Emergency page: "I'm lonely"

[F0nzie]

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Got an emergency page last night while on call from one of the patients of the outpatient clinic crying and sobbing on the other end of the line stating "I'm lonely". Completely helpless and wouldn't stop crying. No clear stressors other than lonliness. How would you guys handle this situation?

 

[kugel]

Got an emergency page last night while on call from one of the patients of the outpatient clinic crying and sobbing on the other end of the line stating "I'm lonely". Completely helpless and wouldn't stop crying. No clear stressors other than lonliness. How would you guys handle this situation?

"I don't know how I can properly assist you with this over the phone. I think you probably need to come into the hospital right now for admission for 4-5 days. It's clear you need the kind of support and intensive treatment that just can't be provided over the phone or even in outpatient clinic. Be sure you are safe to drive, and then come right in. Right now. Tonight. Come in now."

Seriously, there is little point in trying to argue the person out of being lonely. You have to get the patient working to convince you that (s)he will be okay and does not actually need immediate intervention.

 

[whopper]

I wouldn't know what was going on with this person without talking to them for an extended period of time but the first thing to hit my mind would be they suffered some type of acute stressor and/or they have the cluster B feeling of chronic emptiness.

Unless the scenario you are in calls for you to deal with people over the phone and offer them support, and I've never seen this asked of a psychiatrist, I'd refer them to services whether they be outpatient or inpatient after determining the severity of the situation. If you're in a hospital, this doesn't have to be done by you, at least in the hospitals I've worked.

I'd also mention to the person that it'd be better to do this in person than over the phone.

 

[Doctor Bagel]

Such a timely thread. We have to cover calls for our outpatient clinic while on call, and the calls we get are often kind of ridiculous. We get no guidance on how to deal with these calls, and it especially doesn't help that all the non-residents in the clinic (who generally have the patients who are calling), leave very brief notes about treatment plans and whatnot.

From what little I know, I'd assess for immediate safety. If they deny SI and assert that they feel safe, I'd say something like I'll let your provider know that you called, blah, blah, blah. What I've discovered is that some of the callers just want someone to talk listen to them for 10 minutes or so, and then they're OK. I'm not sure about the long term appropriateness of this as a treatment strategy, but I'm not really worried about long term appropriateness of treatment strategies for clinic patients when I'm on call. I've got other stuff to deal with.

At least we don't have to cover DBT calls at the VA anymore. That was fun. 🙄

 

[belle54321]

To Doctor Bagel
Just curious, do you and how do you document these conversations that you have over the phone while you are on call?

 

[nitemagi]

1. Are you safe? Not having thoughts to hurt yourself or anyone else?
2. You sound like you're struggling. It's often hard in the middle of the night. I have to admit that since I'm only the doctor on call I don't know you very well. But there must have been something you've done before for yourself when you feel this way, even just to feel a little bit better? [Presuming it's not cutting.] Ok, that sounds good. Can you do that tonight. Now I think the best thing is to talk out these problems with the person that knows you best - your regular therapist or psychiatrist. Can you call them first thing in the morning? Good.
3. [If still upset, say d/t ongoing anxiety]. Well let me teach you something really quick to get that under control. Then lead through a breathing exercise that they have to practice for 10 minutes straight. As much as is needed.

I agree that this person can't cope with basic stress. I don't know that this necessarily equates to a diagnostic sign for cluster B. Sensitive but not specific. Could be the person is in crisis for other reasons (death of their spouse of 30 years) and having trouble expressing that. Same reason we don't diagnose a PD after a single visit. In the right combination of circumstances, anyone could regress to primitive coping mechanisms and look like a PD.

 

[F0nzie]

I ended up spending about 1 hour on the phone because I felt sorry for this poor lady (it was unfortunate to come at the start of my shift with 5 consults pending to be seen) I had a lot difficulty articulating how to initiate closure and reassurance while she was crying on the other end of the line. The other aspect that made it difficult for me was the fact I had no clue who this lady was. Reading everyone's comments definitely gives me a better grasp of how to handle this type of situation more confidently. Thanks for all the feedback!

 

[nitemagi]

I ended up spending about 1 hour on the phone because I felt sorry for this poor lady (it was unfortunate to come at the start of my shift with 5 consults pending to be seen) I had a lot difficulty articulating how to initiate closure and reassurance while she was crying on the other end of the line. The other aspect that made it difficult for me was the fact I had no clue who this lady was. Reading everyone's comments definitely gives me a better grasp of how to handle this type of situation more confidently. Thanks for all the feedback!

Another strategy I point out is someone's breathing, particularly if they're crying. Have them take 2 or 3 deep breaths (sometimes really have to guide them through it one breath at a time). "When we feel pain, emotionally or physically, we tend to hold our breath. It's natural, everyone does it. But when this happens it makes the emotions feel like they're overflowing. Sometimes just breathing can make us feel we can handle a little more." Guide through a couple of breaths, re-check to see how they feel. Almost Every time this breaks the crying spells, and guides their focus to something else.

 

[toothless rufus]

Got an emergency page last night while on call from one of the patients of the outpatient clinic crying and sobbing on the other end of the line stating "I'm lonely". Completely helpless and wouldn't stop crying. No clear stressors other than lonliness. How would you guys handle this situation?

After 5 years of crisis call experience, a tried and true method for resolution: Crinkle a plastic bag near the phone, say that you are losing the connection, and then hang up the phone. But do it gently.

 

[F0nzie]

crinkle a plastic bag near the phone, say that you are losing the connection, and then hang up the phone. But do it gently.

lol

 

[Doctor Bagel]

To Doctor Bagel
Just curious, do you and how do you document these conversations that you have over the phone while you are on call?

Our EMR has a telephone call entry where you leave the note. Generally, documenting safety is the first priority. After that, I'll leave a brief note about the conversation with a special focus on anything to pass on the provider. For the frequent callers, my notes are quite brief.

I think bigger picture issues around phone calls are really interesting, especially for me as a future outpatient provider. I'll have to try the breathing tip next time I get someone in a crisis. Actually that would have been great for those DBT calls.

 

[Indodo]

I dont know the right answer here but how about letting them cry it out for a couple of minutes.

 

[nitemagi]

I dont know the right answer here but how about letting them cry it out for a couple of minutes.

Recognize the risk that a few minutes could be a much longer period. Depends on how enmeshed in the situation you want to become.

 

[atsai3]

Recognize the risk that a few minutes could be a much longer period. Depends on how enmeshed in the situation you want to become.

The OP also runs the risk of establishing, in the patient's mind, a precedent about the appropriateness of future calls of similar chief complaint, function, or duration. Of course, this likely may not recur when F0nzie is on call but rather when someone else in the call pool is...

 

[Doctor Bagel]

The OP also runs the risk of establishing, in the patient's mind, a precedent about the appropriateness of future calls of similar chief complaint, function, or duration. Of course, this likely may not recur when F0nzie is on call but rather when someone else in the call pool is...

Exactly. This is always a program, especially when covering other people's patients. I had an experience last year where I got called by a guy in similar distress. It was a slow night, so I actually spent probably a little longer than I should talking to him and we wound up agreeing on a plan where he would go buy some ice cream, call some friends, etc., and he felt a lot better.

He called again when I was on call (not that he knew I was on), and I think he was looking for the same thing, which I honestly didn't have time to give on that call. I tried to establish some more boundaries with that call and gave the spiel that if he's in danger he really needs to go to an ED or call 911. He agreed, wound up going into an ED and apparently getting admitted to another facility for like 3 weeks. I know I didn't cause this latter part, but with the first conversation, I set up this idea that he could call for brief counseling whenever he needed it, which really wasn't appropriate.

Calls are hard.

 

[whopper]

A problem here that I think most psychiatrists make is their exact boundary in regard to what they are supposed to do, and I've never actually had anyone give us, as a profession, an accepted answer.

If someone is simply lonely, are we supposed to treat that? Insurance, hospital duty, everything else aside other than our professional ethics, are we supposed to deal with this?

Certainly someone in ER psychiatry shouldn't. IMHO it's a waste of hospital resources. ER psychiatry should be reserved for people in acute need of help and if not referred elsewhere.

Insurance won't pay for something unless it's billable. One could argue that loneliness is a form of adjustment disorder, but most insurance companies as far as I'm aware won't allow you to bill for it.

IMHO these people should be referred for psychotherapy only, and a psychiatrist should only treat for this if he/she sincerely believes the person truly has a form of mental illness. Otherwise they need to be referred elsewhere. Other professions such as counselors are supposed to talk to people and given them therapy if they are not mentally ill. In ER psychiatry, we can certainly refer them to a counselor or other services such as churches, social organizations, etc, but I don't think we should be treating loneliness in and of itself.

 

[nitemagi]

A problem here that I think most psychiatrists make is their exact boundary in regard to what they are supposed to do, and I've never actually had anyone give us, as a profession, an accepted answer.

If someone is simply lonely, are we supposed to treat that? Insurance, hospital duty, everything else aside other than our professional ethics, are we supposed to deal with this?

Certainly someone in ER psychiatry shouldn't. IMHO it's a waste of hospital resources. ER psychiatry should be reserved for people in acute need of help and if not referred elsewhere.

Insurance won't pay for something unless it's billable. One could argue that loneliness is a form of adjustment disorder, but most insurance companies as far as I'm aware won't allow you to bill for it.

IMHO these people should be referred for psychotherapy only, and a psychiatrist should only treat for this if he/she sincerely believes the person truly has a form of mental illness. Otherwise they need to be referred elsewhere. Other professions such as counselors are supposed to talk to people and given them therapy if they are not mentally ill. In ER psychiatry, we can certainly refer them to a counselor or other services such as churches, social organizations, etc, but I don't think we should be treating loneliness in and of itself.

I don't think loneliness should be medicated. And whether it causes functional impairment may depend on the case. To reframe your phrasing whopper, they don't HAVE to be treated (don't need emergency care), but may benefit from psychotherapy. It's elective though.

 

[whopper]

they don't HAVE to be treated (don't need emergency care), but may benefit from psychotherapy. It's elective though.

Agree but I think a psychiatrist needs to make it clear that they're charging the patient something on the order of > $100/hr for psychotherapy for an issue that most people go through frequently and is not considered a form of mental illness unless it's meeting an extreme where it's causing significant impairment in their lives. Further, many psychotherapists are willing to charge less money for simply psychotherapy compaed to a psychiatrist. IMHO, ethically, to charge someone $180/hr for psychotherapy when a non-psychiatric colleague can do it for much less begs that I inform the patient of this.

When a doctor recommends a patient do something, patients often times infer that there's something serious. If we tell a patient they need psychotherapy, the patient might be misled into thinking they really do need it. I wouldn't say that's the case with simple loneliness.

 

[nitemagi]

Agree but I think a psychiatrist needs to make it clear that they're charging the patient something on the order of > $100/hr for psychotherapy for an issue that most people go through frequently and is not considered a form of mental illness unless it's meeting an extreme where it's causing significant impairment in their lives. Further, many psychotherapists are willing to charge less money for simply psychotherapy compaed to a psychiatrist. IMHO, ethically, to charge someone $180/hr for psychotherapy when a non-psychiatric colleague can do it for much less begs that I inform the patient of this.

When a doctor recommends a patient do something, patients often times infer that there's something serious. If we tell a patient they need psychotherapy, the patient might be misled into thinking they really do need it. I wouldn't say that's the case with simple loneliness.

Again, maybe it's semantics. I don't tell them they "need" psychotherapy, but rather that they might benefit from it, and therefore can be something to consider. I don't see the ethical need for informed consent as to costs, though no reason not to do it either. I suppose it could be classified under the "alternatives" of informing about risks/benefits/alternatives. But I don't buy costs differential as significant enough of a risk per se. Don't see cost fitting into issues like justice, autonomy, non-malficence, or beneficence.

 

[F0nzie]

A problem here that I think most psychiatrists make is their exact boundary in regard to what they are supposed to do, and I've never actually had anyone give us, as a profession, an accepted answer.

I've also had emergencies pages like "I just got into a fight with my wife and I don't know what to do." Then you try to ask them if they're suicidal but instead they fill you in on all the historical details of the relationship and enmesh you in a psychotherapy session. I've tried problem solving over the phone with these types of patients but it's a crap-shoot because these patients aren't even mine. Then you try and give them advice and they reject all the possible options. Some of these patients just want to vent and having someone listen?

 

[whopper]

Doctors, without trying to be egocentric, should be golden gooses. I've stated several times that I don't think that doctors should use their higher position to exert the type of bull we often saw as medstudents such as the cliche story of the surgeon screaming at his surgery team.

But we should be golden gooses in the sense that the services we provide are hard to come by so we can extend those services to do the maximum good.

These types of calls should not be handled by psychiatrists in my opinion for the reason above. There should be diversions and filters to prevent this type of stuff from going to a psychiatrist. Other people should handle this. If residents are handling this, it leads me to suspect (and I emphasize the word suspect because I really don't know) that the resident is being used as the filter. As inconvenient as that is, there is some learning value to this but IMHO not much.

Just a story, an attending of mine in residency told me that several years ago, due to several psychiatric patients have poor social support, the state implemented a "friend" program where such patients were linked as a support person for someone else in the same boat, in groups of threes. The theory was this would decrease the need for case management and lead to better outpatient outcomes.

Whenever one of them decompensated, it caused the other two to decompensate because that person, already not too high on the GAF but not bad enough for hospitalization would freak out when their buddy decompensated in a manner similar to above. Not suicidal or homicidal but a low functioning person screaming and crying.

So, he told me, for several months, until the state got rid of the system, the psych ER was 3x as busy and everyone in the unit would be bitter and upset because they had to process these patients with the usual: several reports that took hours to write over something that was almost nothing.

 

[Ibid]

Just a story, an attending of mine in residency told me that several years ago, due to several psychiatric patients have poor social support, the state implemented a "friend" program where such patients were linked as a support person for someone else in the same boat, in groups of threes. The theory was this would decrease the need for case management and lead to better outpatient outcomes.

Whenever one of them decompensated, it caused the other two to decompensate because that person, already not too high on the GAF but not bad enough for hospitalization would freak out when their buddy decompensated in a manner similar to above. Not suicidal or homicidal but a low functioning person screaming and crying.

So, he told me, for several months, until the state got rid of the system, the psych ER was 3x as busy and everyone in the unit would be bitter and upset because they had to process these patients with the usual: several reports that took hours to write over something that was almost nothing.

These peer support networks can work. However they are not easy to set up properly. You have to select the participants carefully. You have to train them and provide them with support and supervision as if they were paid staff.

Essentially the people doing the supporting need to be substantially recovered and need to be prescient enough to recognise when the process is having a bad effect on them or they need to withdraw for other reasons.

This kind of project requires full time staff to coordinate it, train teams to understand it and so on. Do it on the cheap and it will all go to rat **** pretty fast not least because some people will be looking for a project like this to fail and as with anything there will always be some challenges.

Get it right and they can pay dividends in the long run.

 

[peppy]

These types of calls should not be handled by psychiatrists in my opinion for the reason above. There should be diversions and filters to prevent this type of stuff from going to a psychiatrist. Other people should handle this. If residents are handling this, it leads me to suspect (and I emphasize the word suspect because I really don't know) that the resident is being used as the filter. As inconvenient as that is, there is some learning value to this but IMHO not much.

I think you're right about that. When I hear about things like this, I wonder to myself: Is this really the best way to utilize the knowledge and skills of someone with 4 years of college, 4 years of med school, and 1-4 years of residency? I don't think it make sense for residents to be sidelined from dealing with admissions and urgent medical issues on call to keep someone company...though it also doesn't SURPRISE me that a resident would have something like this dumped on them either.

If this were happening in my residency, I would be agitating for a change in clinic policy so that these kinds of calls were screened in some manner (even if it was just that patients were encouraged to call the National Suicide Hotline or a local crisis line first before using the clinic pager). Really, my opinion is that the resident on call should be paged only for things like urgent medication changes.

 

[Quinn1988]

Such a timely thread. We have to cover calls for our outpatient clinic while on call, and the calls we get are often kind of ridiculous. We get no guidance on how to deal with these calls, and it especially doesn't help that all the non-residents in the clinic (who generally have the patients who are calling), leave very brief notes about treatment plans and whatnot.

From what little I know, I'd assess for immediate safety. If they deny SI and assert that they feel safe, I'd say something like I'll let your provider know that you called, blah, blah, blah. What I've discovered is that some of the callers just want someone to talk listen to them for 10 minutes or so, and then they're OK. I'm not sure about the long term appropriateness of this as a treatment strategy, but I'm not really worried about long term appropriateness of treatment strategies for clinic patients when I'm on call. I've got other stuff to deal with.

At least we don't have to cover DBT calls at the VA anymore. That was fun. 🙄

Gotta ask,, your assessment is done on the assumption you are face to face with the person?

 

[Doctor Bagel]

Gotta ask,, your assessment is done on the assumption you are face to face with the person?

Maybe it's because I've been up all night, but I'm a little confused about what you're asking. It's a phone call, so you assess based on the information you can get from the patient (or family) over the phone. If things are questionable, you recommend they come in (and sometimes even call the police) for a face to face safety assessment.

 

[Quinn1988]

Maybe it's because I've been up all night, but I'm a little confused about what you're asking. It's a phone call, so you assess based on the information you can get from the patient (or family) over the phone. If things are questionable, you recommend they come in (and sometimes even call the police) for a face to face safety assessment.

Ah, my apologizes. Here is an example of what I mean:

Dr. A is on call and gains a phone call from a patient that is struggling the same way the author of this thread detailed a certain situation. Dr. A, never having seen or even meet the patient in distress, obviously has little to work with. So how could the physician r/o any safety concerns through telemedicine without knowing who the pt even is?

Also off topic, but I noticed towards the start of this thread, I began adopting the impression some think being lonely is a Dx. Isn't being lonely more of a differential?