Thoughts on invol hosp for SI

[brazilianpsych]

Hey there guys.

We were having this discussion on another thread, so I decided to create this one.

What are your real thoughts about the subject?

This is much more common in the US than in other countries, and I do believe it is mostly CYA than actual treatment. I have seen some very absurd cases of people being locked up due to "SI" when it was actually not. I actually think it's quite harmful to just throw people in a little jail for a few days when they say they have suicide ideation.

I'm obviously not talking about those clear cut or psychotic cases, but I see a movement that if you mention the word "suicide" in the ED, you get hospitalized. Since hosp don't prevent suicide, it seems that suicidal patients are just hot potatoes being thrown around and the system doesn't actually want to help them.

I have a funny case to share. Guy did eye surgery, comes back a day later complaining if eye pain. "It hurts so much I could kill myself", he says. NP actually made a invol admission to psych hospital. Needless to say, he had some complication to the surgery that was quickly treated at the Ed. After the treatment, he remained there 2 says before being transferred to a psychiatric hospital.

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[PsyDr]

1) I've noticed that no one has tried to reconcile:
a. Median length of stay in a psychiatric hospital: 3-5 days.
b. Median time to onset for most SSRIs-13 days

2) Suicide After Wife Requests Divorce

Guy expresses SI after discovering his wife's affair. Once he gets to the ER, guy says that he was just upset and has no intention to commit suicide. ER physician sends him home. EIGHTEEN DAYS later, guy commits suicide. The charm school graduate widow sues the ER physician for $5MM. Actually, the ER physician dies from cancer and the cheating widow sues the estate of the ER physician. Classy.

 

[comp1]

First and foremost, it's more than CYA. Hospitalization is literally the law for patients posing an acute danger to themselves in the vast majority of states in the US. This is not like an ED physician ordering a CT "just in case." It's a literal legal requirement. So the question really is should it be the law. There are many studies on involuntary hospitalization, but they tend to be extrarordinarily qualitative, mostly focused on how patients viewed it as negative. Which of course they did, it's involuntary. And there are studies showing that patients commit suicide at higher rates after psychiatric hospitalizations than in the general population. All that proves is that indeed a lot of the people hospitalized WERE at acute risk of self harm. I genuinely don't how you study this with any sort of ethics. You can't compare Europe or NZ/AUS to the US. The entirety of the cultures are very different and GUNS. Also, the patient who commits suicide isn't the one suing the physician. It's their family. I've yet to see a study done that interviews families of involuntarily hospitalized patients and how they perceived the treatment and encounter and whether they support it. The idea of an involuntary psychiatric hospitalization is to give time from the acute suicidal thought and action in an environment where suicide is very challenging to complete. It DOES do that. If we wanted to firmly show that prevented future suicides, we would need to do something like prohibit involuntary hospitalizations in a given county for a period of time to contrast. Good luck getting politicians who again, are subject much more to the FAMILIES of those involuntarily committed, to agree to this.

 

[nexus73]

This claim that hospitalization does not prevent suicide I think is a misreading of the literature. Correct me if I'm wrong, but my understanding is we don't actually have the data one way or the other because of the low base rate of completed suicide.

The strength of intent to commit suicide fluctuates like a wave. It builds and crests and falls. If we have someone on the building side of that wave and the crest is going to be a suicide attempt, having them in the hospital would seemingly be preventing a suicide attempt at least.

I think we admit patients with SI appropriately at my hospital. Not just that it was mentioned off hand, or passive SI, or SI while drunk, etc. Putting those people on a hold and admitting to psych is high likelihood of them feeling traumatized/resentment.

That being said, I do think hospital admission is helpful for people on the verge of harming themselves. It's ideally a supportive and ideally safe environment for monitoring the patient. They get supportive therapy, some basic CBT/DBT skills potentially, they're around nice people, get some distraction with rec therapy groups. Gives them a chance to uncouple their brain from life worries for a moment. The intensity of suicidal thoughts that could lead to an actual attempt have time to dissipate. The patient gets time to realize the life situation that was driving the SI maybe isn't as dire as they thought. Starting antidepressants and waiting for them to work is not the reason for admission, but since the person is depressed, starting them in the hospital is appropriate. IMO it's the supportive environment and time that is most helpful.

If someone is at that precipice of actual self harm and it takes an involuntary admission to get them in I think that's the right thing to do. I've had majority of patients thank me for helping them get to a place of stability.

 

[nexus73]

One horrendous story of bad SI admission IMO: I had a patient move to Florida that I followed for a short time via telepsych. She attempted to set up a new psychiatrist in Florida because I couldn't keep seeing her. She had BPD and chronic thoughts of death, passive SI, and had attempted suicide in the past with overdose and ended up in the ICU so she did have risk factors, but her reporting chronic SI at most visits was typical. She sees a psych np in Florida and patient mentions her chronic passive thoughts of death, and the np baker acted her. For passive thoughts of dying which were chronic. She was stuck in a hospital from Thursday night until the next Monday when a psychiatrist finally saw her and discharged her. Basically says I'll never tell anyone if I'm feeling suicidal again. The lack of nuance between I have chronic thoughts of death to I am imminently planning to kill myself was too complicated for this bonehead np apparently.

 

[Merovinge]

1) I've noticed that no one has tried to reconcile:
a. Median length of stay in a psychiatric hospital: 3-5 days.
b. Median time to onset for most SSRIs-13 days

2) Suicide After Wife Requests Divorce

Guy expresses SI after discovering his wife's affair. Once he gets to the ER, guy says that he was just upset and has no intention to commit suicide. ER physician sends him home. EIGHTEEN DAYS later, guy commits suicide. The charm school graduate widow sues the ER physician for $5MM. Actually, the ER physician dies from cancer and the cheating widow sues the estate of the ER physician. Classy.

The reason for the IP stay for SI is typically not for therapeutic effect of the biologic intervention. In the cases of ECT, ketamine, or lithium usage it might be, but not for run of the mill oral med changes. Long gone are the month long visits where these meds would have time to work and be adjusted. The purpose is to help the patient work through their SI in a safe environment when they can sit with the thoughts without a fear that they will act on them. Ideally, the stay also marshals support from any available friends/family and ensures good step-down care with a PHP, IOP, or OP (whichever is most appropriate).

 

[mistafab]

First, you gotta define what you mean by SI.

I usually delineate passive SI as longing for death (wishing to be hit by bus, falling asleep and not waking up, etc).
I then would say Active SI is desire to kill self.
And in active SI I would determine levels of planning, access to and lethality of means, and intent.

If we are talking about invol for passive SI, I generally would not do that. But I might invol someone with passive SI if their functional status from the primary disorder is so poor or what have you. So not a "never" for me but pretty much rare or perhaps a handful of times.

If we are talking about invol for active SI at it's lowest stages, sometimes you might and sometimes you might not. Depends on the situation.

 

[clausewitz2]

The reason for the IP stay for SI is typically not for therapeutic effect of the biologic intervention. In the cases of ECT, ketamine, or lithium usage it might be, but not for run of the mill oral med changes. Long gone are the month long visits where these meds would have time to work and be adjusted. The purpose is to help the patient work through their SI in a safe environment when they can sit with the thoughts without a fear that they will act on them 's insurance agree to pay for the hospitalization. Ideally, the stay also marshals support from any available friends/family and ensures good step-down care with a PHP, IOP, or OP (whichever is most appropriate).

FTFY. Let's be real, current patterns of IP LOS are not primarily motivated by therapeutic concerns, at least on the adult side.

 

[comp1]

They aren't motivated by therapeutic concerns OR insurance payment concerns. LOS are motivated by legal concerns. We could easily fill the psych units with psychotic patients. There's waiting lists from EDs everywhere. You're a lot more likely to get sued by the family of someone who kills themselves than by a person who continues to live under the bridge yelling at people after you discharge them.

 

[clausewitz2]

They aren't motivated by therapeutic concerns OR financial concerns. They're motivated by legal concerns. We could easily fill the psych units with psychotic patients. There's waiting lists everywhere.

Those waiting lists exist because payors will not cover hospitalizations for people who are psychotic and do not have immediate and acute safety concerns. It is not just a baffling and incomprehensible decision on the part of hospitals not to operate more beds for these folks who want to come in voluntarily, it is the fact that the funding does not exist and there's only so many baths they are willing to take.

 

[calvnandhobbs68]

First and foremost, it's more than CYA. Hospitalization is literally the law for patients posing an acute danger to themselves in the vast majority of states in the US. This is not like an ED physician ordering a CT "just in case." It's a literal legal requirement.

I think overall there's just a misunderstanding of what involuntary psychiatric hospitalization means here and this came up elsewhere. As you mentioned, this is generally more of a legal question than a medical question.

However, what people are missing here is what the laws actually are. It is not "literally the law" that you have to involuntarily hospitalize every person that could technically meet involuntary hospitalization criteria if they don't agree to voluntary. What "acute danger to themselves" means can vary substantially between different evaluators. Which is why one person might discharge a patient with borderline personality disorder who comes in looking for the 5th admission this year for cutting and saying they're going to kill themselves tonight and someone else might admit them. Which is why two people may have completely different opinions on whether they would send a patient home who cannot legally consent to admission but who was making active suicidal statements or had some suicidal planning but after a review of safety planning with their legal guardians who appear to have capacity and explaining the risks and benefits of different outcomes decides to send that patient home.

It is a mechanism that, if you have some basis for justifying that a patient meets certain criteria, ALLOWS you to detain a person against their will (essentially "police powers") pending a court hearing to determine if they should be allowed to be continued to be detained against their will. It is certainly not a REQUIREMENT that you detain this person against their will (which is how many states refer to involuntary hospitalization by the way).

 

[calvnandhobbs68]

Of course there is more to be done to better identify risk of attempting suicide and the likelihood of being able to do this accurately in our professional careers is quite low. That said I think almost everyone would accept that are elements associated with suicidality that increase risk. From the continuum of keep every kid on earth in an IP to unit, to every kid who mentions having ever had SI, to thought about not waking up to, to wanting to die without a plan, to articulating a specific feasible plan, I think it's pretty easy to understand why we lean towards the last group even when we cannot accurately predict.

Maybe you truly believe that any risk assessment is just CYA and has absolutely no clinical validity and IP stays for SI are no different than asking a magic 8 ball. I strongly disagree if that's your stance and I think it is an overinterpretation of the limitations of (the very limited) studies in this area. I have seen how IP stays change parental perception of mental illness, the almost forced f/u and likelihood of close PHP stepdown that often ensues so even independent of anything occurring on the IP unit, I often see pathways for stays having tangible value.

As a separate point, this ties into our discussion here as well.

Yes, any short term attempts at "risk assessment" truly do come down to CYA at the end of the day when it comes to involuntary hospitalization for purely suicidal ideation (whether that's active or passive or active with a plan or whatever).

Here's the issue, you present this as a given, but WHY do we lean towards that last group? This is a pure argument to authority that "almost everyone would accept" there are elements to suicidal ideation that truly increase short term suicide risk (esp in terms of patients who actually end up presenting for evaluation). What evidence is there that last group is actually going to die via suicide in the next week (or however long their inpatient hospital stay would be) and that we should be involuntarily hospitalizing them? The argument for a forced intervention is lack of evidence showing the intervention is harmful?

Again, the utility of risk assessment, especially for SI, seems to be mostly around longer term prediction of risk and possible utility of resource allocation and support over the long term.

 

[splik]

I am sure this is quite regional. In the areas I trained in and practiced, we routinely discharged patients presenting with SI. In fact, I remember being urged to discharge patients who had attempted suicide when I was a resident. When I worked in acute settings as an attending, we had to deal with the issue of limited beds and we frequently discharged patients with SI, especially if they had medicaid.

The largest driver or hospitalizations is the availability of beds and the availability of other resources. If there are beds available, those beds will get filled and the bar for admission will be lower. If there are fewer beds, more patients will be discharged. If there are a plethora of alternatives to hospitalization available (e.g. crisis beds, residential, urgent care, PHP/IOP) then more patients can be discharged to lower levels of care.

When I attended in the ED, I had the luxury of being able to offer to see people in my office the next day if we were wanting to discharge them (or they did not want admission) and they were high risk. These patients would almost certainly be admitted involuntarily if they saw another psychiatrist whowouldn't have been able to see them as an outpatient the next day.

 

[whopper]

In this era of CYA medicine, I've seen a few obvious cases where people should've been discharged or not brought to the hospital, but they're brought to the hospital.

E.g. someone just told they have terminal cancer so they make a cynical comment. Person sent to the ER only have months to live, and held in the hospital for 18 hours so a psych evaluation could be done.

 

[comp1]

I don't find clearly inappropriate admissions that interesting from an ethical, legal or research oriented perspective. Yeah, the admitting physician should be told to stop that. The argument about involuntary holds being an option, not a requirement, is complete semantics and is not even going to be heard by a jury because a judge isn't going to allow it as an argument against malpractice. The ethical issue is whether there is sufficient beneficence possible to justify the loss of autonomy. The more I think about it, the more I would like to see some research that clearly argues for or against in a quantitative manner.

 

[calvnandhobbs68]

I don't find clearly inappropriate admissions that interesting from an ethical, legal or research oriented perspective. Yeah, the admitting physician should be told to stop that. The argument about involuntary holds being an option, not a requirement, is complete semantics and is not even going to be heard by a jury because a judge isn't going to allow it as an argument against malpractice. The ethical issue is whether there is sufficient beneficence possible to justify the loss of autonomy. The more I think about it, the more I would like to see some research that clearly argues for or against in a quantitative manner.

Saying that something is a “literal legal requirement” and then when it’s pointed out that such thing is not “legally required” saying that it’s “complete semantics” is hilarious.

 

[ObsequiousAplomb]

If a judge or a jury comes up with an interpretation of the law that is clearly a literal misreading of the form you could have filled out, it's a pretty obvious thing to appeal / not going to happen in the first place.

To put it another way: If our only purpose is to be bureaucrats filing in the involuntary paperwork for everyone we're asked to evaluate in an emergency room for any emergency room psychiatric symptom...aren't we just the ED nurse or social worker?

 

[michaelrack]

To put it another way: If our only purpose is to be bureaucrats filing in the involuntary paperwork for everyone we're asked to evaluate in an emergency room for any emergency room psychiatric symptom...aren't we just the ED nurse or social worker?

No, the job of the social worker is to fax the form you fill out to the correct place (which can be confusing in a county based system in which the patient lives in a different county than the er/hospital)

 

[ObsequiousAplomb]

No, the job of the social worker is to fax the form you fill out to the correct place (which can be confusing in a county based system in which the patient lives in a different county than the er/hospital)

in the state where I work, the SW or RN is usually the person filling out the initial certification, and then a physician or psychologist does the second one. Technically, anyone can do the first part.

 

[clement]

Hey there guys.

We were having this discussion on another thread, so I decided to create this one.

What are your real thoughts about the subject?

This is much more common in the US than in other countries, and I do believe it is mostly CYA than actual treatment. I have seen some very absurd cases of people being locked up due to "SI" when it was actually not. I actually think it's quite harmful to just throw people in a little jail for a few days when they say they have suicide ideation.

I'm obviously not talking about those clear cut or psychotic cases, but I see a movement that if you mention the word "suicide" in the ED, you get hospitalized. Since hosp don't prevent suicide, it seems that suicidal patients are just hot potatoes being thrown around and the system doesn't actually want to help them.

I have a funny case to share. Guy did eye surgery, comes back a day later complaining if eye pain. "It hurts so much I could kill myself", he says. NP actually made a invol admission to psych hospital. Needless to say, he had some complication to the surgery that was quickly treated at the Ed. After the treatment, he remained there 2 says before being transferred to a psychiatric hospital.

Being thrown in a little jail can be therapeutic for a broad sampling of SI calibers.

And pain as a sequela of eye surgery can be quite murderous if under treated.

 

[clement]

I am sure this is quite regional. In the areas I trained in and practiced, we routinely discharged patients presenting with SI. In fact, I remember being urged to discharge patients who had attempted suicide when I was a resident. When I worked in acute settings as an attending, we had to deal with the issue of limited beds and we frequently discharged patients with SI, especially if they had medicaid.

The largest driver or hospitalizations is the availability of beds and the availability of other resources. If there are beds available, those beds will get filled and the bar for admission will be lower. If there are fewer beds, more patients will be discharged. If there are a plethora of alternatives to hospitalization available (e.g. crisis beds, residential, urgent care, PHP/IOP) then more patients can be discharged to lower levels of care.

When I attended in the ED, I had the luxury of being able to offer to see people in my office the next day if we were wanting to discharge them (or they did not want admission) and they were high risk. These patients would almost certainly be admitted involuntarily if they saw another psychiatrist whowouldn't have been able to see them as an outpatient the next day.

In the northeast where the cost of malpractice is highest, the threshold to admit seemed rather low. On the other coast a revolving door model is more prevalent.

 

[jbomba]

In the northeast where the cost of malpractice is highest, the threshold to admit seemed rather low. On the other coast a revolving door model is more prevalent.

I've been told it is difficult to sue for malpractice wrongful death in a suicide case in CA because there's something on the about the fact if simply rely upon the LPS involuntary hold criteria and discharge based on the fact the patient is not meeting criteria for a hold you are essentially clear. Can anyone shed insight on this who is familiar?

 

[psycho-matic]

One horrendous story of bad SI admission IMO: I had a patient move to Florida that I followed for a short time via telepsych. She attempted to set up a new psychiatrist in Florida because I couldn't keep seeing her. She had BPD and chronic thoughts of death, passive SI, and had attempted suicide in the past with overdose and ended up in the ICU so she did have risk factors, but her reporting chronic SI at most visits was typical. She sees a psych np in Florida and patient mentions her chronic passive thoughts of death, and the np baker acted her. For passive thoughts of dying which were chronic. She was stuck in a hospital from Thursday night until the next Monday when a psychiatrist finally saw her and discharged her. Basically says I'll never tell anyone if I'm feeling suicidal again. The lack of nuance between I have chronic thoughts of death to I am imminently planning to kill myself was too complicated for this bonehead np apparently.

Was this a psych NP? I'm a psych NP and I agree with you here. Nuance matters.The therapeutic alliance with the patient was destroyed. If I committed every patient with passive SI, I would likely be out of business pretty quickly. I have adult patients that have had chronic daily SI since grade school that have never acted on it and verbalize that they have no plan to do so and agree to a safety plan. Hospitalization will not do anything to cure lifelong SI and will not reduce the risk of such a patient attempting suicide. If anything, the chronicitiy of their SI over years without an attempt provides evidence of some stability, in my opinion, in terms of a lowered risk of making an attempt. I document all of this every encounter and carry on.

There is a gray area that comes with what we do. Last week, I had a patient that was having perhaps a little bit more than passive SI with some intrusive thoughts about committing suicide and they had even thought about how they would do it. However, the patient was able to verbalize they had no plan to carry out suicide, was able to provide concrete reasons why they would not commit suicide, and agreed to a safety plan. In that moment, they weren't in imminent danger. I asked the patient if they would consider voluntary admission, patient declined citing past negative inpatient experiences. Patient is in weekly therapy. I adjusted their depression medication even though it wasn't really a medication issue. What more can one do? I don't think inpatient care would have made the patient safer and wouldn't solve their problems. The fact that they are there telling me about it means they want to get better.

What about the the patient with severe, diffuse recalcitrant pain following a devastating MVA that led to the amputation of 3 limbs but left him very much cognitively intact. Centralized neuropathic pain. Absolutely miserable with no quality of life, no hope of any future. Pain management wasn't giving him enough opiods, like a rediculously low amount. When I inherited the patient, they were on Lyrica 600mg/day and Cymbalta 120mg/day. This was a patient who would tell me the only thing stopping him from committing suicide was lack of access to a method. Had a caregiver during the day. He thought about dying every moment he was awake. I added amitriptyline and this actually gave him some relief because he could sleep at night but did little for his overall pain. Of course I had to tell his wife to absolutely keep that med locked up with the others due to its lethality in OD. The wife who suddenly became the sole family provider and who's physical and mental health was taking a toll due to all the stress she was under, whose company was so small she didn't qualify for FMLA and was close to losing her job due to missing too many days for his appointments. At her wits end because they only real solution was a nursing home. There's no happy ending here. Hospitalzing this patient wouldn't do anything to remove the active intent to commit suicide. Hospice declined him because he didn't qualify. I knew his only real chance for some semblance of quality of life was an intrathecal pain pump. Got him in with the right pain specialist and their psych cleared him for the pain pump trial. He failed said trial. What do you do? I left the organization around that time so I don't know what happened to him. This is probably a case where a patient should be allowed to commit suicide under medical care. I digress. Point is, hospitalization isn't the answer for every time someone is suicidal.

 

[psycho-matic]

In this era of CYA medicine, I've seen a few obvious cases where people should've been discharged or not brought to the hospital, but they're brought to the hospital.

E.g. someone just told they have terminal cancer so they make a cynical comment. Person sent to the ER only have months to live, and held in the hospital for 18 hours so a psych evaluation could be done.

What about the patient in your office with CRPS after an ulnar nerve injury who tells you they will have to do something about their situation soon if things don't get better, they can't go on living like that. They are having SI and know how they might attempt it but they aren't going to attempt today, just one day soon if their pain doesn't improve. Do you admit them? An inpatient stay won't fix the problem and might actually keep them from scheduled outpatient invasive pain procedures that could actually help the pain get better. If patient commits suicide a week or a month later, are you liable?

 

[Osminog]

In my view, involuntary commitment due to suicide risk is a dubious practice at best. Really, as a user mentioned above, it is an exercise in "CYA," not an intervention that is meant to benefit patients. I will elaborate with three general points:

One, there is no empirically reliable way to assess for suicide risk. Despite the development of formal questionnaires and many books written on this topic, we simply have no reliable way to estimate probability of an imminent suicide attempt for particular patients. Categorizing patients into "high," "moderate," and "low" risk groups is not practically useful or evidence-based. A majority of suicides are committed by those who would conventionally be labeled as "low-risk," and a majority of individuals who would conventionally be labeled as "high-risk" will never commit suicide.

Two, the therapeutic value of inpatient psychiatric treatment for suicidal patients is highly questionable. Intuitively, it's not at all clear how being coercively locked up in a gloomy, loud unit surrounded by mentally unstable people would be helpful for someone who is disenchanted with life and wants to escape from existence. Furthermore, not everyone who experiences suicidal thoughts—even intense suicidal thoughts—is mentally ill, contrary to myths that commonly circulate, especially after every celebrity suicides; there are utterly miserable life circumstances from which even highly sane individuals may wish to escape.

Three, involuntary commitment is a violation of basic bodily autonomy. Coercive measures should only be applied when, in the process of attempting to save a human life, the benefits clearly outweigh the risks. In light of our overall inability to accurately assess suicide risk in individual cases and the lack of evidence for the effectiveness of inpatient psychiatric hospitalization in suicide risk reduction, we simply cannot say that the benefits of coercive psychiatric confinement outweigh the risks.

 

[nexus73]

In my view, involuntary commitment due to suicide risk is a dubious practice at best. Really, as a user mentioned above, it is an exercise in "CYA," not an intervention that is meant to benefit patients. I will elaborate with three general points:

One, there is no empirically reliable way to assess for suicide risk. Despite the development of formal questionnaires and many books written on this topic, we simply have no reliable way to estimate probability of an imminent suicide attempt for particular patients. Categorizing patients into "high," "moderate," and "low" risk groups is not practically useful or evidence-based. A majority of suicides are committed by those who would conventionally be labeled as "low-risk," and a majority of individuals who would conventionally be labeled as "high-risk" will never commit suicide.

Two, the therapeutic value of inpatient psychiatric treatment for suicidal patients is highly questionable. Intuitively, it's not at all clear how being coercively locked up in a gloomy, loud unit surrounded by mentally unstable people would be helpful for someone who is disenchanted with life and wants to escape from existence. Furthermore, not everyone who experiences suicidal thoughts—even intense suicidal thoughts—is mentally ill, contrary to myths that commonly circulate, especially after every celebrity suicides; there are utterly miserable life circumstances from which even highly sane individuals may wish to escape.

Three, involuntary commitment is a violation of basic bodily autonomy. Coercive measures should only be applied when, in the process of attempting to save a human life, the benefits clearly outweigh the risks. In light of our overall inability to accurately assess suicide risk in individual cases and the lack of evidence for the effectiveness of inpatient psychiatric hospitalization in suicide risk reduction, we simply cannot say that the benefits of coercive psychiatric confinement outweighs the risks.

Psych units shouldn't be gloomy and loud. Depressed/suicidal patients should be in lower acuity units and not with manic/psychotic/agitated people.

How do you weigh honoring autonomy vs saving someone from death? What percent chance do you need to save someone from death to justify imposing on their autonomy temporarily? How do you quantify the benefit of saving a life vs the risk of imposing on autonomy? This language you use is really loose. Some people would say that any chance of saving someone from death is worth imposing on their autonomy temporarily, that the benefit of saving a life clearly outweighs the risk of temporary loss of autonomy.

 

[nexus73]

I am sure this is quite regional. In the areas I trained in and practiced, we routinely discharged patients presenting with SI. In fact, I remember being urged to discharge patients who had attempted suicide when I was a resident. When I worked in acute settings as an attending, we had to deal with the issue of limited beds and we frequently discharged patients with SI, especially if they had medicaid.

The largest driver or hospitalizations is the availability of beds and the availability of other resources. If there are beds available, those beds will get filled and the bar for admission will be lower. If there are fewer beds, more patients will be discharged. If there are a plethora of alternatives to hospitalization available (e.g. crisis beds, residential, urgent care, PHP/IOP) then more patients can be discharged to lower levels of care.

When I attended in the ED, I had the luxury of being able to offer to see people in my office the next day if we were wanting to discharge them (or they did not want admission) and they were high risk. These patients would almost certainly be admitted involuntarily if they saw another psychiatrist whowouldn't have been able to see them as an outpatient the next day.

It's sad that this is the state of psychiatric services in what I assume is a major metro that should have more resources than most places.

 

[clausewitz2]

Psych units shouldn't be gloomy and loud. Depressed/suicidal patients should be in lower acuity units and not with manic/psychotic/agitated people.

How do you weigh honoring autonomy vs saving someone from death? What percent chance do you need to save someone from death to justify imposing on their autonomy temporarily? How do you quantify the benefit of saving a life vs the risk of imposing on autonomy? This language you use is really loose. Some people would say that any chance of saving someone from death is worth imposing on their autonomy temporarily, that the benefit of saving a life clearly outweighs the risk of temporary loss of autonomy.

If you really believed this you would put people in protective custody who wouldn't quit smoking and ban motor vehicles.

 

[nexus73]

If you really believed this you would put people in protective custody who wouldn't quit smoking and ban motor vehicles.

people smoking and driving don't lack capacity

 

[TheRightMedication]

Osminog and Clausewitz can both be answered by making the distinction between long term outcomes and acute, imminent risk.

It is true that we cannot claim hospitalization changes the ultimate risk of death by suicide. That does not change the fact that it's harder to kill yourself on an inpatient unit, and putting an imminently suicidal person there may prevent a suicide. Edit - prevent that death at that time, I mean.

If I said "I intend to suffer a motor vehicle accident today," and had taken steps to prepare for this, then, yes, it would be good to stop me from driving. This is separate from the fact that our risk of ultimately dying in an MVA is high enough that it's kind of weird we all drive cars.

 

[clausewitz2]

Osminog and Clausewitz can both be answered by making the distinction between long term outcomes and acute, imminent risk.

It is true that we cannot claim hospitalization changes the ultimate risk of death by suicide. That does not change the fact that it's harder to kill yourself on an inpatient unit, and putting an imminently suicidal person there may prevent a suicide. Edit - prevent that death at that time, I mean.

If I said "I intend to suffer a motor vehicle accident today," and had taken steps to prepare for this, then, yes, it would be good to stop me from driving. This is separate from the fact that our risk of ultimately dying in an MVA is high enough that it's kind of weird we all drive cars.

I get what you're saying, but you're left with the difficulty of when you would ever release someone on this logic. It will always be the case for someone with multiple identifiable risk factors that detaining them makes it harder for them to complete suicide than releasing them. Short of mass long-term detention we are still choosing exactly when and who to protect in this way in an arbitrary fashion.

 

[calvnandhobbs68]

people smoking and driving don't lack capacity

Ding ding so you inadvertently hit on the issue here. The reason these statues even exist is because there's the underlying assumption that, by virtue of meeting the criteria laid out, you automatically lack capacity. You then take this one step futher with involuntary hospitalization by essentially stating that, I think that due to your lack of capacity you're at such an elevated risk of killing yourself in the short term that I should involuntarily detain you until you can somehow convince me that you're not a risk anymore (all of this being very vague, unspecified and difficult to predict as noted above).

This is actually one of the BIGGEST sticky ethical things here when we're talking about involuntarily hospitalizing a minor (esp for SI) over parental objection in a state where the minor cannot consent to admission. Typically, you could say well the person I'm involuntarily hospitalizing lacks capacity by nature of meeting criteria. However, the parents by default have capacity unless you have some reason to believe they don't. The only other situations where we override parental decision making without big long ethical discussion involving the hospital ethics committee about this are when it is CLEARLY imminently life threatening that this immediate decision will result in the death or serious morbidity of the minor. That is clearly not the case when we're talking about hospitalization for purely SI.

Some people would say that any chance of saving someone from death is worth imposing on their autonomy temporarily, that the benefit of saving a life clearly outweighs the risk of temporary loss of autonomy.

"some people" isn't a great argument but okay. This is actually very unique to suicidal ideation and is seen in very few other healthcare settings. For instance, as noted above, risk prediction is terrible in the short term, so the best we can usually do is say, well, maybe this person is at higher risk than the general population of actually killing themselves sometime in the next 6 months...maybe.

I always refer people to the studies looking at the CSSRS which tons of hospitals use. "suicidal behavior" is never a very helpful outcome since this gets classified different in many different studies and it's not really the outcome we care about the most.

Evidence - The Columbia Lighthouse Project

The Columbia Suicide Severity Rating Scale (C-SSRS): Psychometric Evidence Table 1: Studies Supporting Specific Psychometric Properties Table 2: Psychometric Properties of the C-SSRS Ideation and Behavior with Coefficients References for Psychometric Evidence (Tables 1&2) Al-Halabí, S., Sáiz, P...

cssrs.columbia.edu

Here's the main one they have as supporting prediction for future suicides:

Columbia-Suicide Severity Rating Scale Screen Version: initial screening for suicide risk in a psychiatric emergency department

Suicide screening is routine practice in psychiatric emergency (PE) departments, but evidence for screening instruments is sparse. Improved identification of nascent suicide risk is important for suicide prevention. The aim of the current study was to ...

www.ncbi.nlm.nih.gov

Wow looks pretty good, some higher OR of suicide in the next 7 days, 30 days and 365 days which is the outcome they measured. If you actually dial down into the information and pull up table 3 though...

<7 day PPV= 0.2%
<31 day PPV= 0.4%
<365 day PPV= 1.0%

and check this out:

"Out of the 3776 patients who scored ⩾3 of the data-derived cut-off on the ideation severity scale, 1928 (51.1%) were admitted to inpatient care in conjunction with the C-SSRS Screening. Among these patients, three, nine and 24 died by suicide within 1 week, 1 month and 1 year, respectively. The number of deaths by suicide for patients who scored ⩾3 on the ideation scale but were not admitted to psychiatric inpatient care was four, six and 13. These figures corresponded to a crude OR of 0.7 (95% CI 0.2–3.2), 1.4 (95% CI 0.5–4.1) and 1.8 (95% CI 0.9–3.5)."

Basically just as many people died by suicide within 7 days who were hospitalized as weren't. We can probably safely assume that some large proportion of those patients were voluntary too. Sure, absolutely you could make the argument that people who were admitted were more acute that the people who weren't, but you're pulling from a baseline population that is at least reporting similar amounts of SI and only 15% of the entire population reported a suicide attempt in the last 3 months.

To this this even back to the beginning, if you pull up their supplementary materials and see how they classify by severity, people who report the highest level of SI (SI with plan), 0.2% of them die via suicide in the next week, 0.6% of the remaining die in the next month and 1.3% of the remaining die in the next year.

 

[Bartelby]

I think there are some extreme cases where an involuntary hold for SI is a very useful or even necessary tool to have. For example, someone just made a serious suicide attempt, remains psychotically depressed, and is clear that they will be attempting again as soon as they are able.

The problem I see is that malpractice attorneys quickly start (intentionally) mixing up *can* and *must." As many others have already pointed out, suicide is very hard to predict. Most of the people we see who have suicidal thinking are not going to act on it, and hospitalizing them involuntarily can be extremely upsetting for the patient, can rupture the therapeutic alliance, and generally only gets the patient a few days on the inpatient unit which for many issues may not modify risk all that much. We probably should not be hospitalizing the large majority of patients with SI that we see in day to day practice, and we don't.

When one of them later commits suicide though (which is pretty much inevitable), a plaintiff's attorney and their expert can take months sitting in their comfy chairs reviewing every step of that person's care with the benefit of hindsight. They can make the case that the standard of care would have been to hospitalize the person, which certainly gets a boost by the fact that you know the case outcome (suicide). While that argument might very well not prevail at trial, who wants to roll those dice? It will probably settle, and over time as a profession we collectively will feel more and more pressure to be "conservative" and involuntarily hospitalize people.

We should probably involuntarily hospitalize a small fraction of the most extreme cases (severe psychotic depression, disorganized psychosis, etc with SI that is markedly worse than their known baseline). I think there should be a small accepted subset of defined "standard of care says hospitalize" situations (for example a patient with psychotic depression tells you in a credible way that they will kill themselves) and that outside of those situations we should not be held liable for suicide. But I wouldn't hold my breath for this.

 

[smalltownpsych]

Our system is designed from a coercive and punitive perspective. Very few of my patients need to be ”forced” into treatment against their will, but almost all of them have experienced punitive involuntary treatment. It often starts at a very young age and then just gets worse until they are psychologically crushed. It makes me very sad to see how we treat people with social and emotional and cognitive problems. I started to say “mental illness”, but that terminology/conceptualization is part of the problem. Leads to a belief that there is something “wrong” that needs to be ”cured” or fixed as opposed to different or more vulnerable and need to understand and ameliorate or adapt.

 

[whopper]

see a movement that if you mention the word "suicide" in the ED, you get hospitalized. Since hosp don't prevent suicide, it seems that suicidal patients are just hot potatoes being thrown around and the system doesn't actually want to help them.

This is a complicated issue for several reasons. 1) Several people make cynical comments in a bad moment that often times is just a bad moment. 2) Several malingerers say they're suicidal when they are not for some type of gain such as free housing. 3) Several people claim to be suicidal for attention.

And as mentioned above, 4) Hospitalization might not be a solution to the real problem, especially if the patient has treatment resistant depression where even the most extreme treatments don't work. Why hospitalize a patient if nothing EVEN ECT doesn't work? Further there's legal precedent that you can only involuntarily commit someone if you can offer them a treatment. If nothing worse, (and I've never seen this definitively answered in a legal sense) and you cannot offer a viable treatment in inpatient, can the involuntary commitment hold given that there's prior court precedents saying involuntary hospitalization is only valid if there's treatment?

5) Further complicating the issue I've seen cases where the patient clearly was dangerous to self or others, and the hospital discharged them, or the police or EMS refused to take the patient, or the judge tossed out the case.

 

[clozareal]

Interesting paper that came out a few months ago with a large sample from the VA saying that hospitalizations prevent suicide but only if the patient made a suicide attempt within the past day. Hospitalization did not lower suicide risk with those who had SI only or attempts 2-7 days prior.

Estimated Average Treatment Effect of Psychiatric Hospitalization in Patients With Suicidal Behaviors: A Precision Treatment Analysis - PubMed

The findings of this study suggest that psychiatric hospitalization is associated with reduced average SA risk in the immediate aftermath of an SA but not after other recent SAs or SI only. Substantial heterogeneity exists in these associations across patients. An individualized treatment rule...

pubmed.ncbi.nlm.nih.gov

 

[comp1]

Wow that study is pretty cool! VA FTW again. The timeline does make sense. I'm not sure future suicide attempt is exactly the end point I'd use. I'm a bit more interested in completed suicides and I think hospitalizations have a lot more benefits (particularly in the VA) than just stopping you from killing yourself, but this is still really cool.

 

[Merovinge]

Interesting paper that came out a few months ago with a large sample from the VA saying that hospitalizations prevent suicide but only if the patient made a suicide attempt within the past day. Hospitalization did not lower suicide risk with those who had SI only or attempts 2-7 days prior.

Estimated Average Treatment Effect of Psychiatric Hospitalization in Patients With Suicidal Behaviors: A Precision Treatment Analysis - PubMed

The findings of this study suggest that psychiatric hospitalization is associated with reduced average SA risk in the immediate aftermath of an SA but not after other recent SAs or SI only. Substantial heterogeneity exists in these associations across patients. An individualized treatment rule...

pubmed.ncbi.nlm.nih.gov

I would be curious to what was different in the group at <24 hours versus say waiting a day then coming in. If anything, the cases I have seen where the attempt was a few days out are more likely to be people intent on dying that didn't want help.

Seperate from all that, pretty sobering that 1/8 people presenting for SI OR SA go on to attempt in the next 12 months. I hope we can get additional data on this with the rise of ketamine or other novel antidepressant treatements trying to show efficacy for SI/SA.

 

[calvnandhobbs68]

Wow that study is pretty cool! VA FTW again. The timeline does make sense. I'm not sure future suicide attempt is exactly the end point I'd use. I'm a bit more interested in completed suicides and I think hospitalizations have a lot more benefits (particularly in the VA) than just stopping you from killing yourself, but this is still really cool.

Let's just be clear here though that the VA has it's own...unique...patient population with it's own set of barriers and incentives that doesn't necessarily extrapolate out to the general population for most studies. 90% male pop avg age 53 with an IQR of 41-59yo and 71% of those people who showed up to the ED got hospitalized.

 

[the5thelement]

Could be heuristics at work too. You are the only psychiatrist in a busy ER at 2am , in a world which seems to get ****tier and ****tier since the pandemic and there is a constant stream of psych patients who are saying they want to kill themselves (or denying it but the collateral info says otherwise). Good thorough evaluations take time but even then can you be really sure? Where there is smoke there is fire. The hospital awaits with its open arms. The Beauty of the House is immeasurable; its Kindness infinite.

 

[aim-agm]

I've been told it is difficult to sue for malpractice wrongful death in a suicide case in CA because there's something on the about the fact if simply rely upon the LPS involuntary hold criteria and discharge based on the fact the patient is not meeting criteria for a hold you are essentially clear. Can anyone shed insight on this who is familiar?

1. Retention is only privileged when all criteria are met
2. Unprivileged retention is a crime
3. There can be no duty to commit a crime
4. There is no malpractice when there is no duty
5. You cannot be sued for malpractice for not retaining a patient who does not meet criteria

However, you can be sued for failing to do what you are allowed to do, such as not safety planning, not recommending voluntary hospitalization or not explaining the risks of being released, etc..

EDIT: I'll add that in such cases you should document that you are "releasing" the patient, not "discharging" them. "Discharge" is a process that involves a medical decision telling the patient they can/should leave the hospital. "Release" is just desisting from preventing them from leaving, in this case to avoid committing a crime.