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15 reid 11-07 pp402-404.qxdPractice Well: Suicide Risk and Suicide Prevention
WILLIAM H. REID, MD, MPH
This month’s column is about suicide, a clinical topic released on bond). There was no known history of involved in well over half the civil forensic matters I psychiatric diagnosis or treatment, but his wife con- review. I will discuss it clinically, because that’s the way firmed that he had shown increasing depression I hope most psychiatrists and other mental health prac- over the past several weeks, with great worry about titioners think about it. If you want to put the column the criminal charges, losing his practice, being into a forensic context, you could consider this risk humiliated, and forfeiting his medical license. management, malpractice vulnerability, or avoiding During the interview, the patient minimized his being sued. However, I would rather you view it as a recent history and said he had not really meant to discussion of the right thing to do.
kill himself (although he almost died of an enor- In over 30 years of inpatient, outpatient, academic, mous overdose). He said the drug-selling charges public sector, administrative, and forensic practice, I’ve were “trumped up,” and that he would “beat them” seen a great many examples of clinical excellence, at trial. He showed no immediate signs of severe maintaining our standard of care in difficult settings, depression other than the history provided by his and grace under the fire of unfair criticism. This is a wife and the overdose itself. His mental status reminder to keep placing patients’ interests before examination appeared essentially normal at the those of virtually anything else. In this column, I use time of interview. He pressed for discharge, as did suicide risk, particularly decisions about inpatient care, his wife, and said that going to a psychiatric hospi- as an example, but many of the principles apply to tal would damage his career. He promised to come to the office for follow-up, and his wife promised to An unfortunate number of clinical tragedies and mal- practice lawsuits beg psychiatrists to think: Nevertheless, and in spite of the patient’s and 1. When a potentially suicidal patient presents for wife’s entreaties, the psychiatrist recommended admission evaluation, don’t decide against admis- against discharge and began commitment proceed- sion unless you have adequately assessed the situa- ings. The patient chose a private facility some dis- tion and are reasonably convinced that the patient tance away, with a different attending psychiatrist, can be protected and cared for outside the hospital; and was transferred there on a 2-week temporary 2. When a psychiatric inpatient has been admitted commitment order. After the 2 weeks were complet- with serious potential for suicide, don’t discharge ed, the patient petitioned for, and was granted, dis- him or her after only a few days unless you are con- charge. He committed suicide within 24 hours. vinced either that the risk is substantially lessenedor that adequate measures have been taken to pro- Case Report 2
Before you say to yourself, “I already do that,” please A woman with a long history of schizoaffective ill- ness was brought to a psychiatric hospital becauseof marked agitation and threats of suicide. Her rea- Case Report 1
sons included bizarre fears that Satan would burnher, guilt over imagined slights by God, and recent The patient, an established local physician, wasseen on an internal medicine unit after being trans-ferred from intensive care. He had taken a signifi- WILLIAM H. REID, MD, MPH, is a clinical and forensic psychiatrist cant overdose 3 days earlier and was now and a past president of the American Academy of Psychiatry and theLaw. Dr. Reid’s website, Psychiatry and Law Updates, is www.psy- demanding discharge. The overdose was precipitat- chandlaw.org. This column contains general information which ed by his arrest for prescribing large numbers of should not be construed as applying to any specific case, nor as any amphetamines to an undercover officer (he had been Journal of Psychiatric Practice Vol. 13, No. 6 loss of custody of her children. She had discontin- Consider the following patient on an inpatient psy- ued her antipsychotic and antidepressant medica- chiatric unit: he looks a lot better, has gotten some tions several weeks before. She was admitted by the sleep, and has gone to a few hospital activities groups; on-call psychiatry resident and placed on one-to-one he says he’s not suicidal and wants to go home.
The morning after she was admitted, the patient What has changed for the patient? Has he been
was seen by another resident and an attending psy- cured? Have his risk factors really decreased suffi- chiatrist. By that time, her immediate symptoms ciently to move him from a high-risk to a low-risk cat- had abated somewhat and she appeared much less egory? If not, can the remaining significant risk agitated. Quetiapine and mirtazapine were pre- factors be managed well enough to place him—and scribed, along with groups for supportive counsel- keep him—in a low-risk group? Have the precipitat- ing and activities of daily living. On the second day ing factors for admission (such as a suicide attempt) of hospitalization, the patient continued to appear been reliably dealt with? Has the patient actually less agitated and showed no side effects from her responded to treatment (e.g., medication, cognitive- medication. She was still somewhat delusional, behavioral therapy, electroconvulsive therapy)? Has with flattened affect, psychomotor retardation, and he had time to respond, given, for example, the expect- some ritualistic behaviors, but denied suicidal ed lag-time in responding to antidepressant medica- ideation. She signed a “contract for safety,” promis- tion? Or is the patient merely responding to the ing to tell a staff member if she thought of harming temporary respite of hospitalization? Does he appear herself. Her one-to-one monitoring was discontin- better because he has learned what to say to the staff ued and she was placed on observation every 15 in order to gain their approval? Has a thorough sui- cide assessment been done since admission (especial- On the fourth hospital day, with no further ly just prior to scheduled discharge, perhaps by a decrease or increase in outward symptoms, the separate discharge consultant)? Finally, how reliable patient was scheduled to be considered for dis- is your answer to each of the above questions? charge. A couple of hours before the treatment teammeeting at which the decision would be made, she If the patient says that he is ready to go home,
hanged herself in an unoccupied patient room. why should you believe him? Suicidal patients are
often inaccurate and they commonly misunderstand
It makes no sense to move at-risk patients prema- their illnesses and symptoms. They often can’t pre- turely from a relatively safe environment with constant dict their own impulses and behaviors very well.
or frequent professional observation and treatment to They often can’t provide complete information about one in which most protections are removed, monitoring their histories and symptoms. Their responses to is sporadic or absent, and the stressors and stimuli questions may be a result of poor interview tech- associated with self-harm are still present. Yet that is nique. And suicidal patients often lie under the influ- exactly what happens to many patients in psychiatric ence of their mental illnesses. Some lie to get out of units and facilities. Each situation is unique, and these the hospital (or to avoid being hospitalized in the first comments are not meant to apply to every eventuality, place or free themselves from close monitoring). Some but even partial hospitalization and “intensive outpa- lie to gain the opportunity to kill themselves or to tient” programs leave patients on their own most of the have control over whether or not they do so. To make day and night, and usually return them to the setting matters worse, psychiatrists and other clinicians are in which the suicidal impulse was, quite recently, very not very good at discerning whether or not their patients are lying about suicidal thoughts.
I am not trying to drag up the old concept of “predict- ing suicide” (the point is risk, not “prediction”) nor to tie Has collateral information about the patient
the hands of good clinicians who treat very sick been sought? It is a mistake to rely solely on a
patients whom they can usually eventually discharge.
recently suicidal patient, whose judgment and insight But it is useful to point out a few things to think about are almost certainly flawed and whose motivations when one is trying to justify early discharge of a patient are often unclear, when other sources of information 3 or 4 days after a potentially lethal suicide attempt or are available. When the patient is the only feasible other evidence of serious suicide risk.
source of information, doctors must be more than usu- Journal of Psychiatric Practice Vol. 13, No. 6 ally cautious about discharge, relaxing patient moni- tem of care that protects them from unacceptable toring, or denying admission in the first place.
risk. The standard of care demands, and doctors andhospitals generally provide, careful and frequent clin- Are substantial problems likely to reappear
ical assessment, attention to indicators of risk or rel- after discharge? Instability and unreliability are
ative safety (especially as discharge is contemplated), serious risk factors. It is not enough for the patient to recovery settings with adequate monitoring, and appear safe on the day of discharge; the psychiatrist scheduled, reliable follow-up care. Those are part of must be reasonably certain that the low-risk condi- our psychiatric standard of care as well.
tion is stable. Many patients have waxing and wan-ing illnesses, unpredictable symptoms, difficulty Conclusion
following treatment regimens, highly stressful homeenvironments, and/or substance abuse problems. If Lest some clinicians still try to reassure themselves so, how have the psychiatrist and the treatment team with the fact that suicide is a fairly rare event, consid- protected the patient from that continuing risk? er this: It is unacceptable to allow a small child to playunsupervised in the street, even when traffic is very Is the patient’s family being asked to assume
light. It is foolhardy to let that child wade alone in a more responsibility than they can handle?
shallow surf when there is a chance of his stumbling Families are often understanding and supportive, but into a deep spot or strong current. The probability of they aren’t trained or equipped to do the jobs of doc- contracting rabies after a dog bite is remote, yet we tors, nurses, and hospitals. Even those who promise insist on careful assessment and, if we cannot be reas- to watch the patient closely cannot (and should not) sured that the dog doesn’t have rabies, we expect pro- phylaxis. The probability of tragedy in such examples islow, but the stakes are very high; the risk is unaccept- How would you want your own child, parent, or
able; and reasonable ways exist to reduce the risk. We spouse to be treated in the same situation?
should approach suicide risk in a similar fashion.
Eliminate utilization review, insurance coverage, and I am happy to send clinicians a copy of my training “average” hospital stay from the equation, since those slides on this topic. They aren’t perfect (and they don’t things are not relevant until acute clinical and pro- ask clinicians for perfection), but they do not apologize tective needs have been met. We sometimes forget for making patient risk and need our top priorities that serious mental illness can bring with it as much whenever possible. Just email me at reidw@reidpsychi- morbidity and mortality as the severe conditions seen atry.com with your name, location, and clinical position.
by internists, cardiologists, and trauma specialists.
The slides are copyrighted, but you are welcome to use We expect patients with acute or suspected myocar- them for teaching or personal review as long as you dial infarctions, for example, to be seen within a sys- keep all text and formatting intact.
Journal of Psychiatric Practice Vol. 13, No. 6
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