SI not requiring hospital admission?

[futuredoctor10]

So I learned that for suicidal ideation you always hospitalize (SI or HI).
Similarly on my psych clerkship we learned that "contracting for safety" is not a good thing to do.

However some places I know do a contract for safety if there is +SI but no plan [and of course hospitalize if +SI, +plan]

For test purposes, what do you all think we should go with?

---

Members don't see this ad.

 

[link2swim06]

So I learned that for suicidal ideation you always hospitalize (SI or HI).
Similarly on my psych clerkship we learned that "contracting for safety" is not a good thing to do.

However some places I know do a contract for safety if there is +SI but no plan [and of course hospitalize if +SI, +plan]

For test purposes, what do you all think we should go with?

I have never seen a contract for safety show up on a standardized test as even an option. I'd choose hospitalization.

 

[StrangerX]

I would tend to lean towards hospitalization but at the same time if the question gave me enough hints...I would be willing to go with outpatient treatment. I remember doing a question where a patient took some pain meds to try to overdose in response to an argument she had with her mother. The right choice wasn't to hospitalize her but rather to let her go outpatient as she had a strong support system AND she tried to down the pain meds in front of her mother AND the med quantity she took was not toxic (the toxicity level was not something the patient knew).

From Kaplon and Sadock:

"...Whether to hospitalize patients with suicidal ideation is the most important clinical decision to be made. Not all such patients require hospitalization; some can be treated on an outpatient basis. But the absence of a strong social support system, a history of impulsive behavior, and a suicidal plan of action are indications for hospitalization. To decide whether outpatient treatment is feasible, clinicians should use a straightforward clinical approach: Ask patients who are considered suicidal to agree to call when they become uncertain about their ability to control their suicidal impulses. Patients who can make such an agreement with a doctor with whom they have a relationship reaffirm the belief that they have sufficient strength to control such impulses and to seek help...."

 

[futuredoctor10]

I would tend to lean towards hospitalization but at the same time if the question gave me enough hints...I would be willing to go with outpatient treatment. I remember doing a question where a patient took some pain meds to try to overdose in response to an argument she had with her mother. The right choice wasn't to hospitalize her but rather to let her go outpatient as she had a strong support system AND she tried to down the pain meds in front of her mother AND the med quantity she took was not toxic (the toxicity level was not something the patient knew).

From Kaplon and Sadock:

"...Whether to hospitalize patients with suicidal ideation is the most important clinical decision to be made. Not all such patients require hospitalization; some can be treated on an outpatient basis. But the absence of a strong social support system, a history of impulsive behavior, and a suicidal plan of action are indications for hospitalization. To decide whether outpatient treatment is feasible, clinicians should use a straightforward clinical approach: Ask patients who are considered suicidal to agree to call when they become uncertain about their ability to control their suicidal impulses. Patients who can make such an agreement with a doctor with whom they have a relationship reaffirm the belief that they have sufficient strength to control such impulses and to seek help...."

cool thanks!

 

[link2swim06]

I would tend to lean towards hospitalization but at the same time if the question gave me enough hints...I would be willing to go with outpatient treatment. I remember doing a question where a patient took some pain meds to try to overdose in response to an argument she had with her mother. The right choice wasn't to hospitalize her but rather to let her go outpatient as she had a strong support system AND she tried to down the pain meds in front of her mother AND the med quantity she took was not toxic (the toxicity level was not something the patient knew).

From Kaplon and Sadock:

"...Whether to hospitalize patients with suicidal ideation is the most important clinical decision to be made. Not all such patients require hospitalization; some can be treated on an outpatient basis. But the absence of a strong social support system, a history of impulsive behavior, and a suicidal plan of action are indications for hospitalization. To decide whether outpatient treatment is feasible, clinicians should use a straightforward clinical approach: Ask patients who are considered suicidal to agree to call when they become uncertain about their ability to control their suicidal impulses. Patients who can make such an agreement with a doctor with whom they have a relationship reaffirm the belief that they have sufficient strength to control such impulses and to seek help...."

Sounds more like borderline personality disorder than suicidal...maybe that contributed to the different answer.

 

[evilbooyaa]

Unless you guys can show me a Question ID that states otherwise, anyone with SI (plan or not) is getting 302'd for Step 2. Obviously real world is much more grey, but active/passive SI gets 302'd.

 

[StrangerX]

From PreTest Psychiatry 12th edition, Ch 1

17. A 22-year-old woman is seen in the emergency room after a suicide
attempt. She swallowed 10 aspirin in the presence of her mother, with
whom she had just had an argument. The patient has a long history of cutting
herself superficially with razor blades, which her psychiatrist of the
last 5 years confirms by telephone. The patient currently lives in a stable
environment (a halfway house) where she has been for 3 years. Which of
the following option is the best course of action for the physician in the
emergency room?
a. Admit the patient involuntarily
b. Admit the patient voluntarily
c. Admit the patient to a medical floor
d. Discharge the patient to outpatient therapy after meeting with the patient’s
mother
e. Discharge the patient back to outpatient therapy and the halfway house

17. The answer is e. (Kaplan, p 906.) The patient in this scenario has
chronic issues with self-injury (which is confirmed by a psychiatrist that
has been seeing her for a long period of time). She lives in a safe and supportive
environment and is in ongoing outpatient care. The suicidal gesture
occurred during an argument, and the gesture itself was not serious (ie,
only 10 aspirin were taken, and in front of the mother, so rescue was a certainty).
Since the patient lives in a setting that is separate from her mother,
it is likely that continued outpatient treatment and returning to the halfway
home to live will be more beneficial to the patient than being admitted.

 

[futuredoctor10]

From PreTest Psychiatry 12th edition, Ch 1

17. A 22-year-old woman is seen in the emergency room after a suicide
attempt. She swallowed 10 aspirin in the presence of her mother, with
whom she had just had an argument. The patient has a long history of cutting
herself superficially with razor blades, which her psychiatrist of the
last 5 years confirms by telephone. The patient currently lives in a stable
environment (a halfway house) where she has been for 3 years. Which of
the following option is the best course of action for the physician in the
emergency room?
a. Admit the patient involuntarily
b. Admit the patient voluntarily
c. Admit the patient to a medical floor
d. Discharge the patient to outpatient therapy after meeting with the patient's
mother
e. Discharge the patient back to outpatient therapy and the halfway house

17. The answer is e. (Kaplan, p 906.) The patient in this scenario has
chronic issues with self-injury (which is confirmed by a psychiatrist that
has been seeing her for a long period of time). She lives in a safe and supportive
environment and is in ongoing outpatient care. The suicidal gesture
occurred during an argument, and the gesture itself was not serious (ie,
only 10 aspirin were taken, and in front of the mother, so rescue was a certainty).
Since the patient lives in a setting that is separate from her mother,
it is likely that continued outpatient treatment and returning to the halfway
home to live will be more beneficial to the patient than being admitted.

As you mentioned earlier, I think the key to this question is (A) she took the 10 aspirin in front of her mother and (B) that she has a history of cutting behaviors. So it makes sense with her social support, that you could discharge to outpatient therapy.

I feel like the questions on this will be clear on Step 2 though and indicate need to hospitalize more than likely.

 

[kaleerkalut]

From PreTest Psychiatry 12th edition, Ch 1

17. A 22-year-old woman is seen in the emergency room after a suicide
attempt. She swallowed 10 aspirin in the presence of her mother, with
whom she had just had an argument. The patient has a long history of cutting
herself superficially with razor blades, which her psychiatrist of the
last 5 years confirms by telephone. The patient currently lives in a stable
environment (a halfway house) where she has been for 3 years. Which of
the following option is the best course of action for the physician in the
emergency room?
a. Admit the patient involuntarily
b. Admit the patient voluntarily
c. Admit the patient to a medical floor
d. Discharge the patient to outpatient therapy after meeting with the patient’s
mother
e. Discharge the patient back to outpatient therapy and the halfway house

17. The answer is e. (Kaplan, p 906.) The patient in this scenario has
chronic issues with self-injury (which is confirmed by a psychiatrist that
has been seeing her for a long period of time). She lives in a safe and supportive
environment and is in ongoing outpatient care. The suicidal gesture
occurred during an argument, and the gesture itself was not serious (ie,
only 10 aspirin were taken, and in front of the mother, so rescue was a certainty).
Since the patient lives in a setting that is separate from her mother,
it is likely that continued outpatient treatment and returning to the halfway
home to live will be more beneficial to the patient than being admitted.

This is exactly the only example I could think of because I remember getting this one wrong.

 

[evilbooyaa]

From PreTest Psychiatry 12th edition, Ch 1

17. A 22-year-old woman is seen in the emergency room after a suicide
attempt. She swallowed 10 aspirin in the presence of her mother, with
whom she had just had an argument. The patient has a long history of cutting
herself superficially with razor blades, which her psychiatrist of the
last 5 years confirms by telephone. The patient currently lives in a stable
environment (a halfway house) where she has been for 3 years. Which of
the following option is the best course of action for the physician in the
emergency room?
a. Admit the patient involuntarily
b. Admit the patient voluntarily
c. Admit the patient to a medical floor
d. Discharge the patient to outpatient therapy after meeting with the patient’s
mother
e. Discharge the patient back to outpatient therapy and the halfway house

17. The answer is e. (Kaplan, p 906.) The patient in this scenario has
chronic issues with self-injury (which is confirmed by a psychiatrist that
has been seeing her for a long period of time). She lives in a safe and supportive
environment and is in ongoing outpatient care. The suicidal gesture
occurred during an argument, and the gesture itself was not serious (ie,
only 10 aspirin were taken, and in front of the mother, so rescue was a certainty).
Since the patient lives in a setting that is separate from her mother,
it is likely that continued outpatient treatment and returning to the halfway
home to live will be more beneficial to the patient than being admitted.

Too vague to be a question on UWorld or Step 2. Fits right into pre-tests nitpicky philosophy. I'm sticking with what I said above.