individual PSE symptoms (as opposed to syndromes) in this study. Pre33
dictably in the self-poisoning series, suicidal plans or acts are the most common initial symptom, present in 100 % of the series. However, this symptom drops to ninth and tenth places respectively at second and third interviews. Two symptoms which might be expected to be most closely related to suicidal plans or acts are depressed mood and hopelessness. They rank in third and fourth places initially. The symptom 'subjective feelings of nervous tension' is prominent at all interviews. The form of disorder in self-poisoning patients is reflected by a comparison of the frequency of different symptoms of depression between these patients and in-patients and out-patients being treated for depression and community 'cases'. These 'cases' were persons identified in a community sample who were not in treatment but would be regarded as being psychiatrically ill, i.e. a PSE 'case' (see Table 8). Caution must be applied in interpreting these symptom frequencies due to the small number of depressed outPSM
9
498
J. G. B. Newson-Smith and S. R. Hirsch Table 8. Comparison of the frequency of selected PSE symptoms in other series^ and self-poisoners
PSE symptoms
In-pts (N = 55) (%)
Out-pts (N = 14) (%)
Depressed mood Hopelessness Inefficient thinking Self depreciation Pathological guilt Lack of energy Loss of weight Early waking Retardation
100 63 46 38 21 63 46 42 21
100 71 43 36 21 79 71 21
Gen. populn. 'cases' (N = 19) (%)
Selfpoisoners (N = 51) (%)
Significant* differences between self-poisoners and other groups
100 11 22 22 6 28 11 28 —
73 61 31 28 2 37 26 20 0
Less than in-pts and 'cases' More than 'cases' NS NS Less than in-pts Less than out-pts Less than out-pts NS Less than in-pts
7
* Significance tested by 2 x 2 chi-squares with Yates' correction, P < 0-05. t Reproduced by courtesy of Professor J. K. Wing (1976).
patients and community 'cases'. Depression was only rated in 73 % of self-poisoners which compares with 100% in the other series. Selfpoisoners resemble treatment patients in the high prevalence of hopelessness. 'Cases' have a low prevalence. The proportion of overdoses affected by inefficient thinking and self depreciation falls between the higher prevalence in patients in treatment and lower prevalence in 'cases'. The remaining symptoms in Table 8 occurred relatively infrequently in self-poisoners and 'cases' as compared with patients having treatment for depression. The total mean PSE score for the selfpoisoners is 16, as compared with 15 for 'cases', 24 for depressed out-patients and 26 for depressed in-patients. Thus, the symptom frequencies and PSE scores of our self-poisoning patients are in many ways like those of community 'cases'. DISCUSSION The patients are not a consecutive series of all self-poisoners brought to hospital. It could be argued that most samples of self-poisoners are unrepresentative of the total group, many of whom go undisclosed or are dealt with by the general practitioner, leave casualty before being assessed, or discharge themselves prematurely from the wards. There is value, however, in knowing about this group, who are assessable to evaluation and treatment in clinical practice. In this group, the GHQ and PSE (neurotic) scores appear to measure much the same type
of disorder, since the correlation between them is so high. The PSE was generally well tolerated by the patients and took about 40 minutes to administer at first interview. The GHQ takes the patient only a few minutes to complete; however, they showed more resistance to filling in a form than to being interviewed. The 30-item version of the GHQ would probably have been more acceptable to them. The GHQ proves a useful instrument for follow-up work, as it does not require a trained interviewer nor does the patient need to be seen in person. This study has confirmed that the patients experienced a high level of neurotic symptoms before the self-poisoning. The method allowed these symptoms to be measured only retrospectively, i.e. after the overdose. The patients were interviewed as soon as possible after regaining consciousness, and little time was therefore allowed for memory falsification, i.e. to put an unpleasant experience behind them or to search after meaning. The second interview was considered important in gaining information about the mental state for the short interval of 1 week after the overdose. This is usually prior to any psychological treatment and also a time when the risk of repeat overdose is high. The time span covered by this PSE interview and GHQ was different, i.e. 1 week as opposed to 4 weeks (a sub-group of 20 patients were rated at first and final interviews for the previous week in addition to the previous 4 weeks and there was virtually no difference in the PSE ratings). The
499
Psychiatric symptoms in self-poisoning patients
second interview was technically the most difficult to obtain. The timing was considered crucial for comparative purposes. There is little information available about the clinical state at this stage. In normal clinical practice, follow-up is usually more than 1 week later and there is a high nonattendance rate. Many patients were visited more than once to obtain this interview, as they 'forgot' about it. Eighteen patients were lost between first and second interviews. This largely reflects the high numbers of persons, mainly men with alcohol and drug problems, without fixed address, who take overdoses in this part of London. However, results have shown that mean scores at first interview are hardly affected by removing their scores. Overall, we have confirmed our initial impression that the act of self-poisoning can have a cathartic therapeutic effect. This is less likely in patients with high initial levels of symptoms, i.e. 72 % of patients with initial GHQ scores in the range 41-60 are GHQ 'cases' at 1 week, and 81 % of patients with definite initial PSE diagnoses remain as probable and definite 'cases' at 1 week. Nevertheless, we have seen that in some patients there is a dramatic drop in symptoms without psychiatric treatment. It would seem that for them the act itself, its effects on significant others and life circumstances together with hospital care have brought definite relief. Spontaneous remission may also be an important factor. Patients with low initial symptom levels do well psychiatrically and few receive treatment. Most are non-attenders at any psychiatric followup appointment offered. We believe that medically-oriented follow-up is neither effective nor indicated for this group. However, early repetition of the act does occur in this group. We hope that initial screening could detect those patients most at risk and likely to benefit from early socially-oriented help. Patients initially in initial middle and high categories for symptoms and levels show a different picture. At 1 week their symptoms have fallen proportionately less and patients in the high category still have a comparatively greater mean score. This is not so at 3 months. Interestingly, the vast majority in these 2 groups have obtained professional psychological help by the final interview. Our results suggest that more active efforts are needed to help these patients
very soon after the overdose in order to reduce the ensuing psychiatric morbidity. The higher the initial level of symptoms, the greater is the indication for early intervention. We stress that the standard clinic appointment a few weeks hence is neither effective nor appropriate. It may partly explain our present unsuccessful management of the whole problem of repetition of parasuicide. Many follow-up studies of parasuicide patients have relied on rates for repeat parasuicide acts and suicide as criteria for judging the effectiveness of intervention. This is a narrow measure, and our findings have shown a considerable number of patients remain in psychological distress yet do not repeat the act. We argue that they would benefit from early intervention. Study of diagnostic PSE results as opposed to scores has yielded interesting results. The general profile is that of neurotic symptomatology with depressive features resembling 'cases' discovered in the general population more than patients having treatment for depression at a hospital. We have stressed from our results the importance of early help, although in most patients we are not dealing with major psychiatric illness. Further work needs to be done to evaluate the effectiveness of different types of early intervention, both alone and in combination. The main types are those which employ psychotherapeutic and social skills and those employing medication. Antidepressants and minor tranquillizers may have some place in alleviating distress for those with moderate and high levels of initial symptomatology (we have noted the high prevalence of the symptom 'subjective feelings of nervous tension'). The next step may be to look at the relative value of medication and psychotherapeutic help for those patients having moderate or high scores on the GHQ and PSE. We are grateful to the following at Charing Cross Hospital: the Clinical Research Committee for awarding the research fellowship to J. G. B. NewsonSmith, the staff of the Medical School Computer Department and Mr Steven Platt for help in analysing the data. We are also grateful to Professor J. K. Wing for advice and analysis of the PSE data and Dr L. K. Hemsi for reading the manuscript.
33-2
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REFERENCES Birtchnell, J. & Alarcon, J. (1971). Depression and attempted suicide: a study of 91 cases seen in a casualty department. British Journal of Psychiatry 118, 289-296. Eastwood, M. R., Henderson, A. S. & Montgomery, I. M. (1972). Personality and parasuicide: methodological problems. The Medical Journal of Australia i, 170-175. Foulds, G. A. & Hope, K.. (1968). Manual of Symptom Sign Inventory (SSI). University of London Press: London. Goldberg, D. (1972). The Detection of Psychiatric Illness by Questionnaire. Oxford University Press: London. Goldberg, D., Kay, C. & Thompson, L. (1976). Psychiatric morbidity in general practice and the community. Psychological Medicine 6, 565-569. Morgan, H. G., Burns-Cox, C. J., Pocock, H. & Pottle, S. (1975). Deliberate self-harm: clinical and socio-economic characteristics of 368 patients. British Journal of Psychiatry 127, 564-574. Newson-Smith, J. G. B. & Hirsch, S. R. (1979). Clinical evaluation of parasuicide: social workers compared to psychiatrists. British Journal of Psychiatry (in the press).
Philip, A. E. (1970). Traits, attitudes and symptoms in a group of attempted suicides. British Journal of Psychiatry 116, 475-482. Vinoda, K. S. (1966). Personality characteristics of attempted suicides. British Journal of Psychiatry 112, 1143-1150. Weissman, M. M. (1974). The epidemiology of suicide attempts 1960-1971. Archives of General Psychiatry 30, 737-746. Wing, J. K. (1976). A technique for studying psychiatric morbidity in in-patient and out-patient series and in general population samples. Psychological Medicine 6, 665-671. Wing, J. K., Cooper, J. E. & Sartorius, N. (1974). The Measurement and Classification of Psychiatric Symptoms. Cambridge University Press: London. Wing, J. K., Mann, S. A., Leff, J. P. & Nixon, J. M. (1978). The concept of a 'case' in psychiatric population surveys. Psychological Medicine 8, 203-217. Zung, W. W. K. (1965). A self-rating depression scale. Archives of General Psychiatry 12, 63-70.
