A suicide attempter is a patient who has survived a suicide attempt. Persons with suicidal thoughts are estimated to be approximately 25 times more likely to attempt suicide than the general population [1,2]. Both individual and social factors have been implicated in suicidal tendencies, as explained by Emile Durkheim in the late 19th century [3]. Many suicide attempters come to the emergency department due to special circumstances, such as psychiatric problems, substance abuse (e.g., alcohol), and physical injury from previous suicide attempts. Since 2013, the Suicide Trial Case Management Team has been deployed as a national emergency center of the emergency management system of the Republic of Korea. However, although most suicide attempters are treated by a physician, most of them are still discharged voluntarily after completing their paperwork, contrary to medical advice. Voluntary discharge of suicidal patients is a problem in terms of the patient’s protection, given that the percentage of patients involved in re-entry with the same diagnosis is higher than that of other patients [1]. In addition, the domestic mental health service has adopted a policy that minimizes forced hospitalization and treatment of severely mentally ill patients; this policy is based on the recommendations of the United Nations Convention on the Rights of Persons with Disabilities that emphasizes the elimination of forced hospitalization and treatment. It is therefore difficult for emergency medical physicians to prevent voluntary discharge of suicide attempters [1].

Among the Organization for Economic Co-operation and Development (OECD) countries with the highest suicide percentages from 1985-2001, Finland and Japan succeeded in decreasing their suicide percentages by conducting government suicide prevention projects and suicide comprehensive measures centered on “psychological autopsy” [1]. The government of the Republic of Korea also enacted relevant laws in 2012, established the Korean Suicide Prevention Center, and started an emergency department-based suicide attempt management project in 2013 [1]. In addition, the Korean Psychological Autopsy Center has been established for the purpose of identifying the cause of suicide death [1]. Despite these efforts, the suicide prevalence in Korea is 27.3/100,000 of the general population, which is twice the OECD suicide average of 12.0/100,000 of the general population in 2014 [1]. Domestic efforts to reduce the suicide percentage have been initiated by the Korea government; however, as these programs are at their beginning, domestic studies on the discharge of suicide attempters are rare.

The purpose of this study was therefore to investigate the characteristics and factors related to the discharge of patients and the effectiveness of state-led case management for suicide attempts by hospital emergency departments.

The voluntary discharge of patients accounts for approximately 2% of all hospital discharges, which results in a quality problem for health care [4]. In a general medical service study, the percentage of rehospitalizations in the voluntary discharge patient group within 15 days of the same diagnosis was always seven times higher than that of the normally treated group [4,5]. In the present study, we classified factors affecting voluntary and normal discharge of suicide attempt patients, including the emergency department and hospital admission [ward or intensive care unit (ICU)] as basic characteristics (demographic variables), suicide attempt-related variables, suicide attemptrelated outcome variables per type of discharge, and treatment modality variables per type of discharge. Of these, demographic variables, suicide attempt-related variables, and suicidal attempt-related outcome variables per type of discharge were variables for predicting the voluntary discharge of patients. However, the category of treatment modality variables per type of discharge was variable due to the voluntary discharge of the patient.

Regarding demographic variables, the percentage of VDG patients was significant depending on the age, level of education, marital status, and physical health. The percentage of voluntary discharges of patients ≤20 years of age was high, and the percentage of normal discharges was high in patients ≥50 years of age. It was found that the younger the age, the higher the probability of voluntary discharge. In the case of elderly patients ≥50 years of age, the patient’s or caregiver’s concerns about the patient’s physical health may have caused an increase in the percentages of admissions and normal discharges. The percentage of voluntary discharge from the married group was the lowest in the VDG, which was presumed to be influenced by the emotional intervention of the spouse.

In the case of alcoholic patients related to suicide attempts, the percentage of drinkers was twice as high as that of nondrinkers in the VDG when the unmeasured patients were excluded. This was consistent with the finding that most past retrospective studies have consistently involved decisions to use a person’s discharge note if there was a drug or alcohol problem [4]. The most frequent method of suicidal attempt was ingested poisoning, including briquette gas poisoning, and wrist cutting/puncture wound was the next most frequent. The percentage of ingested poisoning, including briquette gas poisoning, was also the highest, and wrist cutting/puncture wound was the next most frequent in the VDG. In a Korean study of adolescents aged 10-19 years, ingested poisoning was the most common method of attempting suicide, while hanging and falling were the most lethal suicide attempts, and the percentage of voluntary discharge from the emergency department was 22.8% [6]. Patients with a psychiatric history were more likely to be discharged against medical advice. This result is partially consistent with a study reporting that the discharge of a patient was most commonly predicted from patient factors, such as pessimistic attitudes toward treatment; aggressive, destructive, and anti-social behavior; multiple voluntary discharges from previous hospitalizations; a young age; male; unmarried; and an accompanying personality disorder or substance abuse diagnosis [7]. Other studies have also reported that the percentage of patients discharged voluntarily from the psychiatric group ranged from 3-51% (average, 17%), which was much higher than that of the medical group [7]. In the NDG involving ingested poisoning, medical treatment was often necessary, mainly because the ingested poison involved sleeping pills or psychiatric drugs, leading to a decreased consciousness that made the patient unable to be discharged early.

Awareness condition was not significantly associated with the voluntary discharge of the patient, in contrast to lower medical severity, which resulted in a significantly higher percentage of voluntary discharges. The unmeasured group with future plans for a suicide attempt had the highest percentage of patients in the VDG. In these patients, the non-responders were judged to be untreated patients, and because of the highest percentage of voluntary discharge of untreated patients, it was thought that a 24-h care system was needed to separately manage suicide attempters in the hospital. Suicide attempters were mostly impulsive. Excluding non-responders, impulsive patients were more likely to be voluntarily discharged.

The variables related to treatment, including psychiatric referral, consent, and intervention of a case management service; link with community service; post-discharge psychiatric treatment; and the location of the discharge (emergency department, general ward, or the ICU) were significantly associated with the type of discharge of the suicide attempter. Of the total of 311 voluntary discharge patients, 242 (77.8%) were discharged from the emergency department. The percentage of patients who refused psychiatric consultation in the VDG was more than twice that in the group who refused psychiatric consultation in the NDG. This was consistent with previous results from Holden et al. [8] that indicated the need for early psychiatric intervention as there was a tendency for medical patients to be less voluntarily discharged. The percentage of patients who agreed to psychiatric consultation in the VDG was similar to that of the NDG. In contrast, the percentage of the group who agreed to case management services in the NDG was more than twice as high as that in the VDG. The percentage of patients who agreed to psychiatric outpatient visits in the NDG was four times higher than that of patients in the VDG. These results indicated that the consent of psychiatric consultation alone did not have a significant effect on the patient’s discharge pattern, but it was found that when the case management service was linked, it increased the percentage of connections among normal discharge, community links, and psychiatric outpatient visits. These results indicated that most of the normally discharged patients were discharged from entering the hospital ward, and that the case manager could easily intervene in a stable state, so that the percentage of agreement was high. However, in cases of voluntary discharge, the agreement percentage of the post-management service was lower than that of the NDG. In particular, when a patient was discharged voluntarily from the emergency department, there were many cases in which the case management team member was not able to intervene during the off-duty hours, ranging from 5:00 pm to 8:00 am. Based on these findings, it is important for the national government to establish and fund a system to manage suicide attempters for 24 h.

The percentages of the unmeasured or non-responder group involving variables such as the level of education, physical status, drinking status, psychiatric disease history, hospitalization history due to suicide attempts, plans for future suicide attempts, case management services, link with community services, and psychotherapy after discharge in the VDG were higher than those in the NDG. In VDG patients, there was a tendency not to accurately convey the condition of the patient or the coping process of the suicide attempter in the hospital care system could not be properly determined.

Whether the hospital had a psychiatric closed ward was also considered as a contributing factor for voluntary discharge of suicide attempters. In most of the admitted suicide attempters, in the course of the retrospective chart review of this study, after medical or surgical treatment was terminated, the patient was referred to a psychiatric department for treatment. In the course of this process, it was frequently found that patients and their caregivers were not compliant with the procedures and were discharged voluntarily from the hospital when they were told that they needed to be transferred to other hospitals with closed wards.

Interviews with the case management team staff at this research institute indicated that this team needed active participation by the medical staff. This meant that when the case management team was later contacted, the patient and caregiver showed a favorable attitude that led to post-management and community links with positive results.

Based on the results of the multivariate logistic regression analyses, the OR of the no response group relative to the college graduation or higher group, the physical status of the no response group relative to the healthy group, the psychiatric disease history group relative to the no psychiatric disease history group, and the low medical severity group relative to the high medical group were proportional to the percentages of voluntary discharges. It is anticipated that knowing the characteristics of the variables mentioned above and studying past investigations will help to reduce the voluntary discharge of patients from the hospital. Some studies have suggested that early detection, discussions, and counseling for communication are the preferred methods for reducing the percentage of discharges among patients with a history of drug or alcohol abuse [4]. Targum et al. [9] reported that there was an approximate 30% decrease in all voluntary discharges of psychiatric inpatients from private hospitals after appointing a nurse as a patient spokesperson, whose responsibility was to resolve the patient’s concerns about hospitalization, point out the fears, and alert the hospital staff about these concerns and fears. Alfandre suggested that to prevent voluntary discharges, the patient should be interviewed to recognize mental factors including substance addiction [4]. Another study reported that physicians who started their care with a suspicious attitude tended to meet with patients in uncomfortable conditions and were likely to terminate treatment under poor conditions. All patients should therefore be granted empathy regardless of the diagnosis, but should also be entitled to a more accurate and effective patient assessment [10,11]. Studies have shown that when a medical officer is angered when dealing with a difficult type of patient with persistent physical complaints, increased anger and insomnia may be associated with dependence or loss of disinhibition that prevents communication, which in turn distracts the patient and, in the worst cases, dismisses the caregiver, leading to voluntary discharge without adequate treatment of the patient [4]. However, some studies have shown that if the medical staff has a good understanding of the anger-like feelings that naturally occur while they are in contact with these demanding patients, they can better refocus their discussions with the patient, and a psychiatric interview can be helpful [4]. Another study reported that patients who decide to voluntarily discharge for personal reasons may prioritize financial interests rather than concern for their health and should be respected if it is an informed decision [4]. Levy et al. [12] suggested that if the medical staff was unable to prevent voluntary discharge of their patients, they should perform three necessary steps that will absolve the medical staff from legal responsibilities. First, the medical staff should confirm that the patient is in a condition, with a normal mental status, to refuse treatment. Second, the medical staff should explain all potential risks to the patient and patient guardian or caregiver. Finally, the medical staff should take steps to retain the patient’s discharge with the medical advice consent in a suitable chart.

This study was conducted based on a retrospective medical record survey at a single hospital, and it occurred during a specific period of time, so there was a possibility that there was selection bias and incomplete data discrimination. For example, patients recorded as “ordinary type” may have involved local enrollment or company enrollment, but it was impossible to distinguish between them. To overcome these limitations, future prospective multidisciplinary studies will be necessary.

Because suicide is caused by multiple causes, various forms of follow-up care are needed after discharge, and resources such as case management and community centers should be available.

In conclusions, three hundred eleven patients (61.7%) of the total 504 suicide attempters were discharged from the hospital. The non-response group relative to the college graduation or higher group, the physical status of the non-response group relative to the healthy group, the psychiatric disease history group relative to the no psychiatric disease history group, and the low medical severity group relative to the high medical severity group were all proportional. The VDG had a very low percentage of post-discharge intervention in the ongoing treatment methods of psychiatric outpatients, case management, and community links. Although case management services prevented and reduced the discharge of suicide attempters and increased the link between community and outpatient mental health services after discharge, it was not known whether at least 80% of the total suicide attempters were still linked to community services. Based on these results, further aspects of national supportive measures, including strengthening case management services, should be considered to reduce voluntary discharge of suicide attempters.