Admit or Discharge, s/p 'possible' overdose

[Psychobabbling]

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Middle aged hispanic male, learns brother died the day before, gets drunk, calls for fellow church goer to come over, tells her "he took pills." Collateral and pt are both spanish speaking, interpreter used - pt is adamant he must be discharged because he has "appointments this week" - denies SI, reticent to discuss his brother's death, denies he took overdose, denies SI - loves life, planning with son to visit country brother passed...in 8 months. Collateral says "he told me he took pills" (context unknown), is not helpful beyond that. No one else to call with any knowledge of what happened or who had seen him recently

SADPERSONS score (for those who wish to use it; I have one attending who loves it, I haven't seen anything convincing anything like this is that helpful) is 6

Denies prior history of self harm - but - first contact (by an attending, brief meeting of "why are you here" states he has a history of "multiple attempts")

Decision - admit or discharge from Psych ER & Why

 

[hamstergang]

SADPERSONS score (for those who wish to use it; I have one attending who loves it, I haven't seen anything convincing anything like this is that helpful) is 6

Maybe I should break this out into it's own thread, but the wikipedia article suggested SADPERSONS was useless. I checked the sources if cited and, if my memory's right, the scale does seem to have too low sensitivity and specificity to be useful.

 

[strangeglove]

Sounds like he tried to kill himself and now wants to take it back. Appointments next week are not a factor in decisions to involuntarily hospitalize patients, though the patients themselves will make it seem like the most important thing.


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[notdeadyet]

Maybe I should break this out into it's own thread, but the wikipedia article suggested SADPERSONS was useless. I checked the sources if cited and, if my memory's right, the scale does seem to have too low sensitivity and specificity to be useful.

Yeah, I find it's helpful as a mnemonic for teaching risk factors, but that's about it...

 

[whopper]

People drunk often times don't act the same way sober. We nickname it "drunkicidal" where I'm at.

I can't answer your question without seeing the person. Does his signs match his symptoms? How is his affect, not just in an interview but over the course of an entire day? What do the other staff members see? How reliable is the collateral.

A patient contracting for safety on their own is not good enough. If the person, however, shows no signs of depression for several hours, is future-oriented with a reasonable plan, there's going to be no known acute stressors after they leave the unit, etc.

 

[vistaril]

Middle aged hispanic male, learns brother died the day before, gets drunk, calls for fellow church goer to come over, tells her "he took pills." Collateral and pt are both spanish speaking, interpreter used - pt is adamant he must be discharged because he has "appointments this week" - denies SI, reticent to discuss his brother's death, denies he took overdose, denies SI - loves life, planning with son to visit country brother passed...in 8 months. Collateral says "he told me he took pills" (context unknown), is not helpful beyond that. No one else to call with any knowledge of what happened or who had seen him recently

SADPERSONS score (for those who wish to use it; I have one attending who loves it, I haven't seen anything convincing anything like this is that helpful) is 6

Denies prior history of self harm - but - first contact (by an attending, brief meeting of "why are you here" states he has a history of "multiple attempts")

Decision - admit or discharge from Psych ER & Why

I would discharge

 

[Shikima]

What Whopper said. +1.

 

[MacDonaldTriad]

One of the criteria for admission is that a patient has a ghost of a chance of benefiting from such involuntary treatment. Yes, preventing someone from killing themselves would be considered a benefit, but is the risk of suicide going to be much different after a few days in a hospital? If you tell me that he is an out of control alcoholic and is likely to be disinhibited and morose if let go, I could see using a hospitalization to create some sobriety while working towards ETOH treatment.

Ask yourself how you would feel about this admission if you were the inpatient doctor. If you have trouble answering, “What am I supposed to do for this guy”, discharge.

 

[Shikima]

Also, don't forget that you're violating his 6th amendment rights and need to justify it strongly.

 

[notdeadyet]

People drunk often times don't act the same way sober. We nickname it "drunkicidal" where I'm at.

Ditto this. "You're not suicidal until you're sober and suicidal..."

 

[MacDonaldTriad]

Drunkicidal people can get drunk again and do it.

 

[notdeadyet]

Drunkicidal people can get drunk again and do it.

Or they can do it when they're sober. As intoxication can lead to lower inhibitions and bad judgment, you can ethically hold someone for DTS/DTO when intoxicated. But unless you have good collateral/evidence of suicidality, it is probably a weak call to hold someone who made vague suicidal comments ("I should just kill myself") when intoxicated if it disappears as they sober up.

 

[Bartelby]

I agree with Whopper, much more information than you gave is needed. We don't know anything about his mental status exam, it is unclear who he lives with and what their comfort level is in keeping an eye on him, what means he has access to and whether those can be reduced, anything about his history, or virtually any other information aside from the fact that he appears to have attempted suicide just before coming in (as neither he nor the collateral can provide any alternative narrative like "I was trying to get high" or anything else) and he appears to be lying to you about how often he attempted in the past / minimizing his attempt.

Also keep in mind that there is a difference in saying suicidal things when drunk and doing suicidal things when drunk.

Based only on what you have gathered above I would involuntarily admit the patient. Whether the patient needs it or not is unclear, but the data above suggests (1) he just attempted suicide, (2) he's lying to you (minimizing attempt, lying about past attempts), and (3) you have no useful collateral that mitigates either one or two. Doing some due diligence in figuring out who this guy is and what his situation outside of the hospital is could change things drastically, though.

 

[shan564]

Call his pharmacy to see what scripts he has. Then assess for symptoms of toxicity from those drugs. If he only takes an SSRI and doesn't have any GI distress, he probably didn't actually overdose.

 

[hamstergang]

Call his pharmacy to see what scripts he has. Then assess for symptoms of toxicity from those drugs. If he only takes an SSRI and doesn't have any GI distress, he probably didn't actually overdose.

If the only pills available to him were ones prescribed to him (as opposed to others' prescriptions and OTCs), sure. But when is that ever the case?

 

[shan564]

If the only pills available to him were ones prescribed to him (as opposed to others' prescriptions and OTCs), sure. But when is that ever the case?

Yeah, but it's a start. I agree that people definitely abuse pills that they get from random places, but genuine suicide attempts usually seem to be with things that are easily accessible, since severe depression impairs people's ability to have the motivation to find exotic pills. But of course, that's not reliable enough to be 100% sure. In reality, if I were unsure about whether the patient actually OD'd, I'd probably consult toxicology. But observing in the ED for several hours might be good enough.

 

[hamstergang]

but genuine suicide attempts usually seem to be with things that are easily accessible, since severe depression impairs people's ability to have the motivation to find exotic pills.

You say exotic pills, I say pills that sit right next to the SSRIs in the medicine cabinet. I'd be shocked if any significant number of people who were prescribed only SSRIs had no super-easy access to other pills.

But of course, that's not reliable enough to be 100% sure.

But you did say you could use this evidence to say "he probably didn't actually overdose." That's not 100%, but "probably" is a much larger percent that I would be willing to assign based on this evidence. I honestly think it's dangerous to become so certain from such weak evidence.

 

[primadonna22274]

OMG "drunkicidal". I am totally going to use that one!

 

[AnnoyedByFreud]

So fascinating reading all the differing opinions on here. I did a rotation last quarter at a psych emergency room (in a major city), and I can say with certainty that this guy would have been turfed out. But that's probably because there is a huge pressure on that particular psych ER to get people out and open up beds, since it's the city's safety net hospital. The goal was to reduce the census as much as possible, pretty much at all times. The nurses and docs would chart "denies SI" and move on.

 

[shan564]

But you did say you could use this evidence to say "he probably didn't actually overdose." That's not 100%, but "probably" is a much larger percent that I would be willing to assign based on this evidence. I honestly think it's dangerous to become so certain from such weak evidence.

I meant that he probably didn't actually overdose on an SSRI if he doesn't have GI distress, not that he probably didn't overdose period. Of course, in reality, you'll formulate an extensive clinical assessment based on a multitude of factors if you want to have any level of certainty. I didn't specifically mention that in my post because I figured it was obvious. One of those many factors should be the patient's outpatient scripts. Another should be the collateral history. I'd probably try to get the collateral source to physically go and find out what pill bottles are at the patient's house.

I made the pharmacy comment because it's just one additional source of information that nobody had mentioned yet. Get the information and incorporate it into your risk assessment.

 

[smalltownpsych]

I agree with the poster who stated that one should weigh the benefit of more treatment as far as lowering risk. I would likely recommend a discharge as soon as he sobered up based on the denial of SI alone; however, I would really challenge some of the inconsistencies with the patient. In substance abuse treatment circles, they refer to that as a calling him out on his B.S. Doing so can actually increase rapport and maybe you can find out if the guy really wants some help and is willing to do something about it. The truth is that substance abusers often have chronic suicidal ideation when you get beneath the defenses, find that out, then you would have the grounds.

 

[Psychobabbling]

To add:
(a) lives alone, no family in area
(b) history of alcohol dependence, doesn't want detox/rehab (done in past)
(c) denies history of prior attempts, attending's first note stated he does, has no inpatient psych history at the hospital (or the other major hospital, which I have access to); one prior visit to the psyc ER (punted over for being drunk - no psyc issue); unclear if he's minimizing or if the attending asked a primarily spanish speaking person a quest
ion in english to which he just said "yeah" -
(d) he seemed bright (affect) initially, went into room, became more solemn, didn't bring up brother's death until I did, became more downcast, quicker replies, etc; difficult to tease out "is this because his older brother just passed away from an MI....or is it this plus an attempt"

"Also keep in mind that there is a difference in saying suicidal things when drunk and doing suicidal things when drunk."
--> Thus, the importance of "good" collateral info

Since this is the busiest Psych ER in a pretty large state, we have, on more days than not, 30-40+ patients in the ER at any given time. Talk about being a "safety net" for your community. His exam wasn't overly revealing, collateral was in no way helpful, and when it came down to it - all I had was "guy comes in because he told someone he overdosed in the setting of learning his brother died" - I wrote him up as an admission. (more so to monitor, no mood/psychosis to treat, didn't want help with alcohol). Attending who saw him discharged him (other attendings I know would have admitted)

Nice discussion though. We should do more of these 🙂