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Formal and Informal Help During the Year After a Suicide Attempt: a One-Year Follow-Up
M. Cedereke and A. jehagen Int J Soc Psychiatry 2007 53: 419 DOI: 10.1177/0020764007078345 The online version of this article can be found at: http://isp.sagepub.com/content/53/5/419

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FORMAL AND INFORMAL HELP DURING THE YEAR AFTER A SUICIDE ATTEMPT: A ONE-YEAR FOLLOW-UP

M. CEDEREKE & A. JEHAGEN


ABSTRACT Aims: The aims of this study are threefold: to investigate formal and informal help with clinical and social needs that patients who attempted suicide received during the year after their attempt; to examine whether help from services was estimated to be adequate; and to look at whether patients who repeated suicide attempt(s) during follow-up differed from those who did not. Methods: The Camberwell Assessment of Need instrument measuring 22 need areas was used in semi-structured interviews with 140 patients at 1 and 12 months after a suicide attempt. Results: Help given from services was rated as high at both 1 and 12 months in health-related areas, but lower in areas related to social needs. Informal help was initially frequent, with some exceptions. The amount of help from services did not decrease in any need area during follow-up, neither in repeaters nor in non-repeaters. There were no changes in informal help in repeaters, while in non-repeaters informal help decreased in some areas. At both 1 and 12 months, repeaters and non-repeaters mostly found help from services to be adequate. However, in the areas of information, intimate relationships, psychotic symptoms and sexual expression about half of the patients in both groups did not consider that they had received the right type of help. Conclusions: The generally high level of formal help in health-related areas during the rst year after a suicide attempt and the high rated adequacy of help given is satisfactory. However, in certain areas lack of formal help was evident. Informal caregivers contributed signicantly to the help that patients received. The use of the Camberwell Assessment of Need instrument could improve observation on needs areas and whether help is available. Perhaps this kind of evaluation could be used earlier than after 1 year in such a vulnerable group as suicide attempters. Key words: Activities of Daily Living, caregivers, clinical needs, consumers perspective, mental health, need, services, signicant others, social needs, suicide attempt

INTRODUCTION
Suicide attempters are a heterogeneous group who often have a variety of psychological and social problems, in addition to an eventual psychiatric disorder (Hawton, 2000 (Chapter 29); Magne-Ingvar
International Journal of Social Psychiatry. Copyright SAGE Publications 2007 (Los Angeles, London, New Delhi and Singapore) www.sagepublications.com Vol 53(5): 419429. DOI: 10.1177/0020764007078345

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et al., 1992; Michel et al., 1994; Mller et al., 1982; Pappas et al., 1996; Stiles et al., 1993; van Heeringen, 2000 (Chapter 32); jehagen et al., 1991). Various kinds of psychosocial problems among suicide attempters have been investigated; for example, by the Repetition Prediction Project in the WHO/EURO Multicentre Study on Parasuicide (Stiles et al., 1993). However, the literature is sparse about the specic needs of suicidal patients for help with their psychosocial problems. In two studies of self-reported needs among suicidal and non-suicidal psychiatric patients, suicidal patients reported signicantly more needs, and they above all reported needs for psychiatric treatment, counselling, medication and information (Hintikka et al., 1998; Pirkis et al., 2001). Consumer satisfaction has become an important measure in evaluating mental health programmes and in allocating resources in treatment planning (Crane-Ross et al., 2000; Pandiani et al., 2001; Parslow & Jorm, 2001; Stansfeld et al., 1998). Studies investigating how much help psychiatric patients get from services and from family and/or friends, and how adequate the patient perceives the help to be, have been conducted in patients with severe mental illness, i.e. patients with schizophrenia or other psychoses (Bengtsson-Tops & Hansson, 1999; Hansson et al., 1995). However, to our knowledge, these topics have not been previously addressed in suicide attempters. In a previous study of the present sample the number of needs (in 22 areas) was investigated 1 and 12 months after a suicide attempt using the Camberwell Assessment of Need measure (CAN) (Cedereke & jehagen, 2002). We found needs for professional help in several areas of everyday living. The mean number of needs decreased signicantly during follow-up. Concerning the different need areas, some areas decreased while others remained constant, i.e. basic and social needs. That study was a secondary analysis of a randomized controlled study on whether two telephone interventions had any effect on treatment attendance and thereby suicidal behaviour and psychosocial functioning the year after a suicide attempt. The results are presented in a previous article (Cedereke et al., 2002). Changes in the number of needs in relation to changes in global functioning, psychological symptoms and suicide ideation were analysed in a multiple regression analysis (Cedereke & jehagen, 2002). Changes in needs did not differ between the randomized groups (Cedereke & jehagen, 2002). The number of needs in relation to social characteristics and diagnosis at the suicide attempt was analysed in Cedereke & jehagen (2002). Individuals who were unemployed had more needs (p < 0.001) than individuals in the other employment groups, and patients with mood disorders had more needs and unmet needs (p < 0.05 respectively) than patients with an adjustment disorder. In a further study of the material, the predictors for the repetition of a suicide attempt during follow-up were analysed (Cedereke & jehagen, 2005). We found that the mean number of needs at 1 month was not related to repetition during the next 11 months. Between 1 and 12 months there was a greater reduction of needs in non-repeaters than in repeaters (p < 0.05). In the present study we will further investigate the needs in this sample. We used Kreitman & Philips denition of parasuicide to dene a suicide attempt: Parasuicide is a non-fatal act in which the individual deliberately causes self-injury or ingests a substance in excess of any prescribed or generally recognised therapeutic dosage (Kreitman & Philip, 1979).

Aims
The aims of this study are threefold: to investigate the help that patients received from services as well as from family and/or friends with problems in everyday living at 1 and 12 months after a suicide attempt. Furthermore, to examine whether the patients found the help from services adequate. And nally, whether the amount of help received differed, and estimation of its adequacy differed, between patients who repeated suicide attempt(s) during follow-up and those who did not.

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SUBJECTS AND METHODS Design of the study


Patients who had been treated after a suicide attempt at the Medical Emergency Inpatient Unit (MEIU) at the University Hospital in Lund were followed up after 1 and 12 months by a psychiatric nurse or a social worker using a semi-structured interview. At these interviews a comprehensive needs assessment tool was used the Camberwell Assessments of Need (CAN) (Cedereke & jehagen, 2002). At 1 month the patients were asked to take part in a randomised study (Figure 1). The Research Ethics Committee of the Lund University gave approval for the study.

Subjects
From February 1995 to April 1997 all patients (n = 281) were assessed at the MEIU by a psychiatrist and a social worker in a standardized way (jehagen et al., 1992). All patients were informed that a psychiatric nurse or a social worker would contact them after1 month to assess their need for professional help and to ensure that professional help was given, when needed. Patient ow is presented in Figure 1. After 1 month 246 out of 281 consecutive patients could be reached and 216 consented to take part in the randomized study. Besides ordinary treatment, two telephone contacts would be made randomly with half of the patients (at 4 and 8 months) to assess their need for professional help and to ensure that professional help was given, when needed. All patients would be followed up after 12 months. Those who consented to participate took part in an extended interview, including various assessments, and were then assigned randomly to either telephone contact or no telephone contact. Of the 30 patients (12%) who did not take part in the study, 27 did not want to participate and 3 were too ill or had language problems. Those patients who did not want to participate were more likely to be ordinarily employed (63% vs 42%, p < 0.05), and had been referred less frequently for further inpatient treatment from MEIU (37% vs 62%, p < 0.05). At 12 months 178 out of 216 patients (82%) were followed up. One hundred and forty patients rated CAN at both the 1-month and 12-month interview, and they comprise the sample for the present study. The patients who did not take part in the 12-month follow-up (n = 38) or who did not complete both CAN ratings (n = 38) did not differ from the present sample (n = 140) in any characteristics on admission to MEIU, except that they more often had an adjustment disorder (p < 0.05). The present sample did not differ in any other ratings at the 1-month interview. The characteristics of the sample on the MEIU and CAN ratings at 1 month are presented in Table 1. Between 1 and 12 months, 23 patients made one or more suicide attempts, labelled repeaters. Those who did not repeat a suicide attempt during follow-up (n = 117) are labelled non-repeaters.

Assessments Assessments at 1 and 12 months


The Camberwell Assessment of Need (CAN) is a tool for comprehensive assessment of clinical and social needs and was originally developed to assess the need for help in patients with serious psychiatric illnesses (Phelan et al., 1993). It has been used mainly in the assessment of patients with schizophrenia or other psychoses. The CAN is meant to be an integrated tool in routine clinical practice, as well as an instrument for service evaluation (Slade et al., 1998; Wiersma et al., 1998), and it has been tested with regard to reliability and validity with satisfactory results (Phelan et al., 1995).

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Figure 1. Patient ow and design

The CAN assesses whether a need exists and, if so, the severity of the need during the last month, within 22 identied areas of everyday living: accommodation, food, self-care, looking after the home, daytime activities, physical health, psychotic symptoms, information about condition and treatment, psychological distress, safety to self (self-harm), safety to others, alcohol (use), drugs (abuse), company, intimate relationships, sexual expression, child care, access to a telephone, education, transport, money and welfare benets (Table 2). The presence of a need is rated on a three-point scale: 0 = no problem, i.e. no need; 1 = no/moderate problem thanks to continuous help, i.e. met need; 2 = current serious problem despite any ongoing help, i.e. unmet need. In this article the total number of needs (need rating 1 or 2 = need) is used. If there is a need, further questions are asked to assess the current level of support from friends

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Table 1 Characteristics of 140 patients at the MEIU investigation after a suicide attempt and CAN assessment at the 1- and 12-month interviews in patients who repeated suicide attempt during 112 months after index attempt and in patient who did not repeat All patients n = 140 MEIU investigation Age, (M SD) Male/female Married/cohabiting Working/studying Diagnosis DSM III-R axis I - mood disorder - adjustment disorder - other diagnoses Previous suicide attempt(s) Psychiatric treatment at MEIU 1-month interview Camberwell Assessment of Need (CAN), (M SD) 12-month interview Camberwell Assessment of Need (CAN), (M SD) Repetition of s.a. 112 months n = 23 38 13 7/16 36% 26% 61% 13% 26% 74%* 78%* 6.0 3.0 5.2 2.6*** No repetition of s.a. 112 months n = 117 45 19 40/77 44% 37% 42% 24% 34% 50%* 49%* 4.9 2.3 3.0 2.5***

44 18 47/93 42% 35% 45% 22% 33% 54% 53% 5.1 2.4 3.4 2.7

Repeaters vs non-repeaters; chi-square test, MannWhitney U-test: * p < 0.05, *** p < 0.001

or family (i.e. informal help) and services (i.e. formal help). The current level of help, i.e. both informal and formal, is rated on a 4-point scale: from 0 = no help to 3 = high help. In this article the level of help is categorized to 0 = no help or 13 = help is received. Furthermore, a two-point scale (0 = no and 1 = yes) is used to assess whether the patient considers help from services to be of the right type (i.e. adequate). For each question, a rating of 9 is used for not known. We have used the Standard versions of the CAN in Swedish, in which needs are rated by the patient (Ericson et al. 1997). The nurse and the social worker co-rated the initial 25 patients to ensure similar estimation on all assessments, but no inter-rater tests were carried out.

Assessments at MEIU
At the MEIU assessment, a psychiatric diagnosis according to DSM III-R, axis I (American Psychiatric Association, 1987), was set. In the analyses, the diagnoses were grouped into three categories: mood disorders, adjustment disorder or other diagnoses (anxiety disorder, alcohol abuse, psychosis, eating disorder). A standardized semi-structured interview was used, covering previous suicidal behaviour, previous and ongoing psychiatric treatment and treatment contacts other than psychiatric ones (jehagen et al., 1992). The rst suicide attempt assessed at the MEIU during the study period is referred to as the index suicide attempt.

Statistics
The software used for statistical analyses was SPSS 10.0 for Windows (Norusis, 1999). The chisquare test was used to analyse differences in proportions. Differences between groups were analysed by the MannWhitney U-test. The Wilcoxon matched-pairs test was used to investigate differences in repeated measures. Age differences between groups were tested with Students t-test.

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RESULTS Formal and informal help one month after the suicide attempt
One month after their suicide attempt, the patients estimated their need for help in 22 areas (see Table 2). As presented in a previous article, the six most frequently rated areas of need were, in order: safety to self, psychological distress, physical health, intimate relationships, daytime activities and company (Cedereke & jehagen, 2002). Looking at the three most frequent areas of need (safety to self, psychological distress and physical health), a high rate of formal help was received. In the rst two areas informal help was also high, whereas it was lower for the area of physical health. Thirty-seven per cent of the patients had needs in intimate relationships and 36% had needs in daytime activities. In these areas 33% and 24% of the patients respectively had neither formal nor informal help. Lack of any help was also high in the areas of company, information and sexual expression. The area with the lowest rate of received help concerned sexual expression, where 67% of the patients received neither formal nor informal help. In some more areas, besides physical health, formal help was more common than informal help; especially information and psychotic symptoms, while the opposite was evident concerning company.

Repeaters versus non-repeaters


At one month both repeaters and non-repeaters rated the same main six need areas and with the same frequency. The frequency of individuals who received formal and informal help at one month did not differ between repeaters and non-repeaters.

Formal and informal help 12 months after the suicide attempt


At the 12-month follow-up, the six most often reported need areas are the same as those reported at the one-month assessment (see Table 2). These followed the same order, except for safety to self, which came in sixth place at the 12-month follow-up. Safety to self and psychological distress were still those areas where the patients reported the highest rate of both formal and informal help received at 12 months. Furthermore, the patients still reported a high rate of formal help in physical health, whereas the rate of informal help was lower. Intimate relationships, daytime activities, company and sexual expression were still need areas in which the patients got least formal and informal help. The proportion of formal help did not change signicantly in any area, while the proportion of informal help decreased from one to 12 months in psychological distress (p < 0.05) and in company (p < 0.01).

Repeaters versus non-repeaters


At the 12-month follow-up, repeaters had signicantly more needs than non-repeaters in nine areas. The six most common areas were: safety to self (65% vs 18%), psychological distress (87% vs 62%), intimate relationships (56% vs 27%), daytime activities (52% vs 25%), company (56% vs 23%) and money (22% vs 6%). The majority of both repeaters and non-repeaters had formal help in the most frequently mentioned need areas at 12 months. Repeaters received formal help in psychological distress more frequently than non-repeaters (p < 0.05). In the areas of intimate relationships and company the frequency

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Table 2 Number of patients stating need in the 14 most common need areas at 1 and 12 months after a suicide attempt, and the frequency of those receiving formal and informal help and those receiving neither formal nor informal help. Furthermore, the frequency of patients valuing received formal help as adequate at 1 and 12 months after a suicide attempt n = 140. 1 month Formal help adequate Informal help No formal or informal help Any need Formal help 12 months Formal help Informal adequate help No formal or informal help

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Need area

Any need

Formal help

Safety self Psychological distress Physical health Intimate relationships Daytime activities Company Information Food Looking after the home Alcohol Sexual expression Transport Money Psychotic symptoms

n 134 133 67 52 50 47 28 27 25 24 22 22 20 15

% 92 93 92 33 49 31 68 56 48 79 24 71 61 93

% 85 80 90 86 59 85 33 100 92 88 75 100 100 75

% 81 81* 34 38 32 65** 21 62 56 56 29 65 56 54

% 0.7 0.8 6 46 33 25 32 8 4 13 67 5 6 0

n 36 92 60 45 41 40 10 29 28 11 22 21 12 9

% 86 83 93 24 61 38 90 61 64 64 32 75 54 89

% 79 83 98 54 72 93 44 94 94 100 57 100 71 50

% 63 66* 33 33 22 37** 20 46 36 50 17 65 54 22

% 9 7 5 50 29 37 10 15 15 20 54 0 8 11

Comparison of formal help at 1 and 12 months; Wilcoxon rank test *p < 0.05, **p < 0.01

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of formal help tended to be higher among repeaters, 46% and 58% respectively, than among nonrepeaters, 16% and 30% respectively. About two-thirds of both repeaters and non-repeaters had informal help in two of the six most often rated areas safety to self and psychological distress while less than half of both repeaters and non-repeaters had informal help in physical health, intimate relationships, daytime activities and company. With regard to intimate relationships, repeaters tended to have informal help less often (p = 0.074), and, as mentioned earlier, repeaters more often tended to have formal help (p = 0.076). Among repeaters, informal help was as low as 8% in intimate relationships and daytime activities. There were no changes reported in formal help between 1 and 12 months in repeaters and nonrepeaters. Informal help had decreased in the areas company and psychological distress among nonrepeaters (p < 0.05 respectively), while repeaters did not report any changes in informal help.

Adequacy of formal help at one and 12 months


The patients estimated whether the formal help given was adequate, i.e., if they considered that the right type of help was given from the services. At both 1 and 12 months satisfaction with formal help was high in most areas (see Table 2). However, at one month few patients found help in daytime activities and information to be adequate. At 12 months about half of the patients did not consider formal help as adequate in the areas of intimate relationships, information, sexual expression and psychotic symptoms. The frequency of help rated as adequate did not change in any area between one and 12 months.

Repeaters versus non-repeaters


Both repeaters and non-repeaters generally rated adequacy of formal help to be high at both one and 12 months, with two exceptions: at one month 33% of both repeaters and non-repeaters considered formal help in information as adequate, and at 12 months 50% of repeaters and 60% of non-repeaters considered formal help in intimate relationships to be adequate.

DISCUSSION
The main nding was that for the sample as a whole, formal help given was high in health-related need areas, such as safety to self, psychological distress and physical health, but lower in areas related to social needs, especially in intimate relationships, daytime activities and company. This was found at both one and 12 months. A community survey that included the consumers perspective of need for mental health care and their perceptions of received interventions had similar ndings with regard to social needs (Meadows et al., 2000). Those who consulted GP services due to mental health problems perceived substantially unmet needs concerning interventions in social and occupational domains (Meadows et al., 2001). The authors suggested closer cooperation between psychiatric services and other care providers to improve interventions in these domains (Meadows et al., 2000; Meadows et al., 2001). The occurrence of informal help was initially as high as that of formal help, with some exceptions, e.g. in physical health. Informal help could be a complement to formal help, and is surely of importance for the patient, but suicide attempters have been found to have weak social networks

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(Magne-Ingvar et al., 1992). Furthermore, in one study of signicant others interviewed one year after a patients suicide attempt, many had mental health problems of their own and also worries for the patient, which burdened them and was stressful for them (Magne-Ingvar & jehagen, 1999). Ratings of informal help might be of value to observe in treatment planning, taking consideration of signicant others own views. The number of needs decreased during follow-up in the total sample, but repeaters had signicantly more needs than non-repeaters in ve of the six most common need areas at 12 months: safety to self, psychological distress, intimate relationships, daytime activities and company. At follow-up all repeaters had help either in the areas of safety to self or in psychological distress, which is satisfying. However, in repeaters informal help was low in intimate relationships and daytime activities, perhaps mirroring a weak social network (Magne-Ingvar et al., 1992). Although formal help mostly was rated adequate, in areas of information and intimate relationships the adequacy of help was rated lower. Using a systematic interview form, it was possible to describe the sources of help after an index suicide attempt and during the following year. Furthermore, the patients estimated whether they found received formal help to be adequate. To our knowledge such a systematic assessment of help concerning needs in everyday living has not previously been addressed in suicide attempters. So far, only a few studies have systematically investigated the occurrence of formal and informal help concerning needs in everyday living among psychiatric patients. One study used the CAN to examine formal and informal help among psychiatric in- and outpatients, with varying diagnoses (Hansson et al., 1995). Another study of psychiatric patients found that diagnoses, i.e. psychosis vs non-psychosis, were not related to the number of needs or unmet needs (Simons & Petch, 2002). In that study patients with a diagnosis of a non-psychotic illness had more needs and unmet needs than patients with a diagnosis of a psychotic illness. Services had special difculties in meeting needs in the social and functioning domains, and the study suggests ways of involving multidisciplinary teams, including nurses and informal helpers (Simons & Petch, 2002). Hayward and colleagues (2006) found that the number of unmet needs was related to personality disorder. This analysis could not be made in the present sample, because personality disorder had not been systematically evaluated at the MEIU. The present sample had an equal or lower formal and informal help (score) at one month and at 12 months, except in the area of company. Also, in comparison with another study on outpatients with schizophrenia, the occurrence of formal and informal help in our study was lower or equal, except for company (Bengtsson-Tops & Hansson, 1999). This sample is part of a sample of 246 patients who were followed up one month after their suicide attempt. Those who did not participate in the study were more often ordinarily employed, and they were less often referred to inpatient treatment. Probably they had no more needs than the participants in the study. The patients who did not take part in the 12-month follow-up or who did not complete both CAN ratings did not differ in any characteristics at the MEIU or at the onemonth assessments, apart from the fact that they more often had an adjustment disorder (p < 0.05). The characteristics of this population do not differ from populations of suicide attempters in earlier studies from our unit (jehagen et al., 1992). However, we do not know how representative this sample is for suicide attempters in general. The availability of formal and informal help should be addressed in further populations of suicide attempters.

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CONCLUSIONS
The generally high level of formal help in health-related areas during the rst year after a suicide attempt and the high rated adequacy of help given are satisfactory. However, in certain areas lack of formal help was evident. The use of the CAN instrument could improve assessment on needs areas and whether help is available, both formal and informal.

ACKNOWLEDGEMENTS
Dr Mats Lindstrm set all diagnoses at the MEIU.

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