Attendance at psychological consultations following

Attendance at psychological consultations following non-fatal suicidal behaviour: An ethical dilemma Anthony L. Pillay*, Douglas R. Wassenaar and Anne L. Kramers

Department of Behavioural Medicine and School of Psychology, University of KwaZulu-Natal and Midlands Hospital, P. O. Box 370, Pietermaritzburg, 3200, South Africa e-mail: [email protected] Rates of out-patient psychotherapy follow-up after hospitalisation for non-fatal suicidal behaviour (NFSB) are reported to be poor internationally. A study at a South African general hospital revealed that over a 12-month period 201 patients were admitted and referred for psychological consultation following NFSB. All first appointments were kept. However, only 43.5% of the 191 patients given subsequent out-patient appointments attended. No significant gender or age effects were noted. The results are discussed in the context of possible explanations for the high rate of non-attendance and the clinical value of the first in-patient psychological session. The authors also discuss some of the circumstances surrounding the first consultation and the ethical issues associated with the in-patient management of NFSB. We argue that the benefits of a first in-patient psychological consultation without explicit informed consent appear to outweigh the risks and harms, based on the ethical obligation of responsible caring.

* To whom correspondence should be addressed.

The psychological management of non-fatal suicidal behaviour (NFSB) poses a significant international challenge in the form of non-adherence to follow-up psychotherapy sessions. This is as much a problem in South Africa as it is elsewhere in the world. Patterns of suicide in South Africa appear to resemble those in most other countries that have published epidemiological suicide data (Wassenaar, Pillay, Descoins, Goltman & Naidoo, 2000). Local data suggest that the rate of fatal suicide for males is about 12 per 100 000 and for females, 2 per 100 000, with relatively minor differences between racial or cultural groups. The gender ratio of about 4.5 males to one © Psychological Society of South Africa. All rights reserved. ISSN 0081-2463

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South African Journal of Psychology, 34(3), 2004, pp. 350–363.

Anthony L. Pillay, Douglas R. Wassenaar and Anne L. Kramers

female also resembles international averages (Canetto & Lester, 1995). While exact national rates of NFSB globally are notoriously difficult to estimate, the similarity between South African trends in fatal suicidal behaviour and international averages suggests that rates of NFSB in South Africa for all race or cultural groups will be similar to international trends, and will accordingly be significantly higher than those for fatal suicide. Gender ratios are usually reversed with about 2.5 female cases of NFSB for every male case – confirmed by at least two South African hospital-based studies (Deonarain & Pillay, 2000; Pillay, Wassenaar & Kramers, 2000). Given the documented presence of NFSB in South African clinical settings, poor compliance with psychotherapy attendance remains one of the greatest obstacles in treating suicidal behaviour (Heard, 2000). This is particularly worrying considering the increased risk of suicidal behaviour following NFSB (Bongar, 1991; Williams, 1997) and the evidence regarding the benefits of psychological intervention post-NFSB. A South African study found that individuals receiving psychological intervention after NFSB show significant improvements on measures of hopelessness and psychiatric disturbance, which are key markers of suicide risk (Pillay & Wassenaar, 1995). The successful treatment of depressive or other psychiatric symptomatology also reduces the risk of subsequent suicidal behaviour (Gelder, Gath, & Mayou, 1994; Suominen, Isometsa, Heila, Lonnqvist & Henriksson, 2002). More specifically, clinical trials have demonstrated the effectiveness of brief problem-solving therapy in decreasing suicidal ideation, depression and hopelessness, especially in high-risk patients (Boyce, Carter, Penrose-Wall, Wilhelm & Goldney, 2003; Lerner & Clum, 1990; Rudd et al., 1996). Most studies report that following NFSB, patients usually have an emergency room mental health evaluation and are then referred for out-patient psychotherapy, where the non-attendance rates are high – up to 70% fail to attend follow-up psychotherapy sessions (Boyce et al., 2003). An early study of adolescent NFSB patients found that 44% defaulted on out-patient psychotherapy (Taylor & Stansfield, 1984). Later research by Piacentini et al. (1995) revealed that 42% of patients did not attend psychotherapy sessions after the first appointment. A South African study (Deonarain & Pillay, 2000) reported that 70% of NFSB patients defaulted on follow-up treatment, similar to default rates after the first session of up to 77% reported by Trautman, Stewart and Morishima (1993) in the United States of America (USA). Deonarain and Pillay (2000) found no association between age and non-attendance, although females missed more sessions than males. More recent cross-cultural research found a higher non-adherence rate among Italian women (70%) than Italian men (44%), whereas Swedish men had a slightly higher non-adherence rate (46%) than Swedish women (33%) (Runeson, Scocco, DeLeo, Meneghel & Wasserman, 2000).

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Attendance at psychological consultations following non-fatal suicidal behaviour

BACKGROUND TO THE PRESENT STUDY

The present study was undertaken at a large urban general hospital, where the authors established a clinical psychology service and have consulted since the early 1980s. This facility also serves a training function, with intern clinical psychologists rendering services as part of their clinical rotations. After recognising the benefits of the psychological service to their patients over the years, physicians and other medical staff appear to have developed an unwritten policy of requesting a psychological consultation for every NFSB patient as soon as he or she has been physically and medically stabilised (Wassenaar, 1987). This usually occurs within 48 to 72 hours after admission for the NFSB. Since the immediate goal of in-patient management is the reduction of acute suicidal ideation and intent (Boyce et al., 2003; Maris, Berman, & Silverman, 2000; Williams, 1997), it is understandable that the medical staff, in consultation with the clinical psychologists, preferred the psychological consultations to take place before the patient was discharged from hospital. This approach was also motivated by concerns about maximising immediate therapeutic benefits and patient attendance at such services. It is standard clinical and risk-management practice in several countries to conduct the first mental health consultation while the individual is an in-patient (Bongar, 1992; Boyce et al., 2003; Hawton, 2000; Piacentini, et al., 1995; Runeson, et al., 2000; Wassenaar, 1987). However, the process of referring the NFSB patients to our general hospital psychological clinic has been somewhat different, as described below. Compliant attendance for the first in-patient appointment may well be a developing country phenomenon where patients may be less aware of their right to refuse or question the necessity of specific treatments or procedures recommended or prescribed by the medical and nursing staff. Patients are usually first treated in the emergency room and then admitted to a medical ward for the management of any physical problems caused by their suicidal behaviour (which most often involves an overdose of medication or the ingestion of poisons) (Pillay, 1988). Once stabilised, they are informed that they are being referred for a routine clinical psychology consultation and that they would be discharged thereafter. Patients are not directly or explicitly prescribed a mental health consultation, nor are they necessarily explicitly informed of their right to refuse such referral. Such referrals could be seen as favouring the ethical stance of beneficence over the valuing of the patient’s right to autonomy – an action that arguably could be ethically justifiable in specific clinical circumstances (Beauchamp & Childress, 2001). Traditionally, the valuing and operationalisation of autonomy in clinical service delivery would be expressed as a concern with informed consent and maximising the patient’s rights and ability to make autonomous decisions (Professional Board for Psychology, 2002). Decisions based on the clinician’s beneficence may, however, override concerns with autonomy and are usually justified by clinical emergencies in which the patient’s own judgement is questionable, and where next-of-kin are not 352


immediately available. Whether the present situation (i.e. the post-NFSB management of medically stable patients) ethically justifies this beneficent overriding of autonomy remains ethically ambiguous (Mishna, Antle & Regehr, 2002). Avoiding this apparent dichotomy between patient autonomy and medical beneficence, the Canadian Code of Ethics for psychologists contains the principle of ‘responsible caring’ CPA, 2000). Unlike the South African (Professional Board for Psychology, 2002) and the well-known American Psychological Association (APA) (APA, 2003) codes, the Canadian code seems more sensitive to clinical realities, which results in the clinician’s judgement not being over-determined by autonomous decisionmaking by the patient. The application of the Canadian code in the context of suicide risk would nonetheless also have to satisfy the ethical principle of ‘respect for the dignity of persons’ (CPA, 2000). In our view, a course of action in the context of elevated suicide risk following NFSB, favouring routine referral, satisfies both the principles of responsible caring and respect for the dignity of persons. Respecting dignity through appropriate referral to relevant services in our view is ethically and clinically acceptable. This action would appear to be compatible within the framework of the Canadian ethical code, illustrating that responsible caring and respect for the dignity of persons are more clinically applicable ethical principles than the more polarised concepts of respect for autonomy and beneficence advocated by most other ethical codes (APA, 2003; Professional Board for Psychology, 2002). The question of obligatory pre-discharge psychological referrals for NFSB admissions nevertheless invites a controlled comparison study of the in-patient referral-acceptance rates (and clinical outcomes) of fully informed and consenting referrals versus beneficent physician-initiated referrals. In practice, however, the patient is not forced to accept the consultation. Patients have occasionally refused such referrals. The clinical outcomes of these cases remain unknown. However, it appears that virtually all NFSB patients interpret the referral to the clinical psychologist as a necessary prerequisite to being discharged from hospital. This belief is often evident during psychological consultations when patients sometimes request clarity on whether they will be discharged immediately after the session, or indicate that their (medical) ward doctor promised that they would be discharged ‘after seeing the psychologist’. The NFSB patients’ sense of urgency to leave the hospital can be understood in the context of their need to dissociate themselves from the suicidal event and the associated stigma (Hazell, 2000). It could also be seen as resulting from the patient’s need for psychological equilibrium by returning home, rather than seeking equilibrium through psychological therapy in hospital. This is somewhat ironic, given the high ranking of domestic and interpersonal problems found to be precursors of NFSB in South African studies (Deonarain & Pillay, 2000; Pillay, van der Veen & Wassenaar, 2001; Pillay, Wassenaar & Kramers, 2001; Wassenaar, van der Veen & Pillay, 1998).

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It does appear then that NFSB patients erroneously interpret the medical ward policy to mean that the way to secure a discharge is to attend a psychological consultation. While this is obviously not true, and while it cannot be policy, attendance at the first in-patient psychological consultation has always been close to 100%. The critical value of this initial session has been well documented, especially for the purpose of crisis intervention, and evaluating levels of perturbation, lethality, and further suicidal risk (Bongar, 1991; Maris, Berman & Silverman, 2000; Pillay & Wassenaar, 1995; Shneidman 1981; Vajda & Steinbeck, 2000). Nevertheless, it can be argued that this approach, as tacit and indirect as it is, runs contrary to the Patients’ Rights Charter (Department of Health, 1999). The authors have regularly debated the ethical issue inherent in this approach, and often pondered the obvious question: Should the approach be changed and medical staff advised to give NFSB patients the direct and explicit option of accepting or refusing a psychological consultation, making it clear that their discharge from hospital is not entirely dependent on it? What proportion will choose to have a psychological consultation, and what will the longer-term effects be? In the context of suicidal persons in prisons, Bell (1999) argues for beneficence overriding autonomy in the management of suicidality, with appropriate cautions against clinicians becoming too comfortable with this exercise of power. Against this background, the present study was undertaken to examine the baseline rate of psychotherapy non-adherence following hospital admission for NFSB in a public service general hospital sample.

METHOD

This study was unfunded and was thus constrained by limited financial and human resources. As a result, the number of variables examined was limited to age, gender and adherence to the first three sessions. Although not specifically assessed, all patients were of low socio-economic status, in keeping with the admissions policy of the hospital and the location of the hospital in an area formerly designated for population groups oppressed under the former apartheid policies. The following procedure was adopted: over the 12-month period of study all clinical psychology staff at the hospital’s Suicidology Clinic were requested to enter a serial number for, and the age and gender of, each new NFSB patient onto a register established for the purpose of this study. Alongside these data were three columns, headed ‘first session’, ‘second session’ and ‘third session’. Psychologists servicing the clinic were asked to tick the respective column should the NFSB patient attend the relevant follow-up sessions. No other identifying information was recorded for this study. Only this short register was used for the study and the patient’s clinical records were not accessed for data collection or analysis. This study, in effect, is a simple observational study of clinic attendance patterns. For this reason, and because no research-related demands were made on these patients, informed consent for this study was not obtained from the patients as no significant 354


personal information was recorded or analysed. No identifiable risks or harms could be identified by proceeding in this way. Furthermore, the informed consent form itself could have provided the only link identifying a patient to the study and by itself therefore constituted a possible risk. These two factors were considered in a recent US National Research Council report (NRC, 2003) as grounds for waiving written informed consent. However, in retrospect, verbal informed consent should nevertheless have been obtained from each participant. The timing would have had to be carefully chosen so as not to interfere with the primary context of clinical service delivery in the presence of active suicidal cognitions, mood or behaviours. Patients could possibly have been given the option of not having their age, gender and attendance patterns entered on the research register. Disclosure of the recording of attendance patterns might, however, have influenced actual attendance in unpredictable ways and may thus have constituted an adverse influence on patients’ attendance. If this reduced actual attendance, this informed consent process may have done more harm than good in the context of minimal or low-risk research (cf. Gillon, 2001). The ethical issues attached to this study illustrate the tensions between the confidentiality of clinical information and studies of service utilisation patterns described by some authors (Hurwitz, 2001; Kass, Natowicz, Hull et al., 2003). It must be emphasised that patient records were only accessed by clinicians directly responsible for their clinical care during service delivery. In future studies of this nature it is clear that some form of ‘adequately informed consent’ (Gillon, 2001, p. 258) would need to be obtained, with protocols being approved by independent ethics committees (Fairchild & Bayer, 2004). An analysis of the data was conducted using descriptive statistics and Chi-square tests of significance. Calculations were done specifically on the numbers of patients attending the first and subsequent psychological consultations. In addition, genderand age-distribution analyses were performed.

RESULTS

A total of 201 NFSB in-patients were referred for psychological consultation over a 12-month period. Every patient referred to the Suicidology Clinic attended the first in-patient appointment. Of these, 10 were not given subsequent appointments, due to follow-up elsewhere or referral for psychiatric hospitalisation. The 191 patients given appointments for a second (out-patient) session comprised 145 females (75.9%) and 46 males (24.1%), with an age range from 10 to 62 years (mean age = 25.5 years). This gender ratio corresponds with the general 3 to 1 ratio for NFSB internationally (Canetto & Lester, 1995). Of the 191 patients given second appointments, 83 (43.5%) complied. In total, 108 patients (56.5%) failed to attend follow-up psychotherapy. Of the females, 66 (45.5%) and of the males, 17 (37%) attended follow-up psychotherapy sessions. Thus, 54.5% of the female clients did not follow up, while 63% of the male clients did not. 355


Although proportionately more females than males attended the second session, this gender difference was not statistically significant (Chi-square = 1.05, n.s.). Analysis by age revealed that 38 (45.8%) of the children and adolescents (i.e. under 21 years) and 45 (41.7%) of the adults (i.e. over 21 years) kept their second appointments. This difference was also not statistically significant (Chi-square = 0.32, n.s.). Only 15 (18.1%) of those attending the second session kept their third appointments.

DISCUSSION

The finding that all of the patients referred for psychological consultation attended their first in-patient psychotherapy sessions is encouraging. The clinical and patient management implications of this finding will be discussed first, followed by a return to the ethical issues raised earlier in this article. There may be at least three possible reasons for the high compliance rate noted above. Firstly, these patients may still have been experiencing relatively high levels of distress during their in-patient stay and consequently sought the relief offered by a psychological consultation. Since most NFSBs are triggered by conflict with significant others in the preceding days or hours (Deonarain & Pillay, 2000; Williams, 1997), it is likely that the patients in this study may have preferred to speak to someone other than their ‘significant others’ about the issues surrounding the conflict and their behavioural response. Patients need their pain and its context understood and focused on before they can begin the process of exploring and developing solutions (Maris et al., 2000). Secondly, in-patients may have been more compliant simply because psychology in-patient appointments involved a short walk from one hospital department to another (usually accompanied by nursing personnel), requiring no significant investment of time, money and effort. During the approximately two days in hospital following NFSB, patients are usually confined to bed and the psychological consultation may be the only opportunity to venture outside the austere clinical context of the medical ward. Thirdly, NFSB patients admitted to the medical wards after their emergency room procedures are advised that once medically stable they would be referred for a ‘routine’ psychological consultation prior to being discharged from hospital. As discussed above, although patients are not compelled to have the consultation, they may view it as a means of securing their release from hospital. Therefore, the high rate of adherence to the first session may be influenced by motives other than help seeking. The authors’ clinical impressions, though, are that, regardless of motive, patients generally make appropriate and engaged use of this first consultation to achieve psychological equilibrium following the distress leading to their NFSB hospital admission. The high rate of post-discharge failure to attend the second psychotherapy session (56.5%) is of concern, even though it is similar to rates reported elsewhere (Deonarain & Pillay, 2000; Piacentini et al., 1995; Runeson et al., 2000; Trautman et al., 1993). Many explanations have been put forward for the non-attendance. These include a temporary reduction in family conflict caused by the suicidal crisis, unpleasant 356


experiences in the emergency room, erroneous beliefs about psychotherapy, the desire to minimise the crisis and/or dissociate from the event, the belief that the attempt has served its purpose and had resulted in a reduction of family conflict, significant others giving in to the individual’s demands, and the stigma of being viewed as mentally ill and needing psychotherapy (Hazell, 2000; Hollinger, Offer, Barter, & Bell, 1994; Rotheram-Borus, Piacentini, Miller, Graae, Dunne & Cantwell, 1996). A further reason, not cited in the (Western) literature, is low socio-economic status, which must limit the ability of patients to attend follow-up sessions – either because of their inability to request time off from work or because of limited funds for travel and clinic fees. The present data and the absence of clear strategies and infrastructure to maximise post-discharge psychotherapy follow-up suggest that efforts should be made to maintain the initial high in-patient attendance rate and deliberately to maximise the value and impact of the first in-patient session. As much as possible should be achieved in this session and consideration should be given to extending the time available or even to scheduling two in-patient sessions where feasible, for example, when patients are still actively suicidal. The first session includes evaluation, crisis intervention, catharsis, basic problem solving, no-suicide contracts and providing contact details for crisis centres. Patients must be informed about, and encouraged to attend, follow-up psychotherapy (Boyce et al., 2003). In addition, physicians can provide some valuable preventive input during the in-patient’s stay in hospital by not minimising the (potential) physical consequences of NFSB (Williams, 1997). Patients should be informed quite candidly about the short- and long-term effects of toxic substances in the body (e.g., neurological insults and renal pathology) and the risk of impairment caused by other NFSB methods. Interestingly, the present authors have often encountered NFSB patients complaining about the unpleasant experience of gastric lavage in the emergency room following admission due to overdose of medication or ingestion of poisons. Some patients even responded to the inquiry about possible future NFSB by saying that the emergency room procedures had put them off ever coming back with a stomach full of medication or poisons. Such an experience could serve as a significant negative reinforcement against similar behaviours in the future, but obviously does not exclude the possibility that alternative self-harm methods could be employed. One of the benefits of having the first session while the patient is in hospital lies in the assessment of current suicide risk. Yufit and Bongar (1992) argued that having high-risk patients in the in-patient or emergency room setting affords greater control opportunities in the anticipation and detection of suicidal ideation or behaviour. If the patient is still considered seriously suicidal, immediate plans could include keeping the patient in hospital (with her or his consent) while psychological, social and other environmental interventions are effected. Alternatively, or in more serious cases, the patient could be transferred to the local psychiatric hospital, as a voluntary patient, should she or he agree to such a recommendation from the clinical psychologist. Yet 357


another option, if the patient is considered a serious danger to herself or himself, is to facilitate a transfer to a psychiatric hospital, as an involuntary admission. Section 34 of the new Mental Health Care Bill (Republic of South Africa, 2001), which is expected to come into effect in 2004, also makes provision for a 72–hour assessment period in a psychiatric facility, during which the need for further involuntary care can be evaluated. In the British context, Gelder et al. (1994) emphasised that ‘compulsory detention’ is indicated when the risk of suicidal behaviour is great and the patient cannot be persuaded to receive in-patient treatment. A more serious scenario exists in outlying (and rural) general hospitals, where there are currently no psychological services and no immediate access to psychiatric hospitals. Considering that these public sector facilities are utilised almost exclusively by poor patients of African descent, and noting also the rapid increase in reported suicidal behaviours in young Africans in the last decade or two (Mayekiso & Ngcaba, 2000; Medical Research Council & University of South Africa, 2003; Wassenaar et al., 2000), NFSB patients in outlying areas are, in all likelihood, discharged without any professional psychological intervention. This is a serious issue that needs to be addressed, since the risk for NFSB and fatal suicidal behaviour is considerably higher in individuals with histories of NFSB (Bongar, 1991), and that up to 25% of NFSB patients attempt suicide again during the next 12 months (Gelder et al., 1994). The government’s implementation of one year of mandatory community service for graduating clinical psychologists could be a valuable step in this direction. The allocation of community service clinical psychology posts to the smaller outlying hospitals will result in the development of, at the very least, a basic mental health service that will benefit the surrounding communities. Community service clinical psychologists in these settings could provide appropriate care to, among others, NFSB patients and initiate prevention programmes in the surrounding areas. There is clearly a need to improve psychotherapy follow-up after NFSB. Telephonic contacts and follow-up home visits have been suggested (Hawton, 2000; Heard, 2000). A study by van Heeringen et al. (1995) found that compliance with treatment improved over a 12-month period for NFSB patients who received home visits by health care workers within two weeks of the emergency room presentation. However, in developing countries home visiting programmes are not economically possible. Providing adequately staffed tertiary health care institutions is beyond the budgets of many such countries. Also, many patients have no immediate access to telephones, with the result that they are not easily contactable after discharge from hospital. Not to be forgotten from the equation is the cost of adhering to follow-up appointments. Transport costs in returning to hospital for follow-up visits could militate against adherence. Depending on patients’ place of residence, public transportation may not always be available. In addition, patients have to pay for each hospital visit. Even though the cost may be relatively low for poorer patients, it is understandable when they prioritise other goods and services above a mental health consultation. 358


The ‘Green Card’ study, though not directly addressing adherence to psychotherapy, demonstrated good secondary prevention effects (Morgan, Jones & Owen, 1993). The investigators in that study provided NFSB patients with a green card following their first mental health consultation and informed them that the card entitled them to telephonic or personal contact with emergency services at any time they felt in need of these services, provided they had not engaged in NFSB on that occasion. The researchers found that patients receiving the green card made fewer suicidal attempts during the ensuing year and also did not place as high a demand on mental health services as might have been anticipated. While clinical trials of this type of intervention have not been reported elsewhere, it is certainly worth considering for local use, obviously with some modification, since crisis and emergency services in a country like South Africa (and probably more so in other developing countries) are rather limited in the public sector. The absence of such programmes provides a strong case for maximising attendance of in-patient psychological services for NFSB patients in under-resourced settings. Related to the poor out-patient follow-up pattern found in our study is ‘singlesession therapy’ (Quick, 1996). While this is somewhat unconventional and diametrically in conflict with traditional psychotherapy approaches, there is no research evidence to suggest that the benefit of therapy is positively correlated with the number of sessions. The one-off consultation is certainly not a new phenomenon, nor should it be surprising to clinicians to find that patients achieve a significant amount of benefit from the session. Quick (1996) further points out that effective single-session therapy is not rigidly time-limited, and that the patient may terminate, not because there is no more benefit but because she or he received what was most needed. In other words, in some of these cases psychotherapists need not feel the burden of guilt for the patient terminating, but rather accept that they have provided the help that was required at that time. In his foreword to an early work on crisis intervention, Albee (1974) criticised the conventional mental health service model, arguing that people in crisis want help now, not later by appointment. While the present authors are not of the opinion that the single-session approach is the most effective way of managing NFSB patients, it represents one way of conceptualising the mental health response to this problem, given the non-adherence issue, and the possibility of reconfiguring the content, process and efficacy of the first session. These factors, from a risk/benefit perspective, would appear to support the ethically dilemmatic practice of routinely referring hospitalised NFSB patients for psychological consultation without explicitly requesting informed consent for such referrals. Further controlled comparison research should be conducted on the impact of implementing an explicit informed consent procedure for the initial in-patient referral for psychological services after NFSB. We hypothesise that implementation of such a procedure in place of the present beneficence-based physician-initiated referral will reduce the 100% attendance for the in-patient appointment reported in this study. 359


Furthermore, we hypothesise that a reduction in such attendance will have an adverse impact on NFSB readmission rates at this setting, based on our previous finding of persistently elevated hopelessness scores in NFSB patients who did not attend follow-up appointments in this setting (Pillay & Wassenaar, 1995). Further, we argue that routine referral is a form of responsible caring that does not diminish respect for the dignity of persons (CPA, 2000). Clinicians would have to respect refusal by an NFSB patient to be referred, unless there were persistent and obvious indicators of high suicide risk, which might justify some other legally sanctioned and clinically justifiable control of the patient’s inclinations to self-harm. Some limitations of the study should be noted. Firstly, a more comprehensive study, which includes more demographic and clinical variables would allow for greater generalisability of the results. An increase in the clinical and demographic details recorded would also require more attention to informed consent by patients for the study and independent ethical review. Secondly, it would be useful to compare the non-attendance rates of the present study with those at hospitals where NFSB patients are not under the impression that they have to have a psychological consultation in order to be discharged. Thirdly, since the present study focuses on patients of low socio-economic status, it would be relevant to compare the present findings with NFSB patients of higher social status and/or patients receiving clinical services for NFSB in the private sector. Finally, an experimental intervention comparing follow-up rates in NFSB randomised to routine psychological referral with expressly optional, recommended referral would need to be conducted, with an emphasis on the risk markers of psychiatric symptomatology, hopelessness and further suicidal behaviour. Such research would inform clinical and ethical debates around the case management of NFSB in the public health sector.

CONCLUSION

Psychotherapy attendance following NFSB requires serious research and clinical attention, considering the high rates of non-attendance at follow-up psychotherapy sessions and the established efficacy of psychotherapeutic intervention in decreasing hopelessness levels (Pillay & Wassenaar, 1995). Factors influencing non-attendance, including poverty and social stigma, must be identified through further research and addressed through more local, community-based efforts. The ethical dilemma posed in this article is central to health care providers’ attempts to ensure that NFSB patients receive the evidence-based mental health care and follow-up they require. It is up to mental health practitioners to research and develop more direct, and possibly more ethical and effective ways of increasing compliance with mental health care, especially in the context of life threatening conditions such as NFSB. In the interim, and in the absence of data to the contrary, it would appear that in-patient referrals for psychological assistance without explicit informed consent would appear to be

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warranted, in view of the need for responsible caring, the benefits derived from a single psychological consultation, and the absence of evidence of harm or material costs.

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