I thought you were going to bring up a different thread though the above is a good one.
http://forums.studentdoctor.net/archive/index.php/t-601628.html
http://forums.studentdoctor.net/showthread.php?t=623625
In addition to Nitemagi's post, I was thinking contacting Lambert, the author of the above study, who replicated his data later on with consistent results, but alas, there's so many ideas where I'm not taking the next step forward. Playing D&D, spending time with my daughter, and sitting on my butt watching
Young Justice on the Cartoon Network are taking their toll.
Evidenced-based data shows that conditional AKA contingent suicidality is actually a protective factor, the theory being that most of these people aren't mentally ill to begin with, and are manipulating the system. Despite the data, that IMHO is good enough to defend you in court, the author still suggests that more studies need to be done, probably in an attempt to cover his own butt.
Where I did my training, the doctors were of lower quality then where I'm at now, and given that a substantial amount of doctors in the department are actually top doctors in the country, and some of them are actually working in the emergency center once in awhile, the frustration level is so so so so so much lower than it was in residency with these types of patients.
In residency, if we had a malingerer we had so many chicken docs that immediately admitted them to the frustration of the inpatient doctor. The inpatient doctor would immediately discharge the patient (and rightfully so), and then it would cause the emergency center docs and nurses just get mad at the inpatient ones in a very immature, dysfunctional, and unproductive manner. It was like Jets and Sharks on
West Side Story, and being a resident, I had to work in both while being barraged by the dysfunctional emotional anger going on. To add to the frustration, several of the staff members even in the emergency center thought the patient was malingering, but they were ticked off because they had to deal with the fall-out from their own attending admitting the patient but they weren't allowed to put the attending in his place.
There are a few books from the APA suggesting that there really is no standard of care in predicting suicide. I disagree with that. Asking if the patient is suicidal, their history, checking for static risk factors (e.g. possession of a gun, prior suicide attempts, etc), but from there that's where I'd say the standard becomes murky because anyone in this fields knows that the overwhelming majority of people who come to the ER don't commit suicide, and most of the time it's not because we actually got them better in a psychiatric sense. It's because the patient was FOS to begin with. or drunk, the ER doctor wanted to dump them on you, they really just want a place to stay because they got into an argument with the Mrs. and they don't want to pay for a hotel room, or what have you that got them into the psych emergency center to begin with and it wasn't a real psychiatric issue.
Here's my advice on dealing with such patients.
1) Consistency: the inpatient doctor, if the patient is admitted, needs to continue the evaluation of the patient possibly being FOS or not. Yes, I can understand them still giving them an Axis I disorder, but they should at least document any suspicions of malingering. When a doctor puts a diagnosis on discharge, it can create a domino-effect where each time this patient comes back to the emergency center, it'll just up the odds he'll be admitted.
As for the doc at the emergency center, if you admit them and suspect they are FOS, document so, but write why you admitted them. "E.g. I suspect this patient may be malingering but this is the first time we are seeing this patient, and he does have some behaviors that make me suspect he truly may be in need of hospitalization. Please consider this during his hospitalization."
2) Chair therapy: As termed by NJWXman, if you can't tell if a patient is FOS or not, or you strongly believe they are, hold them in the emergency center for as long as you can before you decide to admit them or not. Often-times, usually the majority of the time, after being in the PES with only crappy sandwiches, pretzels and PB on Ritz crackers to eat, no one to talk to them, and TV that only shows bad TV like
Dr. Phil they'll want out of there themselves after a few hours while contracting for safety.
3) If You Suspect Malingering, and It's Serious, and If You Can, Get Psychological Testing done: Where I'm at, we got a psychologist on our psychiatry dept who specializes in malingering testing, and we can have him test the patient. We only do it, however, if the stakes are high because this testing is expensive. This, unfortunately, will often necessitate they be admitted into inpatient, but you spotting and documenting possible malingering can get the testing done faster.
4) Don't Up the Ante: If you think someone is FOS, don't provoke them and don't give them extra attention either. Getting them even more pissed than they are at discharge might provoke them to up the ante and harm themselves out of anger in an attempt to make you look like you're wrong (even though you're right). If you have a patient that's malingering and you call them a liar to their face, you're just going to piss them off even more and many of these patients have enough knowledge to know that superficially cutting can force your hand, and then on top of that increase liability. Aside from that I've seen too many doctors think they're right when they're wrong.
I handle this just like I handle my Suboxone patients that allege to lose their scripts. I tell them that I'm not replacing the script and it's too bad they lost it, but I don't accuse them of lying. If you've had enough Suboxone patients, you know that as a demographic (not judging individuals) many of them are impulsive, have poor coping, skills, and when you think about, many of them are irresponsible enough to lose it. Just that I'm not going to re-supply them with Suboxone because I can't tell if they're telling the truth or not. I just tell them that they're not getting it again, I can't tell if they're telling me the truth, and as part of the patient contract they signed they should already know this.
For suspected malingerers in a PES, I just tell them that based on all the data, they're better off not being in the hospital and try to get them out of there in a respectful, calm, and non-confrontational manner. Remember, we're supposed to do no harm. I'd only confront a patient with malingering if I was very very very certain. You can be causing severe harm by claiming someone is malingering that is not. That, IMHO, could be one of the worst forms of psychological invalidation a mental health provider could ever do.
I had a woman in PES a few weeks ago that was suicidal to the degree where she made an attempt more than daily, but I knew it was for attention and a product of combined borderline PD and factitious DO (she really has borderline, but she loved the attention). I knew this patient after seeing her on a different unit in the state hospital i worked at. I discharged her from the PES knowing she could full well make another attempt within 24 hours. I gave her a referral to a DBT therapist, told her I wanted her to get better for real, but that PES and inpatient hospitalization wasn't the solution. I did not display any anger towards her, and recommended she give DBT therapy a try. She told me she was going to kill herself if I didn't help her. I only said "please don't do that" while thinking to myself ...-if you really wanted to kill yourself, I'm sure after 10 years of this you would've done it- while not telling her that.
Now, that patient did worry me. I did pause while in PES and think that admitting her into inpatient (which is what she wanted) would've been the easy but wrong thing to do. This happened the same day I was watching
The Avengers on opening night, I kept thinking every few minutes that she might've killed herself, not because she was truly suicidal but because her attempts to get admitted have become more theatrical, histrionic, and dangerous. E.g. she put her leg over a bridge.
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