Procedure
This study used data collected from patients who attended the GCC at St Vincent’s Hospital. The details of the GCC are discussed more fully in previous papers (33–35). In summary, following presentation to the Emergency Department with suicidal behaviour or ideation, all patients receive routine medical and psychiatric assessments (by an emergency doctor and psychiatry registrar). If deemed appropriate for discharge from hospital, the psychiatry registrar will consider referral to the GCC if: (1) the patient is not already under the care of their own psychiatrist/psychologist or community mental health team, (2) they speak English, and (3) they do not have a permanent impairment in cognition. On arrival to their first clinic appointment, patients are asked by the clinic receptionist to complete a number of assessment measures, including those outlined below. Patients included in this study were also given information and the opportunity to consent to their de-identified data being used for the purposes of research. The St Vincent’s Human Research Ethics Committee approved the use of this data for this purpose.
Participants
From 2007 to 2016, of the 665 attenders at their first GCC appointment, 448 provided complete data including current presentation, age, sex, marital status, past history of DSH, psychiatric diagnosis, and self-report measures, as noted below. There were no significant demographic differences between those with complete data and those without. The mean age of clinic attenders was 31.7 years (SD = 10.6 years, range 17–69 years) and 59.1% of attenders were female. Of these, 107 (23.9%) attenders had never engaged in DSH, 162 attenders (36.2%) reported one previous episode of DSH and 179 (40.0%) reported 2 or more previous episodes of DSH. Most (74.5%) attendees were single, 15.9% were married or in de facto relationship, 8.9% separated or divorced and 0.7% widowed. The reasons for their ED presentation were overdose (40.8%), suicidal ideation (41.7%), cutting (10.3%), hanging (1.6%), jumping (2.0%) carbon monoxide poisoning (0.2%) and other (3.3%).
The patients’ principal psychiatric diagnosis was recorded following assessment by the GCC clinician (psychiatrist, psychiatry registrar, psychologist or mental health clinical nurse consultant) and consensus by the team. Diagnoses included depression (33.1%), anxiety (10.7%), personality disorder (4.1%), psychosis (0.2%), substance use disorder (SUD; 18.9%), gambling addiction (0.9%), eating disorder (1.1%), adjustment disorder (11.9%), acute stress reaction (1.6%), situational crisis (13.9%) and relationship issues (2.7%). Three people did not have a diagnosis recorded.
Measures
The Fantastic Lifestyle Checklist (FLC) assesses 11 lifestyle domains using the acronym FANTASTIC (family, friends, activity, nutrition, toxins, alcohol, stress, sleep, personality type, insight and career). The 25 items within these domains include communication, giving/receiving affection, receiving emotional support, exercise, relaxation, eating balanced meals, eating breakfast, consuming excess sugar, salt, animal fats or junk food, weight, smoking, drug abuse, caffeine, alcohol, sleep, screen time, stress, impatience, aggression, anger, optimism, anxiety, depression, job satisfaction and relationships. Each item is scored on a 3-point Likert scale from 0 (hardly ever),, 1 (some of the time),, to 2 (almost always).. There is some variation in wording depending on the item and some items are reverse scored.
The Depression Anxiety and Stress Scales–21 Item Version (DASS–21) (36) measures three negative emotional states (depression, anxiety and stress). The two scales assessing depression and anxiety were used in this study. The depression scale assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest, anhedonia and inertia. The anxiety scale assesses autonomic arousal, muscle tension, situational anxiety and subjective experience of anxiety. Respondents rate the extent to which they have experienced each state over the past week on a 4-point Likert scale ranging from 0 (never),, 1 (sometimes),, 2 (often) to 3 (almost always)..
Outcome measures
The outcome measure for this study was the total number of self-reported lifetime suicide attempts, including the current presentation.
Statistical Analyses
The data were analysed using the Statistical Package for the Social Sciences (SPSS, v22, IBM Corporation, 2013). Descriptive statistics were used to quantify baseline outcome measures and other variables (including demographics, psychiatric diagnosis and lifestyle factors). For the purpose of analysis, several dichotomous variables were created. The two groups in the marital status variable included single/separated/divorced/widowed and married/defacto. The diagnosis variable was made into 3 separate dichotomous variables, (1) depression and all other diagnoses (as listed above), (2) anxiety and all other diagnosis, and (3) substance use disorder and all other diagnoses. In forming dichotomous variables from the lifestyle factors, the decision was made to isolate the most extreme negative response. For example, the balanced meals variable was divided into the two groups: (1) 'hardly ever’ and (2) 'some of the time’ or 'almost always’. The exceptions to this rule were the smoking and drug abuse variables. The smoking variable was divided into the two groups: (1) smokers ('occasional use’ or ‘daily use’),, and (2) non-smokers. Likewise, the drug abuse variable was divided into two groups of people who abuse drugs: (1) ‘some of the time’ or ‘frequently’ and (2) ‘never or seldom’.
The rationale for this was that the middle response options for the smoking and drug abuse variables were particularly difficult to quantify, and considering there is no amount of smoking or drug abuse that is considered ‘safe’ by national guidelines (unlike alcohol) (37), this seemed to be the most logical way to divide these variables into two groups. Additionally, research shows that risk of death from suicide tends to be primarily associated with amount of alcohol consumed per drinking day, rather than drinking frequency or overall alcohol consumption, which supports guidelines that limit consumption to 2 drinks or less per drinking day (38).
One-way ANOVA and correlation analyses were used to explore the relationship between the number of lifetime DSH episodes and a range of variables including gender, marital status, depression, anxiety, substance use disorder (SUD) and the list of dichotomous lifestyle variables (as described above). Demographic and diagnostic variables that were found to have a significant relationship with the number of DSH episodes were included in a multiple linear regression model to assess the predictive ability of the various lifestyle and demographic variables.