Conditional Suicidality-a protective factor

[whopper]

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There was an article on this. Don't remember when it was published, but I believe it was within the last 4 years.

The article basically showed that conditional suicidality (e.g. I'll only kill myself if you don't get me housing) is a protective factor.

Can't find the article on pubmed. Anyone read this article & remember where it was published? A colleague asked for it.

 

[Anasazi23]

There was an article on this. Don't remember when it was published, but I believe it was within the last 4 years.

The article basically showed that conditional suicidality (e.g. I'll only kill myself if you don't get me housing) is a protective factor.

Can't find the article on pubmed. Anyone read this article & remember where it was published? A colleague asked for it.

I don't know the article, but it makes perfect sense. It basically demonstrates forward thinking, which logically is completely opposite of the primitive guise of the intended purpose of the comment, which is a suicidal 'threat.'

 

[Regnvejr]

There was a study done on inpatient psychiatry suicides over 10 years, about 715 of them or so. Conclusion was that the suicidal patients generally were of, it was the intoxicated patients with anxiety that ended up suiciding.

When I check suicidality, I ask for passive vs active thoughts (actually doing something vs "ok if I happen to die"), and whether the thoughts are intrusive or overwhelming, turning into urges that makes the client feel unsafe.

That generally gives me a good sense of the safety issue at stake.

I don't recall the article you ask about, but it would not be significant. It is to insistent on a single event, almost more reflecting of a personality disorder.

Now, in chronic pain, progressive dementia and similar, where today sucks, tomorrow also sucks, and there is no prospect of next week being any better, then such conditional aspects become more significant. And also harder to deal with. If somebody suffers progressive and debilitating pain and relates that when the pain gets to much then they will kill themselves, then there is little you can do. Are you putting them in the hospital? Unless you can fix their pain, then they face the same scenario after discharge and will then be right back again in same situation.

You can connect them with hospice and similar, but if the progressive deterioration is not estimated to be fatal within 6 mths, then they don't qualify for hospice.

At that point, there is not a lot you can do. If they have intent, then they will at some point end up trying.

You can try the various active and passive treatment modalities for pain, but an effective suppression of pain in a longterm scenario will not happen. No physician will put their license to a patient insisting on more pain meds over many years in order to not kill themselves. So then you are thoroughly stuck.

Welcome to that's the hard decisions you get paid the big bucks to make.

Suicidal ideation vs intent and risks is a messy "field" of study that is descriptive only and speculative at best. Just make sure you are in the habit of ALWAYS asking about suicidality. Else you WILL flunk the boards and to your great surprise find you lose a few patients that you thought were stable.

 

[Abram Hoffer]

Not sure about the article, but this is a good site for the topic of suicide.

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[whopper]

I remember the article, but unfortunately can't find my copy of it. I was considering replicating the study. I felt it was a very clinically relevant study since most of us who have worked in an urban psyche emergency center get our fill with people claiming to be suicidal, only if we don't give them food & a place to stay, while not behaviorally showing symptoms of an Axis I disorder other than irritability. The so called "professional patient".

However it was only 1 study, and I could not find similar studies. I believe if more were done, it could lead to a better way to handle these types of patients instead of the typical scenario where the psychiatrist is held hostage by them, forcing the psychiatrist to acquiesce to their demands or to call them on a probable bluff--neither of which are good choices. This is a particular issue I have seen tackled little in academia. My own suspicion is because no one wants to approach this very tough, but very common issue.

I remember the person who presented this for journal club, so I'll give him an email. Faebinder, want to do me a favor & ask Mike C the PGY III where he got the article? He was the guy who presented it.

 

[BabyPsychDoc]

people claiming to be suicidal, only if we don't give them food & a place to stay, while not behaviorally showing symptoms of an Axis I disorder other than irritability. The so called "professional patient".

However it was only 1 study, and I could not find similar studies. I believe if more were done, it could lead to a better way to handle these types of patients instead of the typical scenario where the psychiatrist is held hostage by them, forcing the psychiatrist to acquiesce to their demands or to call them on a probable bluff--neither of which are good choices.

How 'bout just sending them on their way, after a polite explanation that you do not think that they are mentally ill and, while it is of course their right to kill themselves whenever they choose, there is little you can offer them under current circumstances?

During my 3-month long Emergency Psych rotation, I had a patient like that. Worked like magic...at least for a week. He'd still turn up every Friday, demanding the same thing using the same threats - but (SHOCK) did not even inflict any harm upon himself, much less kill himself...

 

[whopper]

Which is actually something I have done several times. I've worked in a psyche ER for 4 years. At my place of residency we had to do call there and do several months of rotations there.

However nonetheless, you are playing poker. You are calling a bluff based on clnical judgement with little evidenced based medicine to back you up.

And--some patients are known to call the bluff. Several of my colleagues were absolutely convinced a person giving the suicidal threat was not willing to kill themself, but after becoming very upset with a doctor that would not admit them to inpatient, were willing to superficially cut their wrist in an angry expression to prove a doctor wrong (which can give people an ego stroke--remember we're docs, if we make people upset or happy, the feeling can be intensified by our status), the desire to use that to sue the hospital, and the knowledge that being in a hospital will get them immediate treatment for the superficial cut.

This action of "upping the ante" is known & documented to happen in the psychiatric literature. Several Borderline patients for example, once their suicidal threats are know, will up the ante & actually start causing superficial harm to themselves, if that is ignored, they would up the ante even more. A doc I had in residency mentioned she had a case where a patient upped the ante to the point where she actually turned on the gas stoves in her house during arguments with the husband, and was known to do so for years, the husband & doc ignored it. She kept pushing & pushing the duration of time she used keeping them on, and eventually died from it.

I had a guy try to play hang himself in the hospital bathroom after we played our "poker" against one another. The guy was still IMHO not suicidal, and knew full well what he was doing. He got a cord, put it on a light on the wall, left the bathroom door open so hospital staff could see him, and they had to react.

So now he's in inpatient, and on day 1 he's calling up people to arrange a drug deal and bragging about how how he's going to stay in the hospital for free food & money until he can arrange for better housing on his own, once he can get some drug trafficking money. He even went on to mention about how he was planning on pickup up some hookers after discharge.

I witnessed the event, and then told the attending, and reccomended the guy be discharged. The attending actually didn't want to do it because the guy became "suicidal" again. However the guy was eventually discharged later that day because higher powers got involved and made the discharge happen (that attending was known to play it too safe).

The worst case I've heard about was about a Borderline person who would go to the most expensive restaurants in a big metropolitan area in the US, ate the most expensive dishes, and when given the bill, took a razor out of his pocket and demanded he be given the meal for free or he'd cut his neck, and he was actually known to cut his neck--which he would do once emergency services had arrived, and the restaurant wasn't willing to drop their demand that he pay the bill.

 

[Abram Hoffer]

Which is actually something I have done several times.

However nonetheless, you are playing poker. You are calling a bluff based on clnical judgement with little evidenced based medicine to back you up.

And--some patients are known to call the bluff. Several of my colleagues were absolutely convinced a person giving the suicidal threat was not willing to kill themself, but after becoming very upset with a doctor that would not admit them to inpatient, were willing to superficially cut their wrist in an angry expression to prove a doctor wrong (which can give people an ego stroke--remember we're docs, if we make people upset or happy, the feeling can be intensified by our status), the desire to use that to sue the hospital, and the knowledge that being in a hospital will get them immediate treatment for the superficial cut.

I had a guy try to play hang himself in the hospital bathroom after we played our "poker" against one another. The guy was still IMHO not suicidal, and knew full well what he was doing. He got a cord, put it on a light on the wall, left the bathroom door open so hospital staff could see him, and they had to react.

So now he's in inpatient, and on day 1 he's calling up people to arrange a drug deal and bragging about how how he's going to stay in the hospital for free food & money until he can arrange for better housing on his own, once he can get some drug trafficking money. He even went on to mention about how he was planning on pickup up some hookers after discharge.

I witnessed the event, and then told the attending, and reccomended the guy be discharged. The attending actually didn't want to do it because the guy became "suicidal" again. However the guy was eventually discharged later that day because higher powers got involved and made the discharge happen (that attending was known to play it too safe).

Too bad you can no longer truly call their bluff and lock these guys up in the state mental health facility indefinitely.

Sometimes, these people are the ones who are so impulsive that they end up accidentally harming themselves to get their way. Then it's on your watch.

 

[whopper]

Exactly.

If you get to clinically know a patient, then perhaps after several times with seeing the patient can you determine the true extent of their bluffs.

However unfortunately, once you let them in a few times into inpatient, you've reinforced their desire to use a suicidal threat.

IMHO the best way to this should be handled (but this will not work with our current medical/legal infrastructure) is if a person is known to use suicidal threats, and once a doctor (or for argument's sake let's say 3 doctors) inspected the person, found them to not suffer from severe mental illness, that person should be discharged, and if the person is known to cause similar disturbances again that person should be arrested for using terroristic threats.

This unfortunately rarely happens. Why? Well doctors aren't supposed to be calling law enforcement & divulging the person's private information unless someone else is put in danger. In this case they are putting themselves, not others in danger.

Another problem, if you're in a psyche ER and you call the police, telling them the person is causing a disturbance, the police will tell the doc to shove it, they're not going to take the person. Its a turfing issue. They're not going to take someone claiming to be suicidal. As a psychiatrist in an ER you're stuck.

And there's no law or organized mental health infrastructure in several areas to deal with this situation.

In part, IMHO why there's no infrastructure is because of the lack of studies in this, and there's a lack of studies on it because hardly anyone is willing to do a study on this high liability issue.

Where I'm currently practicing, its a forensic psychiatric facility, and we got plenty of people who pull this type of thing, though in inpatient, and on a forensic facility, so the privacy issues are not as extensive. Forensic patients sent to such a facility are ordered by the court to be evaluated for legal purposes, and the court has the right to look into their records. In this particular case, if we got someone malingering, that can be thoroughly examined on the course of several days, psychological testing can be done to see if the person is faking symptoms (e.g. the SIRS, M-FAST, MMPI) and in this case, the records are reviewed by a judge. There's also an established procedure in the institution where such a person will be evaluated by a non-treating doctor who will then write a report as to their professional opinion whether or not the person if faking symptoms that will be given to the judge.

And the local jail also has a well established forensic psychiatrist who also calls people known to make fake suicidal threats on their bluff. E.g. the person calls a suicidal threat, they're given a suicide smock (basically a paper gown), and given liquid food or a type of mush like burger which well tastes pretty gross.

However these measures which have been put in place where I'm at are the exception, not the norm. Where I did residency, if someone in jail pulled a suicidal threat, they were immediately brought to psyche inpatient--which actually rewarded the person since the hospital is a nicer setting. Then the doc determined the guy was malingering, then he's brought back to jail, then in jail he pulls a suicidal threat again, and he's brought back to psyche inpatient, yada yada yada....

Too bad you can no longer truly call their bluff and lock these guys up in the state mental health facility indefinitely.

Actually, in some cases, that's the person's game. In the case I mentioned above where the guy was planning a drug deal, he wouldn't want to be in the facility indefinitely. However I have seen others where that was their intent for whatever twisted reason--e.g. they had a boyfriend or girlfriend in the state facility.

 

[Abram Hoffer]

Actually, in some cases, that's the person's game. In the case I mentioned above where the guy was planning a drug deal, he wouldn't want to be in the facility indefinitely. However I have seen others where that was their intent for whatever twisted reason--e.g. they had a boyfriend or girlfriend in the state facility.

I forgot about those societal winners. If you look at it from a cognitive standpoint, you must ask yourself, why the power struggle with these people? It's a quick reminder not to be very much bothered by letting them in the door. If their best coping skills are to use the mental system for safety and security, they are not the most fit to survive in the real world. Rationalization is key. Avoid the emotional whenever possible, right? Back to the original content of this thread... does anyone have this article?

 

[whopper]

Well, somewhat repeating myself, but I've known several who wanted to go to the state facility because--it was summer and that facility had a pool. They had drug dealers out to kill them, they wanted to be in the facility for several months while those drug dealers forgot about them, they were charged with a crime, and wanted to feign insanity for a duration where they hoped statue of limitations would set in--so that'd require a few years.

An old attending I worked under had a rule. If the person was truly mentally ill fine. If not, use the rule of opposites. They want inpatient? Don't admit them. If they wanted discharge, keep them in longer than they wanted (all justifiable IMHO, after all this person frequently claims to be "suicidal", and had been admitted about a dozen times in the last 2 years, shouldn't we be investigating the case more deeply?). If they didn't want to go to the state facility-transfer them there. If they wanted to go there, no transfer there. It was all designed to keep out the professional frequent flyers from not getting what they wanted, so they couldn't successfully play the game. You know what? It worked. Recidivism dramatically dropped once he started working there, and there was no increase in bad outcomes for those people involved.

But getting back to the original point, I remember the specific resident who presented the article. Faebinder is currently a resident at the program I'm at. I posted for him to ask the resident, but he might not have read this thread. So I'll contact the PD, program coordinator and other residents to ask him since I don't have his phone number. If I find out, I'll post about it.

 

[BabyPsychDoc]

whopper, I am curious - is there any legal obligation for a psychiatrist to keep a person with Axis II dx from harming themselves? In the UK, there is not - unless an Axis I co-morbid dx is present. So, upping the ante would not really work well here - especially if you can demonstrate you have exhausted all possible options (ie, referral to therapeutic community, follow-up with PCP, possibly follow-up with Crisis Resolution Team, etc). As you rightly mentioned, admitting these pts only re-inforces their maladaptive behaviour - and in this country, it would be a reasonable argument, acceptable in the court of law.

I am just trying to understand the differences between the two systems.

Thanks,

 

[whopper]

is there any legal obligation for a psychiatrist to keep a person with Axis II dx from harming themselves?

At least in the 2 states where I've worked no, and this is what is going on in at least most states in the US from my understanding (it would depend on the individual's state laws).

The problem though is several with a Cluster B Axis II have a comorbid Axis I, people with an Axis II are at higher risk of harming themselves, even if it is due to reasons of their own volition that are not related to an Axis I disorder, and several with a Cluster B are litigious and/or have litigious family members willing for exploitative reasons to want to sue the doctor.

Also if that case went to court, offer the right amount of money and there'll be doctors going to say the patient might not be borderline, but Bipolar. I've seen that happen several times, even by doctors which may have some respect from their clinical colleagues because those clinical colleagues don't follow that doctor's court records, and see the BS testimonies that person has pulled. (OK sorry for the rant).

The Borderline/Histrionic/Antisocial suicide threat is an issue that IMHO should be more actively investigated, researched, and with better professional guidelines than is currently established. I might consider doing some research in that area, but for now I'm just focusing on the boards.

 

[Regnvejr]

The worst case I've heard about was about a Borderline person who would go to the most expensive restaurants in a big metropolitan area in the US, ate the most expensive dishes, and when given the bill, took a razor out of his pocket and demanded he be given the meal for free or he'd cut his neck, and he was actually known to cut his neck--which he would do once emergency services had arrived, and the restaurant wasn't willing to drop their demand that he pay the bill.

Really doesn't sound like BPD. Scamming with disregard for pain to one own is not borderline PD, it is anti-social PD. I see a big difference.

 

[Regnvejr]

Really, the best fit for real BPD (as per the actual DSM diagnosis, not just "difficult" and "self-harm") is Dialectical Behaviorl Therapy. The research is pretty solid. I recommend everybody study it a bit, also be clear on the difference between borderline and antisocial PD. They are not the same, nor is treatment.

 

[kugel]

is there any legal obligation for a psychiatrist to keep a person with Axis II dx from harming themselves?

Don't know of any law anywhere in the US that poses a legal obligation for psychiatrist to keep ANY person from harming themselves. In most states we MAY hospitalize a pt against their will for being a danger to self/others. That's a different thing.

My hosp has come to the conclusion that "we will not be held hostage by complaints of suicidal ideation." The key is consistency among the staff. In order to achieve that, you have to be communicating the expectation that it is approp to discharge such pts and that admitting such patients because "I just didn't want the liability," is unacceptable. Medical staff should be held accountable to show evidence that the admission is warranted and that admission can be reasonably expected to improve the patient's condition.

When it comes to discharging a patient from Inpt or Emerg with stated SI, document, document, document. Document the exact wording of the complaint, any hints (or direct statements) about the conditional nature of the suicide threats, document the affect during the interview and when just "hanging out" with peers, document statements to other staff, document pt history when known, and document the patient's reaction when told, "When I checked a little while ago, all our beds were spoken for. So, if when I check again, we don't have any beds, where will you be staying tonight?" Document that you discussed the case with another doc (name him/her) who agreed that the complaint appears manipulative. Document something like that "while it is possible that the pt may end up hurting himself, the risk is considered somewhat low due to the info above. Also, it is not in the pt's best interest to allow him to come to believe that the only way for him to deal with adversity is to seek hospitalization with suicide threats." If it ends up in court, you don't want it to look like you had no ability to see that there was some danger - that just makes you look incompetent. But you want your thought process clear and your reasoning on paper.

Document, document, document that "the condition is considered chronic as evidenced by...." and that acute hospitalization is unlikely to improve that and may well continue and strengthen the suicidal cycle.

Call the Chief of the service, and document the time of the call and that the chief agrees that discharge is the appropriate course of action.

I have personally discharged a number of such patients from the psych emerg service, only to have them brought back by police in min to hours. When I explain that the person has been adequately evaluated and determined NOT to need acute inpatient services (one who the scratched her wrist in the parking lot), the police usu get the idea and stop brining him/her (at least on this shift).

Can such people kill themselves? Yes, it does occasionally happen.
Does that justify admitting everyone who admits to conditional SI or even those who make suicidal gestures? IMHO, No. We have a responsibility to advocate for PROPER patient care, not just defending against lawsuits, and we have an obligation to utilize resources properly - and that does not include admitting for the primary purpose of CYA (esp when that will do the pt more harm than good.) IMHO, we should not be INCREASING the eventual risk of suicide by reinforcing this as a coping skill among those who already have more sophisticated capabilities.

Let's hope that's the end of my weekly (weakly?) rant.

 

[whopper]

Scamming with disregard for pain to one own is not borderline PD, it is anti-social PD. I see a big difference.

The case was complicated but from the lecture, his psychiatrist did say he was convinced it was Borderline, though yes, scamming is an antisocial trait. Like the DSM mentions, not every presentation is going to represent the disorder perfectly.

The person had a history of self mutilation, and was institutionalized from a very young age. Per the treating psychiatrist, he learned to figure out how institutions deal with self mutilation and learned to manipulate it.

Don't know of any law anywhere in the US that poses a legal obligation for psychiatrist to keep ANY person from harming themselves. In most states we MAY hospitalize a pt against their will for being a danger to self/others. That's a different thing.

True, and consistency is the key. Where I did residency, 2 attendings were in inpatient. One (X) wrote down "depressive do nos" on the discharge summary often times not very convinced it was even that for whatever reason. Then when the person showed up again at the psyche ER, now the psyche attending there (and it usually was a different attending) has a person holding them hostage with a suicidal threat, and thanks to the other doctor who wrote down "depression" on a discharge summary that other attending is now even less likely to keep the person out of inpatient.
Add to what I thought was ridiculous, the same attending that wrote down the depressive DO NOS diagnosis would get mad everytime the same patient came back, as if he he had no responsibility over it, but at the same time he didn't change the diagnosis. He kept with the DD NOS.
The revolving door begins.......

Attending Y would consistently document that the such a patient had a known history of the problem, didn't show objective behavior of an Axis I (other than malingering or other similar disorders) and everytime he saw the patient he kept up with that.

At the place where I was at (no longer there)--here's the problems I saw...
1) inconsistency with documentation as mentioned above
2) if the police brought back a person, the person always had to be medically cleared. They'd go through the ER doctor. The ER doctor (depending on the doc), some of them just readmitted the person because they knew they could dump them to psychiatry. In that regard it was up to the ER doctor, not the psychiatrist to be the gatekeeper. The better docs were on board with the psychiatrist once they did a doctor to doctor & explained the situation. The more lazy ER docs just kept readmitting them. So it depended on which ER doc was on duty. Once the patient was processed by the ER doc, and then seen by the psychiatrist, if that psychiatrist called the police, they'd refuse the pick up the person, citing "he's suicidal, that's your problem, not mine."
3) since there was an inconsistency among doctors, specifically the psychiatrists & ER docs, what should've happened IMHO (as a former resident so no one was going to listen to me), was that the administration and dept heads of both the ER & psyche dept needed to have a meeting on how to settle this problem. That didn't happen. IMHO it didn't happen because there was a culture were doctors were given a lot more leeway with errors. If someone made a mistake for example, the nursing staff got yelled at a lot, while docs were given more leeway with their own errors. Though in this situation it really wasn't the staff furthering the revolving door.

What ended up happening was that the inpatient nurse manager, who kept track of the problem frequent flyers would always make sure attending Y took the problem patients which solved the problem at least on that end. It was though unfair to that guy since he then had to deal with the problem patients more. Classic case of big institution-good work gets punished, laziness gets rewarded culture.

Now as much as that sounds like a bash of the particular place where I was at, I've seen this cultural thing happen almost everywhere, just manifested in different ways. In big psyche institutions with hundreds of psyche patients for example, the good psychiatrists are given the tougher cases because the administration knows the bad psychiatrists can't handle them--so now the bad psychiatrists got an easier job.

 

[BabyPsychDoc]

What ended up happening was that the inpatient nurse manager, who kept track of the problem frequent flyers would always make sure attending Y took the problem patients which solved the problem at least on that end. It was though unfair to that guy since he then had to deal with the problem patients more. Classic case of big institution-good work gets punished, laziness gets rewarded culture.

Now as much as that sounds like a bash of the particular place where I was at, I've seen this cultural thing happen almost everywhere, just manifested in different ways. In big psyche institutions with hundreds of psyche patients for example, the good psychiatrists are given the tougher cases because the administration knows the bad psychiatrists can't handle them--so now the bad psychiatrists got an easier job.

I am not sure I would agree with "good work gets punished, laziness gets rewarded" statement. If you enjoy your job, you enjoy doing GOOD job and having a good reputation based on that, even if that means more work (after all, you enjoy doing your job, right?). I would be embarrassed if colleagues "eased" my workload based on their perception of my inability to cope/poor judgement. I guess, it depends on the perspective...

 

[whopper]

Which is exactly the attitude people in the administration like. If you have that philosophy good for you if it works for you.

As for me, I got 4 battling robots on my unit who punch each other every few hours, while another guy's unit only has easy patients, and that guy actively tells his patients that psychiatric medications are poison (I'm not joking). I've gotten attacked and so have staff & other patients.

He & I had our units switched. Since the switch the amount of agitated episodes on my former unit dramatically increased, and the one I took over dramatically decreased. The administration saw that and started putting more of the difficult patients on my unit. How difficult? Well pretty much the most difficult in the hospital which has a few hundred psychiatric patients.

and to do the "good" job, I have to spend about 5-10 extra hours a week that I'm not getting paid for to get the job done. Before I had my unit switched, I had about 2-3 hours a day of work with nothing to do. 5-10 hours a week unpaid is 10s of thousands of dollars a year.

And the guy telling his patients that medications are poison is getting paid more than me because he can do some work on the side with his easier setting & more years at the job than I.

But if you'd like to be in that situation, more power to you. Remind me to hire you after you finish your training if I'm in an administrative job.

Its a reality in several job places to put more work on the good people, less on the bad people, and keep those bad people, especially if you can't replace them, which is the situation with the shortage of psychiatrists. I never minded hard work when its done as a team, not because I'm expected to fix the problems from others on the team, but hey that's just something about me that may differ from you.

 

[BabyPsychDoc]

Don't know of any law anywhere in the US that poses a legal obligation for psychiatrist to keep ANY person from harming themselves. In most states we MAY hospitalize a pt against their will for being a danger to self/others. That's a different thing.

My hosp has come to the conclusion that "we will not be held hostage by complaints of suicidal ideation." The key is consistency among the staff. In order to achieve that, you have to be communicating the expectation that it is approp to discharge such pts and that admitting such patients because "I just didn't want the liability," is unacceptable. Medical staff should be held accountable to show evidence that the admission is warranted and that admission can be reasonably expected to improve the patient's condition.

When it comes to discharging a patient from Inpt or Emerg with stated SI, document, document, document. Document the exact wording of the complaint, any hints (or direct statements) about the conditional nature of the suicide threats, document the affect during the interview and when just "hanging out" with peers, document statements to other staff, document pt history when known, and document the patient's reaction when told, "When I checked a little while ago, all our beds were spoken for. So, if when I check again, we don't have any beds, where will you be staying tonight?" Document that you discussed the case with another doc (name him/her) who agreed that the complaint appears manipulative. Document something like that "while it is possible that the pt may end up hurting himself, the risk is considered somewhat low due to the info above. Also, it is not in the pt's best interest to allow him to come to believe that the only way for him to deal with adversity is to seek hospitalization with suicide threats." If it ends up in court, you don't want it to look like you had no ability to see that there was some danger - that just makes you look incompetent. But you want your thought process clear and your reasoning on paper.

Document, document, document that "the condition is considered chronic as evidenced by...." and that acute hospitalization is unlikely to improve that and may well continue and strengthen the suicidal cycle.

Call the Chief of the service, and document the time of the call and that the chief agrees that discharge is the appropriate course of action.

I have personally discharged a number of such patients from the psych emerg service, only to have them brought back by police in min to hours. When I explain that the person has been adequately evaluated and determined NOT to need acute inpatient services (one who the scratched her wrist in the parking lot), the police usu get the idea and stop brining him/her (at least on this shift).

Can such people kill themselves? Yes, it does occasionally happen.
Does that justify admitting everyone who admits to conditional SI or even those who make suicidal gestures? IMHO, No. We have a responsibility to advocate for PROPER patient care, not just defending against lawsuits, and we have an obligation to utilize resources properly - and that does not include admitting for the primary purpose of CYA (esp when that will do the pt more harm than good.) IMHO, we should not be INCREASING the eventual risk of suicide by reinforcing this as a coping skill among those who already have more sophisticated capabilities.

Let's hope that's the end of my weekly (weakly?) rant.

Sounds great to me. The only catch is that this approach, imho, requires a good deal of teamwork and communication - both on horizontal (resident-to-resident, attending-to-attending, nursemanager-to-nurse manager) and vertical (nurse-to-resident-to-attending-to?-Chief of service - to?) levels. I think, frequently such patients are admitted purely due to the lack of such communication (tired resident who does not want to deal; tired resident who does not want to call backup attending in the middle of the night; lazy resident; unsupportive attending; and yes, ER docs that want the pt off their turf...) It sounds like your hospital is doing a great job in overcoming these hurdles - and improving patient care.

 

[BabyPsychDoc]

Which is exactly the attitude people in the administration like. If you have that philosophy good for you if it works for you.

As for me, I got 4 battling robots on my unit who punch each other every few hours, while another guy's unit only has easy patients, and that guy actively tells his patients that psychiatric medications are poison (I'm not joking). I've gotten attacked and so have staff & other patients.

He & I had our units switched. Since the switch the amount of agitated episodes on my former unit dramatically increased, and the one I took over dramatically decreased. The administration saw that and started putting more of the difficult patients on my unit. How difficult? Well pretty much the most difficult in the hospital which has a few hundred psychiatric patients.

and to do the "good" job, I have to spend about 5-10 extra hours a week that I'm not getting paid for to get the job done. Before I had my unit switched, I had about 2-3 hours a day of work with nothing to do.

And the guy telling his patients that medications are poison is getting paid more than me because he can do some work on the side with his easier setting & more years at the job than I.

But if you'd like to be in that situation, more power to you. Remind me to hire you after you finish your training if I'm in an administrative job.

Damn, that sounds really tough. Good luck - and hang in there; after all, you will be starting your fellowship pretty soon, won't you? Hope, it will give you some nice change of pace.

 

[whopper]

Well I actually do like my job. I really actually get an ego stroke getting a patient that 3 other doctors worked on and couldn't figure out what was going on, and I do a few extra hours of research and figure out what's going on.

Just that, and I'm not joking, I'm actually starting to get what may be signs of arthritis on my right leg because I'm running around so much on the unit & in the building, knowing that I'm getting paid about $50K less a year vs the guys that are not putting the feather in the cap because they're able to have a side job because their situation is much easier than mine, and I got 4 battling robots (defined by attacks every few hours) on my unit while most units have none.

And earlier this week, the county board tried to give me a patient with 15 medical problems several of which require higher maintenance, e.g. the person is a brittle diabetic and has several heart problems, but requires large amounts of antipsychotic to be stable. The patient had already been assigned to another doctor, and they were trying to get me to take over the patient. I asked them why me? "Well we like the work you do, we'd rather you work on this patient than Dr. X". Translation-I'm already working overtime without pay, that doctor isn't and you want me to take over a patient that's probably the equivalent amount of work of 4 easy patients?

I do enjoy the work, just that I'd enjoy it a hell of a lot more if I got paid for the work I'm doing. Other places would do that for me. The place I'm at, its been a great run, but I'm going to be thankful when it ends in June. In the administration's defense, they actually have tried to get me more pay, but can't because of constrictions the state has placed on them. E.g. I can't get a raise until I've worked there for more than 1 year. I got a 180/200 score on my attending evaluations, and they said that'd put me in an automatic raise--but not now. They also tried to get me set up with a program where the state pays me more because they realize I'm doing more work than the other attendings, but the idiot in the state that has to send me the contract for me to sign for that never answers the phone, and is in a building somewhere else in the state. My 2 bosses & I have been calling this person since August and no call back. I'm starting to understand the old conservative mantra that the private industry does it better than the state.

It really has been a good year in terms of what I've learned, and wouldn't have elsewhere. Had I stayed at the same hospital where I did residency, I don't think I would've learned much at all, I plateaued with what they could've taught me. I'd actually reccomend any brand new graduate to work here becuase of the experience, just that I don't think I'd stay here unless circumstances changed. I'll be doing fellowship next year and may even stay at the place I'm at, just that if I were to come back to the same place, I'd make sure that my contract pays me for what I'd be doing.

 

[Still Kickin]

Its a reality in several job places to put more work on the good people, less on the bad people, and keep those bad people, especially if you can't replace them...

I've seen this happen in other (non-medical / non-psychiatric) work settings as well. And then the good people can't/won't get promoted / move up the ladder because despite the fact they're the ones most deserving of that recognition, there's nobody who is going to be able to replace them in their current job.

 

[whopper]

Exactly. Office politics go on at the hospital too. Everywhere there are groups of people working there are office politics.

You could have 10 doctors, 4 of which are excellent, 3 mediocre & 3 bad. If you got a shortage of psychiatrists, you can only get rid of one if you have someone to replace him/her with. If you don't you're stuck.

If you can offer a promotion to 1 of the above doctors, only 1 of those 4 excellent doctors will get that promotion. The other 3 will end up pretty much get the same pay vs the other mediocre & bad doctors. The good doctors will also be wanted by the staff & administration to handle the tougher patients because they can't rely on the worse doctors to handle it, but again can't get rid of the bad doctors.


The problem with state institutions with this regard is that they can only modify pay for the better doctors based on a generic logarithm that doesn't apply to the specific situation. A private place for example can have more leeway with a good or bad doctor by the time of the next contract.

but the idiot in the state that has to send me the contract for me to sign for that never answers the phone,

Well lo & behold, today I finally get a call back from the state concerning this. Its only been since August, that 2 of my bosses, myself, and someone in the county board between us probably made about 20 phone calls trying to get this to happen.

All in all, this thing I've been ranting about would solve itself in time, but my contract's up in July. Mentioned this but I'd be up for a raise because of the quality of my work, but I'm not allowed to get the raise becuase of some state employee rule of having to be there longer than a year to get it. My contract will be up before that time. Its been a good learning experience, psychiatrically but also in terms of learning about office politics.

 

[nicodube23]

There was an article on this. Don't remember when it was published, but I believe it was within the last 4 years.

The article basically showed that conditional suicidality (e.g. I'll only kill myself if you don't get me housing) is a protective factor.

Can't find the article on pubmed. Anyone read this article & remember where it was published? A colleague asked for it.

I found the article!

Characteristics and six-month outcome of patients who use suicide threats to seek hospital admission - PubMed

Retrospective review of patients' charts and other records was used to collect data on diagnoses, psychosocial characteristics, and subsequent suicide attempts of 45 patients who made contingent suicide threats, defined as threatened suicide or exaggerated suicidality reported to increase the...

pubmed.ncbi.nlm.nih.gov

Good luck

 

[calvnandhobbs68]

13 years later

 

[hamstergang]

13 years later

And it only took Whopper 2 months: Contingent Suicidality-a protective factor?

 

[nexus73]

I can finally discharge this guy. Thank you!