If you had a patient without a dx significant to suicidal risk, but had (a) mentioned chronic suicidal ideation (b) had a number of significant social/environmental risk factors (c) kept dropping hints regarding there being more to the story (a future plan,) but when pressed simply refused to elaborate... how would you approach dealing with the impasse?
Any thoughts? At what point would you be proactive? A lethal plan? Suicidal bx?
In terms of getting people to talk more about things I usually find a few things helpful:
- repeating back the lasting they said e.g. "maybe?", "a future plan?" 9 times out of 10 gets the patient to continue
- with borderline patient (and others with poor mentalization) who say "I don't know" - I usually say "you do know!" and get them to start thinking more about their feelings, motivations etc... if I feel there is more too it, I press further "what else?" I can sometimes be interrogatory but I have found it to be an effective approach and patients often say things they didn't expect like "I guess I didn't really want to kill myself then", (whilst being adamant that they did)
- tell the patient what you are thinking. they are terrible mind-readers, especially borderline patients. spell it out. "It sounds like there is more to this story...", "I feel like you might be holding back...", "I notice that you have dropped a number of hints that you may commit suicide, and I wonder whether you want me to worry about you.."
- Explain what will happen: "I am reliant on your information in order to make an assessment. Some patients feel they will incriminate themselves if they say too much. On the contrary, the less you say, the less information I will have to make an accurate assessment and tend to err on the side of caution, so you may end up hospitalized"
- Establish what the patient wants to happen - you may have to push them... they may for example want hospitalization, or they may fear it and just want to go home. Patients often withhold this, so 'play stupid' - make it quite clear you have no idea what they want and they will spell it out even though they might think 'this doc's dumb, he doesn't seem to get it!' but I don't like hints, I always get them to spell it out.
- confront the patient in an unexpected way. If they are saying they are not going to kill themselves, ask quite bluntly and incongruent with the rest of the interview "why not? why aren't you going to kill yourself?" if done in the right manner, unexpected and somewhat coldly, most patients who are actually suicidal and withholding it will break down and reveal they cannot answer in and you should be worried. rapport can then be built up by apologizing for the harshness and explaining why you asked the question.
you can document the above risk factors that put the patient in a high risk population at baseline. but that is less relevant than the current clinical picture of the patient in front of you. You are interest in: very recent suicidal behavior, prepartory acts (like writing final notes, saying goodbyes, putting affairs in order), worsening of depression, acute feelings of panic, new or worsening insomnia, recent life event involving loss, failure or humiliation, the patient making suicidal statements, inability to articulate why not suicidal or how they will keep themselves safe, recent changes in psychiatric medication, evidence of current psychomotor agitation, worsening pain, new diagnosis of serious medical illness, recent exposure to suicide - are some of the factors that could suggest more imminent suicide risk.
remember in terms of hospitalization you are concerned with whether in the next few DAYS the patient is going to kill themselves, rather than weeks or months. also there is alot to be said for your instinct. if you don't feel good about discharging them, ask yourself why and how you can justify it.
