Suicidal signs?

[Auvelity]

So guys a tiny grasshoper wants some information. Besides from all the access to guns and signs of a depressive dissorder, is there any way you could tell someone might "be suicidal"? How can you actually prevent these events when the patient is lying to you for example?

I want to pursue a career in psychiatry and a close friend commited suicide this week. He never shown any symptoms of depression, no good bye letters, not the usual "social withdrawal" or anything. He had hx of substance use though. I might have missed the signals because he was close, he might have done while "on to something" But, is there anything you guys have might learned in your vast experience that might point out the patient or person close to us might be prone to do this?
And I know its not ethical to treat people close to you, but, what is the point of doing this if we cant help the people we love or at least point them into another colleague to help if we could read something like this coming...

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[nitemagi]

You'll learn much more in training, but in short -- we're practitioners informed by science, not fortune tellers. Even the best predictive instruments on suicide/violence will only get you 50-70% accuracy. And even then, for how long? Life happens, and there's not a way to prevent a future incident from happening. The most one can tune in on are modifiable risk factors, and enhancing protective factors. It's not perfect, but it's something.

We do far too much risk assessment and far too little preventive medicine in our field for my taste.

Regarding the "treating" of friends, one can't turn off the knowledge/expertise one has, and can use them to be a better/more supportive friend. It should never be treating them, though. That's a really really dangerous road.

 

[Stagg737]

I'm going to leave most of this to the people who have been doing this for a while, but as for the "what's the point" aspect of your post, I think it's a matter of perspective.

Even if there's nothing you can do for the people close to you, you can (and will) still make a huge impact in the lives of complete strangers that you treat. It always hurts more when something happens to someone close to us because we've got an emotional investment. However, it's important to remember that almost everyone you'll treat is important to someone and has other people in their lives that are emotionally invested in them. I think feeling that loss firsthand will give better perspective as to why we are entering/in this field and act as a reminder as to what the point of it all is.

 

[Ceke2002]

And I know its not ethical to treat people close to you, but, what is the point of doing this if we cant help the people we love or at least point them into another colleague to help if we could read something like this coming...

Back in the 90s I had a wonderful GP (Family Physician), who I would still easily put in my top 5 list of best ever Doctors from a patient's point of view. This guy had a wonderful bedside manner, was up to date on all the latest medical research and treatments available especially for chronic pain and addiction problems, was clearly incredibly dedicated to his work and his patients - basically about as close to the ideal of what you could want from a Doctor as you could possibly get (so we're not definitely not talking about some cowboy type here).

In 2014 he was heavily reprimanded, required to pay a substantial fine, and had restrictions placed on his medical license, after agreeing to become involved in the care of a former colleague and close friend. His friendship with the patient lead him to make decisions that were based on emotion, and not best medical practice, and some of those decisions were ultimately a factor in her eventual disability and death from Anorexia Nervosa (a condition he was not qualified to treat). He thought he had his former colleague, and friend's best interests at heart, but ultimately his inability to look at her through the clear lens of the 'medical gaze', because of their close relationship, lead to a good Doctor making some terribly ill informed choices and paying a pretty hefty price for it. There is a reason Doctors do not treat friends or family, and this is a very good example of why.

 

[smalltownpsych]

So guys a tiny grasshoper wants some information. Besides from all the access to guns and signs of a depressive dissorder, is there any way you could tell someone might "be suicidal"? How can you actually prevent these events when the patient is lying to you for example?

I want to pursue a career in psychiatry and a close friend commited suicide this week. He never shown any symptoms of depression, no good bye letters, not the usual "social withdrawal" or anything. He had hx of substance use though. I might have missed the signals because he was close, he might have done while "on to something" But, is there anything you guys have might learned in your vast experience that might point out the patient or person close to us might be prone to do this?
And I know its not ethical to treat people close to you, but, what is the point of doing this if we cant help the people we love or at least point them into another colleague to help if we could read something like this coming...

If the patient is denying suicidality, but is at risk. I use my clinical skills to try and help them anyway. From my experience, when the patient trusts me, they will let me know the truth. If I can’t get them to trust me, then there isn’t really anything I can do.

To the other point, substance abuse is one of the big risk factors for several reasons, and the intoxicated suicide attempt or suicide threat is ubiquitous and about 90% deny need for any help the next day. Whether we know the person or not, there isn’t much we can do. I focus my energies on the people who are wanting to change and lett8mgnthe others know that I care and am there to help when they are ready to make a change. In my mind, it is fine to use our skills and knowledge to help family and friends access treatment. We just don’t provide the treatment.

 

[Nasrudin]

I actually do not think we should be in suicide prediction game.

The right to take ones own life is as sacred as is how to live it, what to do with it, what to give it for.

There are crisis, entrapment, and futility narratives that we want to be able to influence, as in any clinical encounter or intervention. But we as clinicians and friends and family need to get out of the responsibility for other's choices role.

I'm not convinced, in the least, that we are not doing vastly more harm than good, by engaging in the role of goalie between individuals and their attempt to leave this life. And I don't think the predictive value of our data is effective at all. It simply stacks risk factors, not the effect of intervening based on these risk factors.

I consider someone who puts themselves in the ICU after having attempted suicide and then emerge disappointed to be actually suicidal. And even then. What's the solution. Life imprisonment on a dreary inpatient unit? That'll fix'em up clean. right.... So... i think we should be in the meaning orientation game. Not the making choices for people game.

 

[clausewitz2]

I actually do not think we should be in suicide prediction game.

The right to take ones own life is as sacred as is how to live it, what to do with it, what to give it for.

There are crisis, entrapment, and futility narratives that we want to be able to influence, as in any clinical encounter or intervention. But we as clinicians and friends and family need to get out of the responsibility for other's choices role.

I'm not convinced, in the least, that we are not doing vastly more harm than good, by engaging in the role of goalie between individuals and their attempt to leave this life. And I don't think the predictive value of our data is effective at all. It simply stacks risk factors, not the effect of intervening based on these risk factors.

I consider someone who puts themselves in the ICU after having attempted suicide and then emerge disappointed to be actually suicidal. And even then. What's the solution. Life imprisonment on a dreary inpatient unit? That'll fix'em up clean. right.... So... i think we should be in the meaning orientation game. Not the making choices for people game.

I think we are sort of on the same page with this. My one caveat and where I see the possible role of involuntary treatment (or imprisonment in a psych unit, let's be real) is exactly when people are overtly suicidal due to intoxication, a manic mixed state, or a really acute exacerbation of a psychotic disorder. Because we can anticipate that in a week's time they are going to be saying "thank le bon Dieu that I did not actually on those impulses." Then at least you are allying with the very-near-future version of the patient against whoever is standing in front of you, not with some hypothetical future patient who may never exist.

 

[Nasrudin]

I think we are sort of on the same page with this. My one caveat and where I see the possible role of involuntary treatment (or imprisonment in a psych unit, let's be real) is exactly when people are overtly suicidal due to intoxication, a manic mixed state, or a really acute exacerbation of a psychotic disorder. Because we can anticipate that in a week's time they are going to be saying "thank le bon Dieu that I did not actually on those impulses." Then at least you are allying with the very-near-future version of the patient against whoever is standing in front of you, not with some hypothetical future patient who may never exist.

Sure. Those ones are obvious. But to the social class of the co-dependent. Which is too say the majority of us. It's as if a tear shouldn't hit the pavement that also is not accompanied by suicide risk assessment and a plan and bunch of oedipal mothering and useless, harmful bureaucratic expense and process. Such that it's a real option to say you're suicidal after not getting your pain med rx from the medical ED. Such that a full psych consult gets set in motion. And for just the right amount of victimizing yourself you can use the inpatient unit to cop 3 hots and a cot.

And then there's all the quasi suicidal drama that gets crammed into this same ineffectual future prediction process that through the co-dependence of our leadership we've allowed ourselves to be put on the hook for.

Which requires medical-legalese to negotiate. Not actual intervention. Or treatment. Or anything, meaningful whatsoever.