What would you do?

[whopper]

I'm encountering a few problematic situations where I don't see any clear answer or direction. I've noticed when my colleagues are in this situation, they often don't have an answer.

1) Depressed patient who was suicidal with 4 serious prior attempts, patient has done fine in the inpatient unit for several days, you believe she should be considered for discharge, and she wants to go home to her family's home that's armed as if WWIII were to break out. The family refuses to get rid of the guns. She's spent a few extra days in the hospital while you tried to talke to them and explain to them the danger, but you get continual and very one-track responses to the effect of "well if she really wanted to kill herself, she could use a toothpick," demonstrating they really don't understand.

It's getting to the point where keeping her in the hospital is actually causing her problems because she's been there for several weeks and lengthening her stay is just making her mood worse. She has no where else to go, and she is not appropriate for a group home.

2) Patient has HIV and was psychotic. He has a long history of noncompliance. While psychotic he does sexually dangerous behavior (sexting others to the point where he had a restraining order). He is now cleared of his psychotic symptoms as far as you can tell but he denies he has HIV despite being showed labwork to verify it.
It turns out his denial of HIV are within a cultural norm. He is poorly educated, does not have a good understanding of how HIV works. and has no symptoms of AIDS, and his reactions are clearly interpretable as denial, an ego-defense mechanism many people would have. You, the doctor, have attempted to clarify he has HIV over 15 times.
State laws clearly dictate you can only hold someone against their will if someone is dangerous to others based upon a mental illness that affects one's thought, perception, or mood, denial is not included in these categories.

Do you discharge?

3) You have a patient in your outpatient office that you believe is suicidal. The patient is noticeably distressed, crying, and telling you she is suicidal with a plan to run her car off a cliff. You call 9-1-1 to have emergency services pick up the patient. The police arrive, and they refuse to transport the patient because now the patient is telling them she is not suicidal. You remind them that according to state law, you the doctor can still place a 72 hold on the patient, thus forcing the patient to be brought to the hospital.

The police state "then in that case doctor, you bring the patient to the hospital." They go to their squad car and leave.

What do you do?

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[Manicsleep]

1) Sounds like you need to discharge.
Regular outpatient follow up with PCP, therapist and psychiatrist.
Perhaps a day program.

2) That is not imminent danger. If all other psychotic symptoms have truly resolved you have no right to keep that person there. You can try for incompetence but not for imminent danger to others.

3) I don't know what the law is in your state. Document carefully. Get the names. Call 911 again and report what happened so that everything they said is recorded. Call your local news. Most officers have an IQ less than 100 to start and usually drink heavily. I lot of my 'friends' from HS are now cops. They were idiots then and they are idiots now.

 

[nitemagi]

1. Discharge but document a lot about your efforts. State laws tie your hands.
At least suggest to family about gun safes, separating ammo from weapons, Some type of barrier. Though it may be futile. Close and frequent follow-up.
2. Notify the health department and see if they have other venues for intervening. At this point it's less of a psychiatric and more of a public health risk.
3. Agree with manicsleep. My argument for a hold would be that people can minimize suicidality when confronted in certain circumstances, and needs hospitalization regardless. I once caller police on a patient that was decompensating at home. Recent severe SA. Called police, but they weren't going to bring her in because she denied SI. I got a call from the pt's GF, who told me this so I spoke to the police and gave them the logic over the phone and that she definitely needs a full evaluation.

 

[kugel]

1) Depressed patient who was suicidal with 4 serious prior attempts, patient has done fine in the inpatient unit for several days, you believe she should be considered for discharge, and she wants to go home to her family's home that's armed as if WWIII were to break out. The family refuses to get rid of the guns. She's spent a few extra days in the hospital while you tried to talke to them and explain to them the danger, but you get continual and very one-track responses to the effect of "well if she really wanted to kill herself, she could use a toothpick," demonstrating they really don't understand.

It's getting to the point where keeping her in the hospital is actually causing her problems because she's been there for several weeks and lengthening her stay is just making her mood worse. She has no where else to go, and she is not appropriate for a group home.

Document, document, document.
Document your concerns and your efforts so far.
Document a conversation with the patient about the increased with having firearms in the home. Ask the patient for her understanding of why you are concerned, and document her responses. Document your statements to her regarding that there is no real reason to keep the pt in a locked setting, and explain the housing alternatives (just like you would document your discussion of R/B/SE of a treatment). Ask her what she wants to do about housing post discharge. Ask her how she would respond if SI returns, who she would call, where she would go for extra help. Ask her how she thinks it would affect her friends/family if she harmed herself, and what her religious beliefs are about suicide (documenting all her statements about reasons she shouldn't kill herself).
If you still feel really uncomfortable...
Then review the case with the Chief Psychiatrist or Medical Director, ask him/her to review the chart and interview the patient, and document the responses. Then contact the hospital Risk Management officer/consultant. That person will likely confirm that you have done everything possible to ameliorate the risks at home, and that you can't force the pt to live elsewhere. The Risk Mgt officer might recommend something like sending a registered letter to the family reminding them of the increased risk, or of having another MD discuss the risks with the pt, but ultimately you will need to discharge the pt. In the long run, it is sort of like discharging an MI pt who refuses to quit smoking, or whose family refuses to quit smoking.

2) Patient has HIV and was psychotic. He has a long history of noncompliance. While psychotic he does sexually dangerous behavior (sexting others to the point where he had a restraining order). He is now cleared of his psychotic symptoms as far as you can tell but he denies he has HIV despite being showed labwork to verify it.
It turns out his denial of HIV are within a cultural norm. He is poorly educated, does not have a good understanding of how HIV works. and has no symptoms of AIDS, and his reactions are clearly interpretable as denial, an ego-defense mechanism many people would have. You, the doctor, have attempted to clarify he has HIV over 15 times.
State laws clearly dictate you can only hold someone against their will if someone is dangerous to others based upon a mental illness that affects one's thought, perception, or mood, denial is not included in these categories.

Do you discharge?

And that danger to self/others needs to be pretty imminent. "Might maybe do something someday that could endanger someone" is not imminent risk.
Again, discuss with Medical Director and Risk Management.
This is the sort of stuff Risk Management lives for. This is why they took the job.
Then, yes, discharge.
If there are local laws stipulating that you can/must report such to Law Enforcement, Risk Management will know that and instruct accordingly.

3) You have a patient in your outpatient office that you believe is suicidal. The patient is noticeably distressed, crying, and telling you she is suicidal with a plan to run her car off a cliff. You call 9-1-1 to have emergency services pick up the patient. The police arrive, and they refuse to transport the patient because now the patient is telling them she is not suicidal. You remind them that according to state law, you the doctor can still place a 72 hold on the patient, thus forcing the patient to be brought to the hospital.

The police state "then in that case doctor, you bring the patient to the hospital." They go to their squad car and leave.

What do you do?

Write the hold, call 911 again, tell the operator that this time you would really appreciate it if there is a patrol supervisor on-hand to discuss the situation, and tell the operator that the pt has made it clear she has and will lie to the police to try to avoid hospitalization. While waiting for the police, note the pt's description, attire, car, license plate if possible, address - in case the pt leaves you can give this info to the police. When police arrive, ask for names & badge numbers, hand them the hold you wrote and a copy of your documentation of the conversation with the pt and the reasons you feel sure this patient meets criteria for a hold, and politely step out of the room to allow the officers to do their job. You can't FORCE the police do anything, but you certainly should try again.

Next day, call the police dept and ask to speak to the patrol lieutenant or captain. Explain the situation and your concerns. When you are done, write a letter to the supervisor thanking him/her for taking the time to talk with you and summarizing your concerns and the results of the conversation, including any agreements made in the phone call. Send a registered copy to that same supervisor - and keep a copy with the registered letter receipt in your files.

Call your malpractice company Risk Managment lawyer to discuss and see if there is anything different you should do in the future or in addition now.


Seeing a pattern here?
We so often forget that there are lawyers working on our side to prevent us from ending up in court. Consult them.

 

[loveoforganic]

Just to add to #1, there's a lot of room between getting rid of guns and keeping them chambered, cocked, and on the table. A trigger lock is $5. Guns aren't cheap. If they have an arsenal, I would think they can afford enough $5 trigger locks to keep them safe.

 

[Manicsleep]

I will retract my 'call the news' portion.
Don't get into a pissing contest. Educate them first.

 

[whopper]

All very reasonable answers!

Let's add some more layers of complexity, all of which either happened or I have realistic fear they will happen based on prior experience.

1) The woman who's only disposition is her family home armed to the teeth? (and this really did happen)...
The family dynamics are very dysfunctional and chaotic. They did contribute to her depression including a spouse where divorce is a possibility and she can't stand her in-laws. As for locking the guns, that's a problem too. We're talking no exaggeration about my preparation for WWIII comment. The family has actually prepared for the upcoming apocolypse, but aren't meeting a diagnosis of a psychotic disorder. They have so many guns they've lost track of them. Open a door, clost, drawer, there's a gun with ammo pretty much everywhere in this house. The guns are owned by the father-in-law, and the patient can't stand him.

2) HIV infected psychotic guy, he always stops his meds after discharge Always! Yeah, we usually discharge patients that we ancitipate may even stop their meds and become psychotic again, but they usually, while psychotic, do something not so bright, but no so dangerous either (e.g. found eating food out of a guy's garbage can and the guy calls the police, no one is physically harmed).

This guy was stalking a woman and sexting pictures of his penis and she was in fear that he was going to rape her.

So I really don't want to discharge the guy anyway, but the law clearly dictates I'm supposed to do it. Just not at the current moment the guy is psychotic, but I can realistically see him being dangerous within a few weeks.

So guess what? I have good reason to believe that when I ask a non-treating doctor to go over my case, he's just going to write the guy's psychotic only because the guy doesn't accept that he has HIV. I've seen this thing happen before in the hospital, and I chalk it up to a doctor simply just wanting to find anything to close his involvement in the case and get out ASAP. This in effect freezes this case because I can't discharge, but I'm not going to be able to improve a symptom of psychosis that's not a symptom of psychosis.

I'm caught in the ethical dilemna of having a patient that I feel should be discharged even though I don't want him discharged, but can't be discharged because the other doctor is having a difference of opinion with me....and I'm not liking it, but if he were to be discharged I wouldn't be liking that either. (Maybe I got a personaity disorder?)

Just to clarify, the patient is currently in a legal status where he can only be discharged if multiple doctors agree with it.

3) The not-so-bright-police officer situation---Agree. Just to answer the question above, yes in Ohio, there is a law saying a doctor can do a 72 hour hold...
Ohio Revised Code 5122.10

Any psychiatrist, licensed clinical psychologist, licensed physician, health officer, parole officer, police officer, or sheriff may take a person into custody

IMHO, a cop refusing to bring a patient to the hospital is pretty much for all intents and purposes dead in the water. I will not drive a patient myself. If the patient really wants to not go, they can refuse me, and I am in no position to physicallly force the patient. All I can do is document.

By the way, I called the mental health board of the county to tell them of this problem but they told me they are working with the police and if the above happened they didn't have a solution.

In the real situation I was in, the police actually did end up taking the person but they spent several minutes doubting whether or not take the person even though I told them that it was my opinion the person had to be taken in and I told them I was exercising my authority under the Ohio Revised Code that they apparently had a different idea of how it worked.

 

[atsai3]

The family dynamics are very dysfunctional and chaotic. They did contribute to her depression including a spouse where divorce is a possibility and she can't stand her in-laws. As for locking the guns, that's a problem too. We're talking no exaggeration about my preparation for WWIII comment. The family has actually prepared for the upcoming apocolypse, but aren't meeting a diagnosis of a psychotic disorder. They have so many guns they've lost track of them. Open a door, clost, drawer, there's a gun with ammo pretty much everywhere in this house. The guns are owned by the father-in-law, and the patient can't stand him.

Doesn't really change things. You have a current treatment plan (inpatient hospitalization for safety & stabilization) that sounds like it has run its course. I assume there is nothing else pharmacologically at your disposal (and even if there were, the problem here does not sound pharmacologic in nature). You have no alternative disposition. It's home or bust. If you magically come up with an alternative disposition and the patient refuses the alternative disposition, discuss that in the family meeting. If the family refuses to remove means, discuss that in the family meeting. Discuss everything in multiple family meetings and colleagues so that there can be no doubt that the patient and family were critically involved in the process of discharge planning and that everybody, including reasonable colleagues, is on the same page with regard to the discharge plan. Document, discharge, and schedule follow-up. That's all you can really do here. It's not a happy situation, but unhappy discharge situations are nothing new in inpatient psychiatry...

-AT.

 

[digitlnoize]

I'd like to say that as a med student, this discussion ROCKS, and should happen more often. Perhaps a Friday case conference?

Anyways:

1. It sucks, but they've gotta go. CYA, follow up like a mofo if you really care, and document x 3. Unless there is anywhere else she can go...

2. Tough. Health Dept is prob the best bet here, until the guy gets criminal charges and gets locked up. Won't be long.

3. Make friends with the force. I have a couple cops who I could call for backup if the random badge sucked. Perhaps you could offer to give a lecture to the Department about this, and other, mental health issues? Good way to rub elbows and maybe pick up some patients...

 

[kugel]

#3. If in Ohio the psychiatrist can write a hold, why not just call the ambulance? Once the hold is written, why do you need to involve the police? In CA, those professionals who are authorized to write a hold often just call for an ambulance and hand them the hold. Call the EMS administration and see if they have any policy that would permit them to refuse to take the pt.

 

[whopper]

why not just call the ambulance?

9-1-1 was called. We could of course call them again and tell them the police refused to help so bring in an ambulance, but that's up to the 9-1-1 operator's discretion.

Thanks for all the responses. I agree with everyone. Lots of these cases are pretty much I can't do anything else, but these are also situations I've rarely seen encountered in training.

 

[kugel]

9-1-1 was called. We could of course call them again and tell them the police refused to help so bring in an ambulance, but that's up to the 9-1-1 operator's discretion.

"911. What's your emergency?"

"I'm Doctor Whopper. A patient at my office requires emergency medical assistance. The address is 1313 Mockingbird Lane."

"What kind of medical emergency is it?"

"Ms. Smith has admitted to me that she is suicidal and intends to kill herself upon leaving my office. I've already written a 72-hour hold on her. She's not violent or resistant. She has agreed to go with the ambulance, but will likely run if she sees police, so please just send an ambulance. If the situation changes, I will certainly call back. If you like, I'll leave the line open with the speakerphone on, so you can hear if the situation changes."

It's not foolproof, but likely to work.
If the police do show up, you can tell them that you've already summoned an ambulance, and the pt is quite afraid of police, so you would appreciate it if they it would be acceptable for them to wait outside the open door until the ambulance arrives.

NEVER helps to tell police what they "must" do.
Always better to offer them choices and whatever assistance you can provide, making it entirely clear that They are in control, and you will abide by whatever they tell you to do.

Frankly, it rarely helps to tell anyone what they "Must" do.

 

[whopper]

Thanks for the advice Kugel.

Anyway, I later found out that the patient who did go with police was handcuffed, and kept in cuffs for several hours. The law specifically states that when transporting the patient, it must be done in the least demeaning way possible.

It seems the county doesn't know WTF they are doing in cases like this. I called up the mental health board over this and they told me they don't know what to do about this. I told the person from the board that I would be happy to work with them in dealing with emergency services to prevent a future occurrence like this and I was willing to spend several hours with them and the police but I felt the conversation was going nowhere.

In other counties in the state, if such an even occurs, they sent a mobile crisis team. A police or ambulance is only brought in if it has to be that way. Not in the county where I do private practice.

 

[kugel]

Hope it helps, Whopper.
In CA, there are lots of specific rules about how people detained on a mental health hold are to be treated, most of which are completely ignored by the police. And counties are loath to try and hold them accountable because, "we need them on our side." Really? Since when is it a good idea to let the police mishandle someone (suspect or patient) because reporting it might cause a rift with the police? The rift exists! Reporting it and trying to find ways to correct it is about repairing the rift. Not reporting it tacitly condones it and assures it will continue to happen and serves to reinforce it.

The only way I've ever seen it successfully addressed is if hospital personnel write up incident reports on such events, since it is difficult (not impossible) for hospitals to retaliate against staff who write up incident reports on events that endanger or harm patients - even if it is "only" the dignity of patients that's harmed. Such incident reports Must get forwarded to the State (at least in CA) and then the hospital has to address why no one else has been reporting such events to the State. If the State Dept of Health won't assist/encourage police changing their tactics for dealing with patients, then I really do throw up my hands.

Sometimes NAMI can help bring to light how the police could better follow the laws that are in place. But that's the only other option I really know.

 

[heyjack70]

#2: Can you put the guy on a long acting injectable. Can he be release conditionally with the requirement that he make injection appointments or the police will look for him and bring him to the hospital for admission. I think this is the best solution for a guy you have to discharge but believe needs significant oversight because he's med non-adherent.

 

[heyjack70]

#3. If in Ohio the psychiatrist can write a hold, why not just call the ambulance? Once the hold is written, why do you need to involve the police? In CA, those professionals who are authorized to write a hold often just call for an ambulance and hand them the hold. Call the EMS administration and see if they have any policy that would permit them to refuse to take the pt.

If the patient elopes from the ambulance the EMS workers have no recourse but to call the police. Depending on the patient this may or may not be a good idea. I can imagine that for a lot of suicidal patients who are willing to be hospitalized/voluntary an ambulance would be fine because they do want to go to the hospital. Once you start talking about psych holds though and you have a patient lying to police about psych symptoms, IMHO getting the police to secure the patient's transfer to a locked psych unit would be required.

 

[kugel]

If the patient elopes from the ambulance the EMS workers have no recourse but to call the police. Depending on the patient this may or may not be a good idea. I can imagine that for a lot of suicidal patients who are willing to be hospitalized/voluntary an ambulance would be fine because they do want to go to the hospital. Once you start talking about psych holds though and you have a patient lying to police about psych symptoms, IMHO getting the police to secure the patient's transfer to a locked psych unit would be required.

At least in CA, if the pt is on a psychiatric hold, the ambulance personnel can and will place the pt in restraints and prevent him/her from leaving. If the fight gets too violent, the ambulance personnel will call the police. In that case, the police will typically handcuff the pt to the stretcher and follow to the hospital. Or they will handcuff the pt and put in the back of the police car.

 

[kugel]

#2: Can you put the guy on a long acting injectable. Can he be release conditionally with the requirement that he make injection appointments or the police will look for him and bring him to the hospital for admission. I think this is the best solution for a guy you have to discharge but believe needs significant oversight because he's med non-adherent.

Some states have such "outpatient commitment" laws, but even in those states that do, the local mental health agency's enforcement is spotty at best. And you still have your problem of showing imminent danger due to a mental disorder. Lack of belief in a diagnosis of HIV and lack of belief in the consequences are not confined to the mentally ill. In those few places that are enforcing laws regarding knowingly infecting people with HIV, you have to leave it up to law enforcement to make the criminal case.

 

[nitemagi]

Let's add some more layers of complexity, all of which either happened or I have realistic fear they will happen based on prior experience.

1. Same outcome, but could --
Try to use her dislike for her father-in-law, roll it therapeutically into a desire to live elsewhere or to stay far away from all guns. Get her to associate guns with her father-in-law.

2. A middle ground might be some kind of ACT or case management on the outside. Is there a 3rd physician to back you up. I agree the overdiagnosis of psychosis in the community is astounding. I try and hammer into med students and residents over and over again to dig deeper. Just because someone said "yes" to being asked if they have voices does NOT = schizophrenia. 1/2 the time it's not psychosis at all, just a mislabeling of their own thoughts as voices in the relatively uneducated or someone trying to game the system.

3. If the patient went on to do something, and the PD didn't take them in, the family might have grounds for a lawsuit against the PD.

 

[kugel]

1. Same outcome, but could --
Try to use her dislike for her father-in-law, roll it therapeutically into a desire to live elsewhere or to stay far away from all guns. Get her to associate guns with her father-in-law.

Interesting idea. Conditioning her against both her Father-in-law and guns, and using the another pairing of stimuli to encourage her to live elsewhere.

Let's see:
Attach an unloaded gun to her hand.
Show her slides of different people in random order.
Whenever her Father-in-law appears, the gun transmits a shock 0.5 seconds later, and headphones tell her she is foolish, stupid, childish, selfish, cruel, evil, etc.
The only way to turn of the shock is for her to turn on photos of various apartments or Room & Boards, photoshopped to show the patient entering or living in them.
Along the way, we should generalize to different guns and to photos of her family's house, the yard, the street. You could use audio recordings of her father-in-law, staff dressed up to look like him, catch phrases he uses. If he has a white beard, be careful. You don't want to accidentally make her afraid of white rats.
http://psychology.about.com/od/classicpsychologystudies/a/little-albert-experiment.htm

Would Skinner be proud?

 

[whopper]

#2: Can you put the guy on a long acting injectable.

The guy was tried on Risperdal and had serious side effects to it including oversedation. He also told me that he felt "wierd" on it and couldn't describe it more than that other than he was very uncomfortable and would rather be dead than on that medication. Zyprexa pretty much knocked him out. He couldn't get out of bed.

Haldol or Prolixin weren't tried. Recent data from Nasrallah mentioned that typicals likely do not slow down the neurodegeneration that is associated with schizophrenia. For that reason, I'm trying to put patients on atypicals more so than typicals. In addition to that, after being placed on Abilify, the guy actually did improve and told me he is feeling great on that medication and does not want a different one. He has the competency to decide what medication he's on after discussing the issue with him and he doesn't want to be on any other medication.

2. A middle ground might be some kind of ACT or case management on the outside

By all means I believe he needs the best services one could be on for his safety and others. I can realistically see this guy sexually assaulting someone sometime down the road, but further hospitalization is not appropriate.

But the problem here is in the current situation he's in, he can't get discharged unless at least another doctor agrees.

Just because someone said "yes" to being asked if they have voices does NOT = schizophrenia.

Ever hear of the Martha Mitchell Effect? I hadn't heard of it in formal training, but I've seen it happen time and time again.
http://en.wikipedia.org/wiki/Martha_Mitchell_effect

A guy I was with in residency (that I sometimes wonder is actually not too competent) would ask patients "do you hear voices?" They often responded, "yes I hear your voice." He then immediately put them on Risperdal. I remember one guy was already on Risperdal Consta 50 mg, and he put the guy on 8 oral mg more because the guy said "yes" and the good resident didn't check his prior meds. The patient wasn't psychotic. His psychosis was actually under control. He was in the hospital because he was very angry over a social situation and his case manager told him to go to the hospital. The guy wasn't my patient, and I noticed him tremoring and suffering tremendous anxiety. I had to intervene because the other resident, even the attending, weren't doing anything about it.

Getting back to the Mitchell effect, I had a Paris Hilton-like patient in the unit once. She was a jet-setter given about $100K every few months by her very wealthy parent. Her mother, angry that the daughter was not going to attend college cut off the funds. The patient, angry, assaulted her mother. Emergency services were called, found a young and attractive lady screaming, brought her to the hospital. There she screamed how she knew several rich and famous people (that was actually true). They "haldoled" her and she ended up on the inpatient unit.


IMHO this was a borderline, narcissistic and spoiled patient. Turned out she knew plenty of famous people, but in an ER and crisis center, someone screaming out "you better not mess with me, I know famous people" is going to make them think the person is manic or psychotic.

 

[kugel]

IMHO this was a borderline, narcissistic and spoiled patient. Turned out she knew plenty of famous people, but in an ER and crisis center, someone screaming out "you better not mess with me, I know famous people" is going to make them think the person is manic or psychotic.

I've had several who were well-connected, but we didn't know it at the time.
If you treat everyone with basic dignity, it's always a good start. If someone claims to know the governor, or the MH Board, or Jesus, or DaVinci, there's no point in confronting that directly. Unless you have proof that such is impossible, label it as "possibly delusional, but unable to determine at this time." However, the pt is "demanding, irritable, thinking that she cannot be held despite the behavior that put her on a Hold because of her connections. Overall, she is sufficiently unaware of her situation (and how her own actions caused it) that she is certain to repeat similar actions if released at this time." If her original actions were dangerous to self/others, this kind of summary statement helps bolster your arugment to "continue the hold for now in order to provide more complete evaluation and to determine if sufficient supports exist in the community to help the pt access outpatient MH services without repeating the behaviors that got her placed on a Hold."

So far, for me, these kinds of statements have worked whether the pt is manic or well-connected, both or neither.

 

[whopper]

Agree. Even if the person wasn psychotic, the appropriate response is to try to calm the person down verbally and only resort to emergency medications if that does not work.

Weird things do occasionally happen, and to assume anything going on weird is immediately psychosis will likely cause a doctor to misdiagnose and mistreat at least a handful a year. I've seen the Martha Mitchell effect happen at least once every few months. There's a reason why inpatient units have social workers. It's to figure these things out.

Correction on a prior post. I used the word "competency." I, of all people, should know that is not the correct term which should have been "capacity." Doctors do capacity, judges do competency.

 

[TheWowEffect]

The guy was tried on Risperdal and had serious side effects to it including oversedation. He also told me that he felt "wierd" on it and couldn't describe it more than that other than he was very uncomfortable and would rather be dead than on that medication. Zyprexa pretty much knocked him out. He couldn't get out of bed.

EPS/Akathisia

 

[nitemagi]

Correction on a prior post. I used the word "competency." I, of all people, should know that is not the correct term which should have been "capacity." Doctors do capacity, judges do competency.

Though in forensic settings or as a forensic consultant you can do competency evals for the court, right? Correct me if I'm wrong.

But in usual hospital/clinical care, we're always assessing capacity.

 

[zenman]

The guy was tried on Risperdal and had serious side effects to it including oversedation. He also told me that he felt "wierd" on it and couldn't describe it more than that other than he was very uncomfortable and would rather be dead than on that medication. Zyprexa pretty much knocked him out. He couldn't get out of bed.

.

Do you add Benztropine with Risperdal?

 

[nitemagi]

A guy I was with in residency (that I sometimes wonder is actually not too competent) would ask patients "do you hear voices?" They often responded, "yes I hear your voice." He then immediately put them on Risperdal. I remember one guy was already on Risperdal Consta 50 mg, and he put the guy on 8 oral mg more because the guy said "yes" and the good resident didn't check his prior meds. The patient wasn't psychotic. His psychosis was actually under control. He was in the hospital because he was very angry over a social situation and his case manager told him to go to the hospital. The guy wasn't my patient, and I noticed him tremoring and suffering tremendous anxiety. I had to intervene because the other resident, even the attending, weren't doing anything about it.

Ah the all too often misdiagnosis. I once had a guy carry a diagnosis of schizophrenia into a surgical admission, had a behavioral code called on him, because he didn't want to cooperate. I go up, guy's in a spitmask, swearing and yelling. I do a thorough history, talk to his mother. Turns out he's a gangbanger and just oppositional to authority. No psychotic history, ever. Trace it all back to the source, turns out a paramedic said he just "seems that way [schizophrenic]." The triage nurse in the ER wrote it down, and it followed him through his admission without anyone ever inquiring.

And don't get me started on kids and "psychosis."

 

[whopper]

Though in forensic settings or as a forensic consultant you can do competency evals for the court, right? Correct me if I'm wrong.

Yes, and I've done several, but I'm only writing a report that gives the Court a recommendation on competency. It's ultimately the judge that decides competency. They often times do what the doc tells them but not always.

I was in Court once, and I told the judge I could not render an opinion. Well, let's just say the judge was ticked off because she was expecting me to pull out the crystal ball and say something that allowed her to not critically think about the issue herself. (The case was a stalker. The Judge asked me if I thought the stalker was safe for discharge. I told her I could not render an opinion because he showed chronic and consistent signs of predatory violence without affective violence. That is the person could show a flat affect, stab someone, and show no signs of any emotion before or after the attack. The simple fact that he was in a forensic hospital for one year with no problems gave me no insight http://forensis.org/PDF/published/2006_TheEmpiricalBas.pdf ).

I also saw a judge in-chamber and privately tell me that she thought one doctor's opinion was pretty much bull$hit because she knew he was a hired gun willing to say anything to get anyone off so long as he got paid enough money. (Yeah and this guy is a PD at a fellowship at a brandname institution.... )

Do you add Benztropine with Risperdal?

Nope. I stopped the Risperdal. I too thought EPS and akithesia. He did have tremor, but I did specifically ask him if he had anxiety (he said no) and if walking around made him feel better, and he said no to that one too. He basically told me he couldn't explain it better than that, and after a few moments told me something to the effect that he was sincerely trying to work with me and my medication recommendations. That was of relevance to me because we were both in Court just a few days prior, where the judge ruled in my favor to force medications as his treating psychiatrist saw fit. I didn't go the benztropine route because he was on a low dose of Risperdal, and it had no benefit so I expected even worse results with a higher dosage. I decided to actually believe him and I after try #3, Abilify, he said he actually felt better from the medication with no side effects.

In the case of patient #2, it turned out (thankfully) he was transferred to unit where he actually went to a real psychiatrist. I was fearing he'd get some idiot who'd label him as psychotic (when IMHO his psychosis was under control) and then put him on forced-medication gumbo because the patient refused to acknowledge he had HIV. Since I was able to get court-ordered meds with the order good for a few more months that would allow an idiot overmedicating doctor to have free reign to unleash their horrors. I think that's the biggest reason why I was frustrated over this case.

Thankfully my fears did not become a reality. The new psychiatrist learned that the patient was raped in prison. After talking about it, he is now of theory that the patient had a PTSD like disorder, where he did not have many of the symptoms of PTSD, but the humiliation effect it had on his ego and masculinity was tremendous. His denial of HIV, while an ego-defense mechanism, is ingrained in his humiliation over his rape in prison. To admit he has HIV would be a type of admission that his rapist will ultimately have the final victory, by giving the guy a fatal illness, and taking away something the guy truly loves and that is being with women.

When the other doctor told me this, I felt a reaction like he caught lightning in a bottle. It all made sense. Ever have a bunch of theories, but when you land on the one that turns out to be true you just have a feeling it's true before you test it? Happened here. (Of course it may not be true, but we both got the feeling he's right in the way described). The good doctor is now doing psychotherapy with him concerning this and is hoping to convince the guy to open up for HIV follow-up.

That was something I needed for my faith in medicine after seeing a bunch of quack doctors one after another in private practice. I got 5 new patients in the last week and each of them had a horror story about their prior psychiatrist (e.g. he met them in a parking lot to hand them their Suboxone script, gave an amount not considered appropriate, refused to wean the patient off the medication, and when the patient called the office to have his records transferred to me, the doctor didn't have any. Could it be he basically just gave anyone who asked Suboxone so long as they paid him?)

Ah the all too often misdiagnosis. I once had a guy carry a diagnosis of schizophrenia into a surgical admission, had a behavioral code called on him, because he didn't want to cooperate. I go up, guy's in a spitmask, swearing and yelling. I do a thorough history, talk to his mother. Turns out he's a gangbanger and just oppositional to authority. No psychotic history, ever. Trace it all back to the source, turns out a paramedic said he just "seems that way [schizophrenic]." The triage nurse in the ER wrote it down, and it followed him through his admission without anyone ever inquiring.

And don't get me started on kids and "psychosis."

Exactly what I'm whining about above. There's too many idiot doctors out there with their 3.9X GPAs from college and medschool that don't have any common sense, diagnose and label anyone showing any type of frustration and anger, and then the real doctors got to clean it up. A bunch of those kids who got diagnosed as bipolar but don't have it are showing up in forensic units being found not guilty by reason of insanity or having their charges dropped becuase of "Bipolar disorder" and it turns out the kid actually had Conduct Disorder and they had some case manager get the kid diagnosed so the kid could get better services and the parent could get some type of check in the mail.

Of course we cannot comment on the following case, but it begs questions that I think are valid. I see a generation of several children being misdiagnosed, and as a result, plenty of problems happening.

http://www.cbsnews.com/stories/2007/09/28/60minutes/main3308525.shtml

 

[Manicsleep]

I saw a case of a guy like your gangbanger get conserved because he was on massive doses of antipsychotics and remained defiant and antisocial. So he would fight and get agitated, refuse meds, attack staff which everyone thought was a confirmation of the psychosis diagnosis.

We did the same thing, found his family who really didn't care about him and with serious effort realized he was just more a sociopath than anything. Gradually took him of 7 psychotropic medications and eventually placed him on strict behavioral modification. He continued to be a jerk but that was about it.

Residency...good times.

 

[kugel]

when the patient called the office to have his records transferred to me, the doctor didn't have any.

It's also possible that the pt was not telling the entire truth.
There're probably unjustified complaints or bad stories against all of us out there somewhere.
Patients who don't like what we did or said twist the story in their favor (as do we all).
When patients (or anyone else) tell me a story of how they were mistreated, I tend to believe that it's about 50% true.
When anyone tells me about how "Everyone" has mistreated him, I tend to believe about 20% of the story.

 

[Ibid]

http://pn.psychiatryonline.org/content/46/5/16.3.full

Psychiatric News March 4, 2011
Volume 46 Number 5 Page 16
© American Psychiatric Association

"A bill introduced in the Florida legislature would prohibit doctors from asking patients about gun possession, threatening both freedom of speech and the doctor-patient relationship."

I suppose you just assume everyone has an AK-47 and a good stock of RPGs if this goes through.

 

[whopper]

It's also possible that the pt was not telling the entire truth.

True, but I've got a few patients who had the same doctor that are all telling me similar stories, and these patients don't know each other. They also told me they didn't want to see the guy anymore because they didn't think he was on the up-and-up.

It's to the point where I find the story believable. One guy, one story, I would be neutral. 5 guys, five similar stories on the other hand....

 

[kugel]

It's to the point where I find the story believable. One guy, one story, I would be neutral. 5 guys, five similar stories on the other hand....

Absolutely agree. A pattern is a pattern.

I just want to warn students and residents against accepting stories regarding other docs at face value. It's very tempting to accept stories that indicate "I'm so much smarter than your previous doctor."

The vast majority of "bad doctor" stories I get are of docs doing reasonable things that just didn't work out, or the patient just didn't like that the doctor "wouldn't just do what I said." Often, when I question further, it turns out every former doctor for this patient has been "bad" and every medication and combo has been either useless or produced side-effects. If at this point I'm convinced of a Personality Disorder (esp Borderline), I express my sympathy that all of these medicines have not worked as hoped. Then I suggest that there is little chance I will magically happen onto a mystery cocktail that will solve all the patient's problems. If the patient agrees, I suggest a program to taper off the medications and concentrate on therapy and skills training as the primary treatments. I suggest the pt google something I heard about called "dialectical behavior therapy," so the pt will begin looking for a therapist and advocating for him/herself. Often enough, it works.

If the patient explodes yelling that it's my job to keep trying ever-more complicated combinations, and I must be an idiot to think the pt should go without medications (that have done nothing but harm), well then we've arrived at the expected outcome, i.e. I'm the next worthless doctor. We just got there sooner than planned. And the pt can go on to tell the next doctor what an idiot her last psychiatrist was. I'm sure I am that person to a number of patients. I hope the pattern is not consistent enough to make me one of Whopper's stories.

But, yes, Whopper. I diagnose nearly everyone with Bipolar Type VII.
JK!