Psychiatric Consultation for Suicidal Behaviour in Emergency Departments: A Comparison Between the University Hospital Systems of Alessandria and Novara

doi:10.21203/rs.3.rs-7999534/v1

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Psychiatric Consultation for Suicidal Behaviour in Emergency Departments: A Comparison Between the University Hospital Systems of Alessandria and Novara

https://doi.org/10.21203/rs.3.rs-7999534/v1

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Background: Suicide attempts constitute a significant public health emergency, with Emergency Departments (EDs) serving as a primary point of contact for individuals in acute psychiatric distress.

Methods: This observational, multicentric study aimed to analyse and compare the profiles of psychiatric consultations provided in the EDs of the University Hospital Systems (AOU) of Novara and Alessandria between January and December 2024, focusing specifically on suicidal behaviours, clinical characteristics, and intervention outcomes. Data were collected anonymously and pseudonymized from the institutional software (Track Care, REDCap).

Results: The study included 1,196 accesses requiring psychiatric evaluation. Significant differences emerged between the centres: the Novara cohort was significantly younger (mean age 42.5 vs. 47.1 years; p < 0.001), presented with more complex, chronic psychiatric histories (76.3% previous psychiatric history vs. 57.3% in Alessandria; p < 0.001), and showed higher rates of suicidal ideation and low-lethality self-harm. Consequently, Novara utilised acute pharmacological therapy more frequently (51.13% vs. 39.59%; p < 0.001) and hospital admissions more often (voluntary admissions 40.74% vs. 25.85%; p < 0.001). Conversely, Alessandria’s population was older, often self-referred (58.4% vs. 34.7% in Novara), and showed a significantly higher frequency of conscious suicidal intent (will to self-preserve 39.68% vs. 23.36%; p = 0.024), often associated with high-lethality suicide methods (e.g., hanging 13.1%, defenestration 8.2%). Alessandria adopted a more territorial management approach, with higher discharge rates (27.23% vs. 18.89%) and referral rates to community mental health services (CSM) (21.23% vs. 17.96%).

Conclusion: Multivariate analysis confirmed the gender paradox, showing that women were significantly associated with self-harm (Odds Ratio - OR = 1.57; p = 0.008). Crucially, substantial methodological differences were observed in substance use screening (Novara: 67.84% positive vs. Alessandria: 12.22% positive), underscoring the need to standardise diagnostic protocols for reliable epidemiological data. The findings highlight the need for tailored, integrated care models based on the specific demographic and clinical profiles served by local EDs.

Trial registration: The study was approved by the Interaziendale Territorial Ethics Committee of the AOU Maggiore della Carità of Novara (Prot. n° 912/CE, July 3, 2023) and by the University of Piemonte Orientale.

Emergency Department

suicide

suicidal ideation

suicidal behaviours

self-harm

psychiatric consultation

Suicide represents a critical global public health concern, estimated as the fourth leading cause of death globally among young people aged 15 to 29 (World Health Organization, 2021b). In 2019, over 700,000 individuals worldwide died by suicide (World Health Organization, 2021b). Suicide attempt, defined as a voluntary act intended to end one’s life but without resulting in death, is a significant indicator of future suicide risk (Klonsky et al., 2016). Attempts occur approximately 30 times more frequently than completed suicides. While depression is the primary cause, contributing factors include anxiety, personality disorders, trauma, organic disorders (Bachmann, 2018), and socio-economic issues (Ying & Chang, 2009). Furthermore, limited access to mental health services and the stigmatisation of mental disorders can obstruct individuals from seeking timely help (Arnaez et al., 2020).

The Emergency Department (ED) plays a pivotal role in suicide prevention, managing an estimated 80% of attempted suicide cases (Wallaert et al., 2022) and often serving as the only point of contact with health services for these individuals. Given that the risk of repeating the suicidal act is highest in the weeks immediately following a previous attempt (Zeppegno et al., 2015), a rapid and robust management strategy initiated directly within the ED is imperative. Effective prevention requires an integrated, multidisciplinary approach that includes specific psychological and pharmacological treatments, social support, and public awareness campaigns to reduce stigma (Shaffer et al., 1990).

The current study is motivated by the understanding that variability in local service organisation can lead to differing care patterns, which significantly impact care quality and resource allocation.

This study aims to analyse and compare the characteristics of psychiatric consultations performed in the EDs of the AOU SS. Antonio, Biagio, and Cesare Arrigo in Alessandria and the AOU Maggiore della Carità in Novara, focusing specifically on suicidal behaviours. The key objectives include defining the socio-demographic and clinical profiles of patients accessing emergency psychiatric services; characterising the caseload based on prevalent pathologies and symptoms; investigating the incidence and modalities of suicidal behaviours stratified by age and gender; evaluating dependency issues; and comparing acute therapeutic strategies and intervention outcomes between the two centres. Understanding these territorial differences is essential for developing personalised suicide prevention strategies tailored to local needs.

3.1. Study Design and Data Collection

This was an observational study. Sociodemographic and clinical data related to psychiatric consultations were collected anonymously from the institutional clinical data management software, Track Care, used in the EDs of Alessandria and PsNet used in Eds of Novara. Data were subsequently pseudonymized and recorded in the REDCap web application (https://www.project‐redcap.org/) in compliance with General Data Protection Regulation (GDPR).

The study was conducted in accordance with the Declaration of Helsinki (2024). It was approved by the Interaziendale Territorial Ethics Committee of the AOU Maggiore della Carità of Novara (Prot. n° 912/CE, July 3, 2023) and by the University of Piemonte Orientale.

3.2. Population and Sampling

The study population consisted of patients aged 18 years or older who received a psychiatric consultation in the EDs of the two hospitals between January 2024 and December 2024. A total of 1,196 ED accesses requiring psychiatric evaluation were recorded during this period.

Variables collected included: socio-demographic details (age, gender, civil status, occupation, living conditions, referral source); psychiatric history (previous psychiatric care, addiction treatment services-SerD involvement, hospitalizations, noted diagnoses); organic comorbidities and medical therapy; dependencies (alcohol, substances, tested positivity); suicidal behaviors (ideation, self-harming act, will to self-preserve, short-circuit behavior, type of act/ingestion); type of acute therapy administered; and intervention outcome (e.g., Compulsory Admission - TSO, voluntary admission, discharge, Community Mental Health Centers - CMCH referral).

3.3. Data Analysis

Continuous variables were reported as mean and standard deviation (SD). Categorical variables were presented as absolute frequencies and percentages. Logistic regression was used to evaluate the association between categorical variables, reporting odds ratios (ORs) and 95% confidence intervals (CIs). Statistical significance was determined using Pearson’s Chi-square test, with p-values less than 0.05 considered statistically significant. Analyses were performed using Stata v18.

4.1. Socio-Demographic Characteristics

The mean age differed significantly (p < 0.001). Novara’s patients were younger (42.5 ± 18.29 years) compared to Alessandria’s (47.1 ± 17.07 years). The 18–34 age group was significantly more represented in Novara (41.6%) compared to Alessandria (27.3%). Gender distribution was similar (47.43% male, 52.57% female; p = 0.986).

Self-referral was significantly higher in Alessandria (58.40%) compared to Novara (34.68%; p < 0.001). Novara recorded a greater incidence of referrals from General Practitioners (GPs)/118 (25.05%) and specialist psychiatric physicians/SerD (12.52%). Novara patients were also more frequently single/celibate (63.76% vs. 47.85%; p < 0.001). Alessandria showed a higher proportion of married/cohabiting individuals (36.36% vs. 27.75%) and pensioners (21.95% vs. 10.39%) (Table 1).

4.2. Clinical Precedents and Pathology

Novara reported significantly higher rates of previous psychiatric history (76.25% vs. 57.30%), prior psychiatric hospitalisations (49.81% vs. 36.62%), formal psychiatric diagnoses (78.25% vs. 61.85%), and current psychopharmacological therapy (71.38% vs. 55.71%) (p < 0.001 for all comparisons). This pattern suggests a Novara population with greater clinical complexity and chronicity (Zimmerman et al., 2018; Di Lorenzo et al., 2020) (Table 2).

Alessandria showed higher rates of current (10.26% vs. 5.08%) and previous SerD follow-up (17.49% vs. 7.69%; p < 0.001).

Regarding psychiatric diagnoses, Novara showed a higher prevalence of Personality Disorders (26.60% vs. 21.57%) and Schizophrenia spectrum disorders (23.99% vs. 17.26%). Alessandria showed higher percentages of Depressive disorders (20.30% vs. 8.08%), Bipolar disorders (11.42% vs. 5.94%), and Anxiety disorders.

In terms of pharmacotherapy, Novara showed a greater use of typical oral neuroleptics (22.92% vs. 10.54%), atypical oral neuroleptics (36.98% vs. 27.64%), benzodiazepines (68.75% vs. 58.69%), and Long-Acting Injectable (LAI) formulations (typical 8.59% vs. 3.70%; atypical 6.25% vs. 3.99%). Alessandria reported higher prescriptions of mood stabilisers (29.06% vs. 14.32%) and anticonvulsants (10.54% vs. 7.03%).

4.3. Symptomatology

The distribution of main symptoms differed highly significantly between the centres (p < 0.001). Novara reported higher rates of anxious state (34.62% vs. 30.66%), psychomotor agitation (20.07% vs. 14.64%), psychotic symptomatology (11.97% vs. 9.86%), and cognitive alterations (2.95% vs. 0.77%). Alessandria showed a higher frequency of mood alterations (15.10% vs. 7.92%), intoxications (11.86% vs. 6.45%), and cases with a negative psychiatric objective exam (12.33% vs. 7.18%) (Table 3).

4.4. Dependencies

Novara reported a higher prevalence of dependence diagnoses (27.26% vs. 22.22%; p = 0.048). Conversely, elevated blood alcohol levels (>0.5 ng/ml) were slightly more frequent in Alessandria (13.31% vs. 9.42%; p = 0.050).

Crucially, Novara had a significantly higher percentage of positive screens for other substances (excluding alcohol) (67.84% vs. 12.22%; p < 0.001). This disparity is likely due to methodological differences in toxicological screening protocols. The most frequently reported dependency diagnoses overall were alcohol (51.24%), cannabis (36.4%), and stimulants (29.3%) (Table 4).

4.5. Suicidal Behaviours

Novara displayed a higher incidence of suicidal ideation (19.89% vs. 12.42%) and self-harming acts (20.60% vs. 10.16%) (p < 0.001). Conversely, the will to self-preserve (conscious suicidal intent) was significantly higher in Alessandria (39.68% vs. 23.36%; p = 0.024). Short-circuit behaviours (impulsive acts) were similarly distributed (p = 0.509).

The most frequent self-harm modality overall was voluntary ingestion (56.7%). Alessandria reported higher rates of potentially lethal acts such as hanging (13.1%) and defenestration (8.2%) (Table 5).

4.5.1. Age and Gender Associations (Multivariate Analysis)

Multivariate logistic regression confirmed a significant association between female sex and self-harming behaviours (OR = 1.57; CI 95%: 1.13–2.19; p = 0.008). This indicates women had an approximately 1.6 times increased probability of self-harming acts compared to men. Other outcomes, including suicide, conscious intent, and acute presentation, did not show statistically significant associations with female sex (Table 6).

Analysis of mean age revealed that subjects with reported suicide, self-harm, and acute presentation were significantly younger (p-value = 0.0002). However, the group exhibiting the will to self-preserve (fatal intent) was considerably older (45.39 years) than those without this intent (36.01 years; p = 0.0014) (Table 7).

4.6. Acute Therapy

Novara administered acute therapy significantly more often (51.13%) than Alessandria (39.59%; p < 0.001). This is correlated with Novara's higher prevalence of psychomotor agitation and anxiety. The most common acute pharmacological intervention overall was parenteral benzodiazepine administration (50.1%) (Table 8).

4.7. Outcome

Intervention outcomes differed significantly (p < 0.001). Novara registered a higher prevalence of compulsory hospitalisations (TSO) (7.04% vs. 3.08%) and voluntary hospitalisations (40.74% vs. 25.85%). This suggests a more intensive, hospital-oriented approach in Novara. Alessandria utilised territorial services more, with higher discharge rates (27.23% vs. 18.89%) and referral rates to Community Mental Health Centres (CMHC) (21.23% vs. 17.96%) (Table 9).

5.1. Interpretation of Results

The comparative analysis demonstrates two distinct service delivery models driven by differing patient populations.

The Novara cohort is characterised by a significantly younger mean age (42.5 years), a higher burden of chronic and complex psychiatric conditions, such as psychotic and personality disorders, requiring an intensive, hospital-based approach. This profile is reflected in the higher incidence of previous psychiatric history (76.3%) and hospitalisations (49.8%). The presence of psychomotor agitation (20.07%) and psychotic symptoms also correlates with the increased rate of acute medication use (51.13%). The younger age and the prevalence of self-harming acts (20.60%) in Novara are consistent with literature linking impulsivity and Non-Suicidal Self-Injury (NSSI) (Wilkinson, 2013) to younger populations.

In contrast, the Alessandria cohort is older (47.1 years) and often accesses the ED autonomously (self-referral 58.4%). This older group exhibited greater intentionality, measured by the will to self-preserve (39.68%), and used high-lethality methods (hanging, defenestration). This supports the established risk profile for older adults, where suicidal gestures are typically more planned and lethal (Rossom et al., 2017; Gramaglia et al., 2022). Alessandria’s management pattern—higher discharge rates and CSM referrals—reflects a territorial approach suitable for patients with greater autonomy.

The confirmed association between female sex and self-harm (OR=1.57) supports the gender paradox (Shelef, 2021), where women exhibit higher rates of non-lethal suicidal behaviour while men tend towards more violent acts (Schrijvers et al., 2012). Furthermore, male patients showed a greater likelihood of TSO admission and SerD referral, consistent with higher rates of impulsivity and substance abuse observed in men (Grant & Weissman, 2007).

A crucial limitation highlighted is the inconsistency in substance use detection: the vast disparity in positive screens (Novara 67.84% vs. Alessandria 12.22%) suggests a difference in the application of screening protocols (e.g., systematic screening in Novara) rather than true epidemiological prevalence. This gap underscores the urgent need to standardise diagnostic protocols to ensure consistent, evidence-based management (Pincus et al., 2016).

5.2. Strengths and Confines

The study's multicentric approach, comparing two hospitals in the same region with distinct patient profiles, is a significant strength, allowing for the identification of specific territorial patterns. The exhaustive, multidimensional data collection covering clinical history, symptomatology, substance use, and outcomes provides an integrated clinical picture.

However, the retrospective nature introduces potential biases related to the completeness and accuracy of clinical documentation. The absence of randomisation may introduce selection bias related to local demographic differences. Furthermore, the study lacks a follow-up period, limiting the ability to assess the long-term effectiveness of the interventions in terms of relapse or quality of life. Finally, discrepancies in screening protocols (e.g., substance use detection) pose a significant methodological challenge to comparability.

This multicentric study revealed significant territorial differences in the management of psychiatric emergencies and suicidal behaviours between Novara and Alessandria, suggesting that no single care model is optimal.

The Novara centre manages a younger population with complex, chronic disorders, requiring an intensive, hospital-oriented approach reflected in higher admission rates (40.74% voluntary, 7.04% TSO). Conversely, Alessandria serves an older population with higher conscious suicidal intent, managing them primarily through territorial services, emphasising discharge and CSM referral (27.23% discharge, 21.23% CSM referral).

The strong evidence of methodological differences, particularly in substance screening (Novara: 67.84% vs. Alessandria: 12.22%), underscores the priority of standardising diagnostic protocols for uniform, evidence-based care.

Future priorities should include targeted training for ED staff and the development of age- and gender-differentiated risk assessment tools. Early identification of NSSI behaviours is critical in younger patients (Novara), while immediate attention to lethality and intent is necessary for older patients (Alessandria). Only through an integrated, multidisciplinary approach, adapted to the specific needs of the local population, can suicide prevention policies be genuinely effective.

Ethics approval and consent to participate

Data were collected anonymously from the institutional clinical data management software, Track Care, used in the EDs of Alessandria and PsNet used in Eds of Novara. Data were subsequently pseudonymized and recorded in the REDCap web application in compliance with GDPR. The study was conducted in accordance with the Declaration of Helsinki (2024). It was approved by the Interaziendale Territorial Ethics Committee of the AOU Maggiore della Carità of Novara (Prot. n° 912/CE, July 3, 2023) and by the University of Piemonte Orientale. Informed consent was obtained from all individual participants included in the study.

Consent for publication

All participants provided written informed consent for the publication of this manuscript.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

There are no potential conflicts of interest for any of the authors in the past years

Funding

There was no funding received for this work

Authors' contributions

Conceptualization: C.G. and E.G. (Formulation of overarching research goals).

Methodology: F.G, and M.B. (Development of the study methods).

Investigation: V.F and C.M. (Performing experiments, data collection).

Formal Analysis: D.F. (Application of statistical techniques to data).

Writing – Original Draft: E.G. and C.G. (Writing the initial draft).

Writing – Review & Editing: E.G. (Critical feedback and revision).

Supervision: P.Z. (Overall direction and project management).

Funding Acquisition: not applicable

Acknowledgements

Not applicable.

General and Institutional Abbreviations

ED – Emergency Department

AOU – Azienda Ospedaliero-Universitaria (University Hospital System)

CMHC / CSM – Community Mental Health Centre / Centro di Salute Mentale

SerD – Servizio per le Dipendenze (Addiction Treatment Service)

GDPR – General Data Protection Regulation

TSO – Trattamento Sanitario Obbligatorio (Compulsory Admission)

REDCap – Research Electronic Data Capture (data management software)

GP – General Practitioner

Clinical and Research Abbreviations

NSSI – Non-Suicidal Self-Injury

OR – Odds Ratio

CI – Confidence Interval

SD – Standard Deviation

LAI – Long-Acting Injectable (form of medication)

p – Probability value (used in statistical significance testing)

Software and Data Tools

Track Care – Clinical data management system used in Alessandria

PsNet – Clinical data management system used in Novara

Regulatory and Ethical References

Prot. n° – Protocol Number (used in ethics approval reference)

CE – Comitato Etico (Ethics Committee)

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Psychiatric Consultation for Suicidal Behaviour in Emergency Departments: A Comparison Between the University Hospital Systems of Alessandria and Novara

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