Association of ethnic concordance between patients and psychiatrists with the management of suicide attempts in the emergency department

According to the World Health Organization (WHO) report from 2018, as many as 800,000 people die by suicide each year worldwide with the main risk factor being a previous suicide attempt (World Health Organization, 2021). Even though death due to suicide is tightly related to severe mental illnesses, most suicide cases occur among people with no major psychiatric diagnosis, both in the general population (Bertolote and Fleischmann, 2002) and specifically in patients that were recently discharged from psychiatric inpatient care (Haglund et al., 2019). Suicide attempts are often impulsive (Gvion and Apte, 2011), and occur during a crisis, as an expression of inability to cope with everyday stresses and demands. A meta-analysis from 2017 showed that patients released from the hospital following a suicide attempt have the highest risk for a subsequent suicide attempt, compared to general population (Chung et al., 2017). The risk for a recurrent suicide attempt during the first 3 years following the first attempt is 12- 30%. As a result, many efforts are invested in developing effective suicide prevention strategies to reduce the risk for recurrent attempts (Zalsman et al., 2016).

Several studies have demonstrated the efficacy of different interventions aimed at preventing the recurrence of suicide attempt (Cedereke et al., 2002; Zalsman et al., 2016). A critical component within different suicide prevention strategies is the ability to create continuous care and follow-up (Doupnik et al., 2020). Such strategies include phone calls, in-person interventions, and mail/email contact. This methods were found to be effective in preventing a recurrent suicide attempt (Fleischmann, 2008; Miller et al., 2017). Moreover, a study based on personal interviews with suicide attempt survivors found that the survivors themselves believe that access to mental health services and continuity of care play a meaningful role in suicide prevention (Hom and Stanley, 2021). The described approaches are all based on crisis intervention techniques and take place in an outpatient setting, allowing effective psychosocial interventions while maintaining the patient in their natural environment. An alternative strategy is hospitalization for inpatient treatment that enables a rapid intervention of a multi-disciplinary team, with the purpose of reaching a reliable diagnosis, initiation of pharmacotherapy and psychosocial intervention. While both inpatient and outpatient interventions have their advantages and disadvantages, the decision for psychiatric hospitalization was found to associated with increased suicide risk (Miret et al., 2011).

In Israel suicide rate completion is approximately 7.9:100,000, and suicide attempts are ∼90–100:100,000 (Zalsman, 2019). In 2021 there were approximately 9.45 million citizens in Israel, out of them 73.9% were Jewish, 21.1% were Arabs (Israel Central Bureau of Statistics, 2021). A recent comparison of suicidal behavior in different cultural groups in Israel revealed marked differences with lower rate of suicide attempt and complete suicide among most Arab communities and increase in early-age suicidal behaviors among Israeli Arabs (Brunstein Klomek et al., 2016). The cultural diversity in Israel is also reflected in health care providers, raising questions regarding cultural differences in management of suicide attempts between Jewish and Arab psychiatrists and possible effects of ethnic concordance between patient and psychiatrist.

Previous studies found that ethnic concordance between patient and physician resulted in a better therapeutic experience, an earlier start of the treatment, and more continuous care (Blanchard et al., 2007; Jerant et al., 2011; Shen et al., 2018). Furthermore, the ability of the physician to clinically evaluate the extent of openness and reliability of the patient was also related to sociodemographic concordance (Cheng et al., 2021). When examining suicide attempts in the United States, researchers provided provisional evidence of racial/ethnic differences in healthcare visits made before the suicide attempt (Ahmedani et al., 2015). In Israel, studies found that sociodemographic mismatch (age, religion, gender) between patients and therapists, correlated with higher rates of misdiagnosis (Nakash et al., 2015). However, little is known about the role of ethnic concordance in effective suicide prevention.

In this study we sought to examine whether sociodemographic variables are associated with suicidality and suicide prevention strategies in the emergency department (ED). Examining ED cases from a 5-year period, we compared demographic variables between Jewish and Arab patients. Then we tested whether demographic variables and specifically patient's ethnicity and its concordance with psychiatrist's ethnicity, are associated with decision on psychiatrist intervention, demonstrating that clinical decision is only weakly affected. Finally, we explored whether these factors determine the type of intervention (inpatient vs. outpatient), uncovering a significant bias for outpatient interventions in dyads of Arab patients and psychiatrists.

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