Handling Stigma Against Mental Illness/treatment

[Sardonix]

Currently going through psych block at school. I find myself enjoying it, however it has also made me increasingly aware of several non-healthcare friends' stances on mental illness.

As a child, I had always been raised to believe that mental illness is a disease, so I've had no trouble viewing psychiatry as the medical field that it is. But just in the last couple weeks I've had several nearly identical discussions regarding the nature of mental illness.

One person claimed psychiatrists aren't real doctors. Whatever, that's annoying and false but wasn't going to be a discussion at the time. The part that really bothered me was a different friend who I considered to be relatively smart adamantly claimed that mental illness was a matter of life decisions and character failings. He's had several severe cases of bipolar/MDD family members so I know he has a complex history informing his current viewpoint.

I guess I'm wondering what is the best way to handle people that believe mental illness is not really a disease but a choice or moral failing.

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[erg923]

Currently going through psych block at school. I find myself enjoying it, however it has also made me increasingly aware of several non-healthcare friends' stances on mental illness.

As a child, I had always been raised to believe that mental illness is a disease, so I've had no trouble viewing psychiatry as the medical field that it is. But just in the last couple weeks I've had several nearly identical discussions regarding the nature of mental illness.

One person claimed psychiatrists aren't real doctors. Whatever, that's annoying and false but wasn't going to be a discussion at the time. The part that really bothered me was a different friend who I considered to be relatively smart adamantly claimed that mental illness was a matter of life decisions and character failings. He's had several severe cases of bipolar/MDD family members so I know he has a complex history informing his current viewpoint.

I guess I'm wondering what is the best way to handle people that believe mental illness is not really a disease but a choice or moral failing.

You really cant control other people's opinions/views on most subjects of any depth and complexity. I would stop trying and move on with your business unless they are causing direct harm to the field or to patients.

 

[Sardonix]

You really cant control other people's opinions/views on most subjects of any depth and complexity. I would stop trying and move on with your business unless they are causing direct harm to the field or to patients.

Fair enough.

Out of curiosity, how do you handle a patient that refuses to acknowledge the biological basis of their diagnosis? Just do the best to inform them and then move on, hoping they come around?

 

[erg923]

Fair enough.

Out of curiosity, how do you handle a patient that refuses to acknowledge the biological basis of their diagnosis? Just do the best to inform them and then move on, hoping they come around?

Most disorders we see (sans Schizophrenia and true/severe Bipolar Disorder) do not really have a "biological basis" in the sense that dysfunctional biology is the root etiology. Most of what psychiatry and clinical psychology sees on daily basis in an outpatient clinic is due to psychosocial stressors, poor life/coping skills, lack of resources (financial, psychological, intellectual), societal and familial dysfunction that is beyond our control, personality pathology, and plain old bad luck.

Biologic vulnerabilities can affect all of this, but its not like most of what you see its gonna be a "disease"in the same way that Parkinsons is.

 

[Sardonix]

Most disorders we see (sans Schizophrenia and Bipolar Disorder) do not really have a "biological basis" in the sense that dysfunctional biology is the root etiology. Most of what psychiatry and clinical psychology sees on daily basis in an outpatient clinic is due to psychosocial stressors, poor life/coping skills, lack of resources (financial, psychological, intellectual), societal and familial dysfunction that is beyond our control, personality pathology, and plain old bad luck.

Biologic vulnerabilities can affect all of this, but its not like most of what you see its gonna be a "disease"in the same way that Parkinsons is.

Ah, I see. I guess I was too focused on things like catecholamine theory of certain disorders and got tunnel vision. But then, how else would I broadcast to the world that I'm just a 2nd year med student?

Thanks!

 

[clausewitz2]

Most disorders we see (sans Schizophrenia and true/severe Bipolar Disorder) do not really have a "biological basis" in the sense that dysfunctional biology is the root etiology. Most of what psychiatry and clinical psychology sees on daily basis in an outpatient clinic is due to psychosocial stressors, poor life/coping skills, lack of resources (financial, psychological, intellectual), societal and familial dysfunction that is beyond our control, personality pathology, and plain old bad luck.

Biologic vulnerabilities can affect all of this, but its not like most of what you see its gonna be a "disease"in the same way that Parkinsons is.

Apart from wanting to add legit, YBOCS > 25 OCD to your list of disorders with an apparently strong or primary biological basis, so much this.

 

[thoffen]

I would be very leery of drawing conclusions about any person you meet or especially offering them, but as a whole it is definitely common that pejorative stances and harsh moral stances against mental illness and treatment are defensive in nature, warding off a person's identification with a shameful situation. In any case, just sharing your experience and why you find it valuable is probably the best thing to do. It helps me to recognize the defensive purpose of stigma because I can empathize with it and see people as human beings instead of attackers.

 

[nitemagi]

I would be very leery of drawing conclusions about any person you meet or especially offering them, but as a whole it is definitely common that pejorative stances and harsh moral stances against mental illness and treatment are defensive in nature, warding off a person's identification with a shameful situation. In any case, just sharing your experience and why you find it valuable is probably the best thing to do. It helps me to recognize the defensive purpose of stigma because I can empathize with it and see people as human beings instead of attackers.

This should be in the differential, but mostly I just see plain ol' ignorance, combined with the fact that we all generalize from our experience. Everyone thinks they understand people by the nature of them, themselves, being a person. "What's true for me must be true for everyone else, right?"

Recognize it as a cognitive bias and can always drop the "well you don't really have idea what you're talking about" and walk away.

 

[Onions]

Most of what psychiatry and clinical psychology sees on daily basis in an outpatient clinic is due to psychosocial stressors, poor life/coping skills, lack of resources (financial, psychological, intellectual), societal and familial dysfunction that is beyond our control, personality pathology, and plain old bad luck.

Though, aren't the border regions between personality, personality disorder, and axis I blurry? The factorial analytic models of personality seemed to produce orthogonal dimensions that were repeatedly replicated and allegedly unrestricted by culture, which suggests a biological underpinning. Of course, those models are only as good as the data used for the intercorrelations. But then I also recall reading about behavioral research that mapped some of these personality dimensions (and hence categories of personality disorder) onto broad themes of neurotransmitter activity.

Of course it's not surprising that personality lives in the brain. And at the same time, bearing in mind all the philosophical debates on meaning, I agree that modeling all of human experience as strictly neurochemical may be heuristically impossible.

OP- the truth is, the categorical nosology that we use is comfortable within the sphere of Medicine, but ultimately the DSM is just one approach to a complicated and unresolved taxonomy of pathologic mental phenomena. For example, would you consider "moral failing" itself to be a mental illness? Because the DSM includes disorders of the personality within its pages, and when you consider moral failure in a longitudinal formulation, I think at least a space for the argument become apparent.

 

[erg923]

Though, aren't the border regions between personality, personality disorder, and axis I blurry? The factorial analytic models of personality seemed to produce orthogonal dimensions that were repeatedly replicated and allegedly unrestricted by culture, which suggests a biological underpinning. Of course, those models are only as good as the data used for the intercorrelations. But then I also recall reading about behavioral research that mapped some of these personality dimensions (and hence categories of personality disorder) onto broad themes of neurotransmitter activity.

Of course it's not surprising that personality lives in the brain. And at the same time, bearing in mind all the philosophical debates on meaning, I agree that modeling all of human experience as strictly neurochemical may be heuristically impossible.

OP- the truth is, the categorical nosology that we use is comfortable within the sphere of Medicine, but ultimately the DSM is just one approach to a complicated and unresolved taxonomy of pathologic mental phenomena. For example, would you consider "moral failing" itself to be a mental illness? Because the DSM includes disorders of the personality within its pages, and when you consider moral failure in a longitudinal formulation, I think at least a space for the argument become apparent.

That's fine mental masturbation on your part.

Of course all our "personalities" (if you buy into that construct...behaviorists might disagree) are beset, to some degree, on temperament set my biological underpinnings. But that's obviously not what the poster was referring to/asking about.

I think the sad reality of clinical practice is that our treatments work best on symptoms... rather than on "diagnoses." Much less any higher level heuristic of personality or psychopathology that we may have come up with thus far. Thus, we treat what we can observe. And, what we observe may not necessarily be the whole truth. The true depth of the interaction between environment and brain functioning and subsequent behavior is not known at this time.

 

[Attending1985]

Many people behave in undesirable/untoward ways wreaking havoc and we call it mental illness. When we stop calling this unspecified bipolar disorder the stigma may decrease.

 

[erg923]

Many people behave in undesirable/untoward ways wreaking havoc and we call it mental illness. When we stop calling this unspecified bipolar disorder the stigma may decrease.

Would like to quote this alot.

 

[Onions]

That's fine mental masturbation on your part.

Ah yes, my mental left forearm is noticeably beefier than my right

Seems like we're saying the same thing though?

 

[nexus73]

I guess I'm wondering what is the best way to handle people that believe mental illness is not really a disease but a choice or moral failing.

Emphasizing the biology of mental illness by highlighting genetic inheritance may be a place to start. The guy with schizophrenia, whose dad had schizophrenia, whose uncle had schizophrenia...

It may be a starting point for somebody to realize a person with schizophrenia is not choosing to be psychotic anymore than they chose to have blue eyes like mom and dad had.

 

[nitemagi]

There's an interesting conundrum in all of this. The nosology was an attempt to codify and legitimize mental illness, creating a disease model to allow for things to be taken seriously by those with no experience in it. Along the way, though, people found they could use it to excuse bad behavior. Combining that with the porousness of our diagnoses in the first place, there doesn't seem to be a good solution.

I remember in undergrad my abnormal psych professor talked about how all the jargon gets bad associations after about 20 years and so gets thrown out and rebranded. But it's just language.

Somewhere there's a balance between accommodation and accountability. Like the two ends of a spectrum. It's always clear when we're too far in one extreme.

 

[SeniorWrangler]

The disease model has its drawbacks too. Studies have shown that when you tell people that mental illness is a brain disease, it doesn't make them any less negative towards the sufferers, and actually makes them more fearful because now you have the disease stigma on top of the "madness" stigma.

 

[Nasrudin]

Onions is not masturbating in my opinion. Well. Maybe he or she is. But that would be impressive. At the multi-tasking cybernetic action bottleneck. Because (s)he is speaking right at the issue. That the OP stumbled upon inadvertently. Such that explaining the conundrum we’re in to the OP is damn near impossible. I’ve been reading psychological theory and practice avidly for 2 years. I’ve been working hard seeing patients and feeling the clunky, awkward, clinically useless and meaningless of DSM constructs the whole way. Coming up with questions that lead to more questions. Doubts that have begotten doubts.

This question of biological vs psychological is a false dichotomy. We are biological creatures. And our psychological processes are rooted in our biology. How could it be otherwise?

A comprehensive, meaningful, integrated view of human intrapersonal and interpersonal function and dysfunction is on the horizon.

Models that are far more powerful and explanatory. That generate discovery and that validate known disparate sciences at multiple levels of analysis are already here.

But as Gonzo says, we’re stuck on the linguistics of the past century. Which is what the DSM amounts to. Archaic linguistic structures that map poorly and awkwardly onto neurobiology, normal range personality, social experience, and evolutionary science and are therefore due for the scrapyard. And not soon enough.

OP. You’re friend is right. We are not real doctors. We’re psychospiritual artist-explorers who paddle crude scientific canoes into the great unknown rivers of human consciousness. This is not timid and tepid territory of your waddling white coated single file line of ducks. This is for fearless wayfarers of the unknown territories.

I don’t want to be a real doctor. That’s like saying a real IRS auditor. With your chest popped out. Waiting for me to be impressed. Rather than glad you’re the pedestrian, well ordered little mind who prefers that than me.

Real doctor. Haha. ****. Good for you, Ace.

But keep in mind OP. You’re friend is both more right and wrong than they imagine.

Don’t fret over the cognitive dissonance of trying to make the grand unknown knowable to the callous and uninterested. Anyone who has more answers than questions about human consciousness. Who hasn’t devoted their life to the questions. Hasn’t even begun to wonder how complex their own reality is.

And don’t fret over being the red-headed step child of medicine. The ones who do hasten too much to compress human consciousness into expedient DSM criteria sets to appear logical and consistent and scientific and have destined themselves to be neither of these. In sad irony accomplishing nothing for patients except the coding of consciousness into billable items for insurance companies.

 

[DisorderedDoc417]

Onions is not masturbating in my opinion. Well. Maybe he or she is. But that would be impressive. At the multi-tasking cybernetic action bottleneck. Because (s)he is speaking right at the issue. That the OP stumbled upon inadvertently. Such that explaining the conundrum we’re in to the OP is damn near impossible. I’ve been reading psychological theory and practice avidly for 2 years. I’ve been working hard seeing patients and feeling the clunky, awkward, clinically useless and meaningless of DSM constructs the whole way. Coming up with questions that lead to more questions. Doubts that have begotten doubts.

This question of biological vs psychological is a false dichotomy. We are biological creatures. And our psychological processes are rooted in our biology. How could it be otherwise?

A comprehensive, meaningful, integrated view of human intrapersonal and interpersonal function and dysfunction is on the horizon.

Models that are far more powerful and explanatory. That generate discovery and that validate known disparate sciences at multiple levels of analysis are already here.

But as Gonzo says, we’re stuck on the linguistics of the past century. Which is what the DSM amounts to. Archaic linguistic structures that map poorly and awkwardly onto neurobiology, normal range personality, social experience, and evolutionary science and are therefore due for the scrapyard. And not soon enough.

OP. You’re friend is right. We are not real doctors. We’re psychospiritual artist-explorers who paddle crude scientific canoes into the great unknown rivers of human consciousness. This is not timid and tepid territory of your waddling white coated single file line of ducks. This is for fearless wayfarers of the unknown territories.

I don’t want to be a real doctor. That’s like saying a real IRS auditor. With your chest popped out. Waiting for me to be impressed. Rather than glad you’re the pedestrian, well ordered little mind who prefers that than me.

Real doctor. Haha. ****. Good for you, Ace.

But keep in mind OP. You’re friend is both more right and wrong than they imagine.

Don’t fret over the cognitive dissonance of trying to make the grand unknown knowable to the callous and uninterested. Anyone who has more answers than questions about human consciousness. Who hasn’t devoted their life to the questions. Hasn’t even begun to wonder how complex their own reality is.

And don’t fret over being the red-headed step child of medicine. The ones who do hasten too much to compress human consciousness into expedient DSM criteria sets to appear logical and consistent and scientific and have destined themselves to be neither of these. In sad irony accomplishing nothing for patients except the coding of consciousness into billable items for insurance companies.

Onions is not masturbating in my opinion. Well. Maybe he or she is. But that would be impressive. At the multi-tasking cybernetic action bottleneck. Because (s)he is speaking right at the issue. That the OP stumbled upon inadvertently. Such that explaining the conundrum we’re in to the OP is damn near impossible. I’ve been reading psychological theory and practice avidly for 2 years. I’ve been working hard seeing patients and feeling the clunky, awkward, clinically useless and meaningless of DSM constructs the whole way. Coming up with questions that lead to more questions. Doubts that have begotten doubts.

This question of biological vs psychological is a false dichotomy. We are biological creatures. And our psychological processes are rooted in our biology. How could it be otherwise?

A comprehensive, meaningful, integrated view of human intrapersonal and interpersonal function and dysfunction is on the horizon.

Models that are far more powerful and explanatory. That generate discovery and that validate known disparate sciences at multiple levels of analysis are already here.

But as Gonzo says, we’re stuck on the linguistics of the past century. Which is what the DSM amounts to. Archaic linguistic structures that map poorly and awkwardly onto neurobiology, normal range personality, social experience, and evolutionary science and are therefore due for the scrapyard. And not soon enough.

OP. You’re friend is right. We are not real doctors. We’re psychospiritual artist-explorers who paddle crude scientific canoes into the great unknown rivers of human consciousness. This is not timid and tepid territory of your waddling white coated single file line of ducks. This is for fearless wayfarers of the unknown territories.

I don’t want to be a real doctor. That’s like saying a real IRS auditor. With your chest popped out. Waiting for me to be impressed. Rather than glad you’re the pedestrian, well ordered little mind who prefers that than me.

Real doctor. Haha. ****. Good for you, Ace.

But keep in mind OP. You’re friend is both more right and wrong than they imagine.

Don’t fret over the cognitive dissonance of trying to make the grand unknown knowable to the callous and uninterested. Anyone who has more answers than questions about human consciousness. Who hasn’t devoted their life to the questions. Hasn’t even begun to wonder how complex their own reality is.

And don’t fret over being the red-headed step child of medicine. The ones who do hasten too much to compress human consciousness into expedient DSM criteria sets to appear logical and consistent and scientific and have destined themselves to be neither of these. In sad irony accomplishing nothing for patients except the coding of consciousness into billable items for insurance companies.

Nasrudin, I feel like you... get... me...

Please tell me how you force yourself to read/know the garbage in common DSM-5 informed psychiatric texts? Simply knowing it [an understanding that makes more sense than voting on which symptoms should be clustered and labelled as a disorder] is, "on the horizon" isn't cutting it for me -- especially after my 6th admission in the morning for someone whose boyfriend of 3 hours broke up with them and it was at that moment they knew they could no longer go on living and decidedly took the 1000mg of Gabapentin to 'end it all'.

 

[Nasrudin]

Nasrudin, I feel like you... get... me...

Please tell me how you force yourself to read/know the garbage in common DSM-5 informed psychiatric texts? Simply knowing it [an understanding that makes more sense than voting on which symptoms should be clustered and labelled as a disorder] is, "on the horizon" isn't cutting it for me -- especially after my 6th admission in the morning for someone whose boyfriend of 3 hours broke up with them and it was at that moment they knew they could no longer go on living and decidedly took the 1000mg of Gabapentin to 'end it all'.

I hear you. I'm woodshedding on personality models that are making a go for all the marbles in terms of creating the comprehensive, mechanistic, systems for understanding normative vs non-normative function along dimensional axes. That are also cross-referenced tightly to neuroscience. And evolutionary science. My favorite so far is Colin DeYoung's--Cybernetic Big 5 Theory. Not in the least because it sounds cool. Like a rap group from the 90's.

I'm trying them out in my clinical laboratories. Including the type of silliness clogging your night shift. And it's making me more effective as the ideas are finding traction in my patient's minds. As far as I can tell.

I hope you scared the crap out of Suicidal Gabapentin girl.

 

[Onions]

I hope you scared the crap out of Suicidal Gabapentin girl.

When I see patients in the ED and the clerk asks me what diagnosis to put down in the log, I tell him to pick his favorite three or four letters of the alphabet and write them down in his order of preference. He thinks I'm kidding. Since he doesn't let me off the hook, I started just saying "MDD," but admitting patients for depression while arguing against affective illness in my admission notes only kept me so entertained. I eventually had the epiphany that "adjustment with mood disorder" is the perfect mental illness.

Bald's Leechbook, with it's encyclopedic collection of 9th century medical remedies (some even effective!), recommends that "In case a man be a lunatic ; take skin of a mereswine, work it into a whip, swinge the man therewith, soon he will be well. Amen." Sometimes it feels as though prevalent attitudes toward mental abnormality have not become much more sophisticated since the 9th century. We are in a special position to do something about this, but the categorical, full-stop, square holes furnished by the DSM end up becoming the nidus from which we're afforded the luxury of not caring, so long as we satisfy some invisible Big Head who just really needs that SRA to be filed in the chart, even if it's clinically useless and no one will ever look at it. A world where everything stops because someone said "suicidal ideation" will continue to produce and reproduce bad clinicians--through no fault of their own, but for lack of time to develop into anything other than box-checkers--and as such will continue to generate and regenerate a discourse of disgust and ignorance.

So yeah, I really think it basically starts with the bull**** paperwork. Not that I have any illusions that it will go away, but I believe we can and should put a collective foot down and effect some limitation on the grip that Liability, Billing, and Policy hold on the thoughtful documentation of the doctor-patient transaction.

 

[Attending1985]

When you think about the principles of DBT admitting these patients constantly is harmful, reinforcing the cycle of dysfunction. No one will do differently because of liability but I guess we’re not liabile for poor outcomes.

 

[Nasrudin]

Awww yeah!

We need to form a band. You guys jam in the way I love to.

Good to hear from you. It's rejuvenating to find fellow like-minded travelers on The Road to Perdition.

 

[Onions]

It's rejuvenating to find fellow like-minded travelers on The Road to Perdition.

I'll bring a flask to share for when we're both sitting sheepishly in the figurative principal's office of [insert your favorite mental health regulatory body].

 

[clausewitz2]

When I see patients in the ED and the clerk asks me what diagnosis to put down in the log, I tell him to pick his favorite three or four letters of the alphabet and write them down in his order of preference. He thinks I'm kidding. Since he doesn't let me off the hook, I started just saying "MDD," but admitting patients for depression while arguing against affective illness in my admission notes only kept me so entertained. I eventually had the epiphany that "adjustment with mood disorder" is the perfect mental illness.

Bald's Leechbook, with it's encyclopedic collection of 9th century medical remedies (some even effective!), recommends that "In case a man be a lunatic ; take skin of a mereswine, work it into a whip, swinge the man therewith, soon he will be well. Amen." Sometimes it feels as though prevalent attitudes toward mental abnormality have not become much more sophisticated since the 9th century. We are in a special position to do something about this, but the categorical, full-stop, square holes furnished by the DSM end up becoming the nidus from which we're afforded the luxury of not caring, so long as we satisfy some invisible Big Head who just really needs that SRA to be filed in the chart, even if it's clinically useless and no one will ever look at it. A world where everything stops because someone said "suicidal ideation" will continue to produce and reproduce bad clinicians--through no fault of their own, but for lack of time to develop into anything other than box-checkers--and as such will continue to generate and regenerate a discourse of disgust and ignorance.

So yeah, I really think it basically starts with the bull**** paperwork. Not that I have any illusions that it will go away, but I believe we can and should put a collective foot down and effect some limitation on the grip that Liability, Billing, and Policy hold on the thoughtful documentation of the doctor-patient transaction.

Do you guys really not have the institutional support to discharge people when admission would clearly be countertherapeutic just because they say suicide?

 

[Onions]

Do you guys really not have the institutional support to discharge people when admission would clearly be countertherapeutic just because they say suicide?

I never meant to imply that I'm admitting patients just because they said the S word, only that admission diagnoses, documented for billing purposes, often do not capture (or poorly capture) my own formulation, which itself justifies the admission however it foes and hopefully goes beyond some ridiculous hypervigilant CYA nonsense.

 

[clausewitz2]

I never meant to imply that I'm admitting patients just because they said the S word, only that admission diagnoses, documented for billing purposes, often do not capture (or poorly capture) my own formulation, which itself justifies the admission however it foes and hopefully goes beyond some ridiculous hypervigilant CYA nonsense.

Surely this is the attitude towards the DSM of anyone who has actually seen patients and thought even a little bit about what it is we are doing?

 

[Nasrudin]

Do you guys really not have the institutional support to discharge people when admission would clearly be countertherapeutic just because they say suicide?

My institution has a committee ready to F you if something goes wrong. Other than that they support you. With reams of paperwork to codify the patient into future risk algorithms that also F you.

But. I do how sees fit to do.

By being the arbiter of clinical reality.

Which is hardly what someone says.

I also try to co-formulate with the patient, even malingerers, towards supra-ordinate principles than safety. Which is a patently absurd clinical premise. By using your counter-therapeutic idea among other things. I like to use Psychodrama. Where I play various characters trying to provoke the patient's agency and creativity. A bull**** SI routine is flat, victimized, drab character to play with stupid lines. They know it's not sexy. They viscerally hate it. They just need the right interplay to drop it. And if they have any ego strength at all, they want to express their survival genius.

 

[psychm]

Think for yourself, that is probably a good start. Read, I don't know, anything objective? That could possibly lead you on the right path. Chances are, when huge portions of your society are addicted to drugs and killing themselves in high numbers regardless, mental illness is real. If you don't care about those people, you will have an opinion perpetuating that stigma. If you do care about them, and believe that people can change in many ways and their lives can be saved, then you won't feel this way. I am sorry, but if you are still at this stage with psychiatry then it doesn't matter because it probably isn't for you. Just learn to respect it and find a place for it with your patients as needed.

It takes a mature person to get it. If the goal of a doctor is to decrease morbidity and mortality, then what the hell are you possibly struggling with? I was in my 20's going through interviews, and not for a second have I regretted my choice, and I didn't even match. What is important to you?

 

[FlowRate]

Do you guys really not have the institutional support to discharge people when admission would clearly be countertherapeutic just because they say suicide?

It depends. Suicide without plan or intent, no prior attempts, modest life stress, and with good social supports is a pretty easy overnight discharge, assuming I can get some reasonably reliable collateral to say they can stay with the patient for a day and aren't worried that the patient will try to harm themself.

Borderline with silly overdose who is wellish known to the department (no serious prior attempts, hospitalization not usually helpful) and at their usual chronic level of SI is not usually discharged overnight, instead held to be staffed by an attending in the morning with the expectation of discharge.

I was actually meaning to make a thread on this, curious how people practice in other places. This year our overnight call is at our ED with the most conservative attendings/culture, so not a ton of discharging borderline/malingering overnight. Supposedly next year there's more of that (different ED + more leeway as PGY3).

 

[clausewitz2]

It depends. Suicide without plan or intent, no prior attempts, modest life stress, and with good social supports is a pretty easy overnight discharge, assuming I can get some reasonably reliable collateral to say they can stay with the patient for a day and aren't worried that the patient will try to harm themself.

Borderline with silly overdose who is wellish known to the department (no serious prior attempts, hospitalization not usually helpful) and at their usual chronic level of SI is not usually discharged overnight, instead held to be staffed by an attending in the morning with the expectation of discharge.

I was actually meaning to make a thread on this, curious how people practice in other places. This year our overnight call is at our ED with the most conservative attendings/culture, so not a ton of discharging borderline/malingering overnight. Supposedly next year there's more of that (different ED + more leeway as PGY3).

That would be a very interesting thread. Our overnight experience is radically different. Make it and I will definitely post.