Weighing Risk for Suicide

[The Long Way]

Greetings All,
PGY 1 here finally done doing all of my general medicine requirements and getting back into Psych.

I've started taking psychiatry call now, and it seems that the bulk of my work is evaluation of suicidal ideation. I have read Shea's book on suicide assessment, and continue going back through it, as I feel that it is an excellent primer on suicide assessment. However, I feel that I am still having some difficulty with projecting actual risk for individual patients.

Some patients are obvious and clearly need to be admitted (i.e. I tied the rope into a noose and had it around my neck last night), however, some seem to be more impulsive and manipulative, yet I feel that we are stuck admitting. I have discussed this with some of my senior residents and attendings, and the feedback I seem to be getting, goes something along the lines of "better safe than sorry" when it comes to patients who seem relatively low risk for completing. It seems to me that inpatient psych admission, and particularly involuntarily psych admission, is not necessarily a benign process if a person does not need such care. In addition, it is wasteful and uses up a person's inpatient days that they are alotted from their insurance and that they may actually need later in the year.

I know that in these "low risk" patients we need to ensure that their is adequate supervision upon discharge, that the home environment will be safe, that they have appropriate follow-up, etc... but I am looking for something more solid to stand on.

So far, I've done a Pubmed search and have found a few articles, but thought perhaps someone here may be able to recommend a book, article, etc. that was particularly helpful in providing more objective data regarding how to stratify patients

Thanks,
The Long Way

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[atsai3]

Greetings All,
PGY 1 here finally done doing all of my general medicine requirements and getting back into Psych.

I've started taking psychiatry call now, and it seems that the bulk of my work is evaluation of suicidal ideation. I have read Shea's book on suicide assessment, and continue going back through it, as I feel that it is an excellent primer on suicide assessment. However, I feel that I am still having some difficulty with projecting actual risk for individual patients.

Some patients are obvious and clearly need to be admitted (i.e. I tied the rope into a noose and had it around my neck last night), however, some seem to be more impulsive and manipulative, yet I feel that we are stuck admitting. I have discussed this with some of my senior residents and attendings, and the feedback I seem to be getting, goes something along the lines of "better safe than sorry" when it comes to patients who seem relatively low risk for completing. It seems to me that inpatient psych admission, and particularly involuntarily psych admission, is not necessarily a benign process if a person does not need such care. In addition, it is wasteful and uses up a person's inpatient days that they are alotted from their insurance and that they may actually need later in the year.

I know that in these "low risk" patients we need to ensure that their is adequate supervision upon discharge, that the home environment will be safe, that they have appropriate follow-up, etc... but I am looking for something more solid to stand on.

So far, I've done a Pubmed search and have found a few articles, but thought perhaps someone here may be able to recommend a book, article, etc. that was particularly helpful in providing more objective data regarding how to stratify patients

Thanks,
The Long Way

Researchers have tried, but failed, to come up with a risk model that performs satisfactorily with regards to prediction of suicide attempts and/or completed suicide. If you discharge a patient from the ED or hospital and she goes on to commit suicide and you are sued for it, you are on firm legal ground if you did a thorough assessment (i.e., identified and documented all risk factors and all protective factors) and executed a plan that one of your peers would consider reasonable in light of the assessment. Sometimes you will make the wrong call, but that is okay. One book that I found extremely helpful is a book by Shawn Christopher Shea, The Practical Art of Suicide Assessment.

The reason why your attendings say "better safe than sorry" is because it is much harder to be successfully sued for making the wrong call to detain a patient in the hospital against her will (vs. making the wrong call to discharge her from the hospital). "I think this patient is malingering and just wants a hot meal" is not a firm case.

I'm not a forensics specialist -- perhaps whopper or someone else can give you more informed feedback -- but I suspect that the difference has to do with demonstrating harm. For the patient whom you discharge from the hospital who ends up committing suicide, the harm is (obviously) that she is dead. For the patient whom you detain in the hospital, (a) the probability of her committing suicide is decreased (although in-house suicides do occur); and (b) assuming she does not successfully complete suicide in-house, then what is the harm? A few days of bad food? Being injected with intramuscular lorazepam during an episode of acute agitation?

-AT.

 

[whopper]

Atsai gave a good post. As was written, the best research only leaves the accuracy of a suicide risk evaluation better than not doing one. It still leaves much room for error. The only thing you can do is cross your Ts and dot your Is and hope for the best.

If you discharged someone that showed no signs of suicidal ideation and had no symptoms of it for a reasonable amount of time, got a good history, you gave appropriate treatment, and had a safe discharge plan, you can't do anything else and satisfied the standard of care. In that case a malpractice suit should not win against you even if the person did end up committing suicide right after discharge. That doesn't mean the suit won't happen, just means if the Court does the right thing, it won't succeed against you.

some seem to be more impulsive and manipulative, yet I feel that we are stuck admitting. I have discussed this with some of my senior residents and attendings, and the feedback I seem to be getting, goes something along the lines of "better safe than sorry"

I have seen some patients that over time I became convinced were malingering. The problem here is that in the clinical setting I was in, there needed to be across the board cooperation between the inpatient attending, the attending in the crisis center, and the ER staff. This was not happening.

E.g. if the inpatient attending is correctly convinced the person is a malingerer and is not suicidal, the ER psychiatrist could write down the person is at high risk for suicide simply to push the door open for an admission and get the patient off that psychiatrist's back. Now this puts the inpatient attending in a legally defensive position of having to keep a patient he believes is malingering becuase another doctor wrote something down that was at best an exaggeration.

Happens actually quite a bit. It's called turfing, a dump job, among other things.

"better safe than sorry"

Often times I will hear this argument when in fact it really is turfing. Plenty of times on the medical floor the patient claimed he never said he was suicidal and the medical staff said they heard him say it. Of course one time, fine. A pattern of it from specific staff members and only when they find patients difficult? It begs the question.

Now if everyone was working as a team this wouldn't happen as much, but unfortunately that is not often the case.

If you feel some of this is going on, you really can't do much about it other than politely bring it up the chain of command. Don't overstep your boundaries as a resident and remember that it's really the attending, not you, calling the shots. As a PGY-1, there's a lot learn and you are likely still getting used to the different clinical styles you see from different attendings, staff members, and environments. Many of them may be doing things that you may think are not correct now, but later on you may learn to understand they were doing the right thing.

 

[TexasPhysician]

If you discharge a patient from the ED or hospital and she goes on to commit suicide and you are sued for it, you are on firm legal ground if you did a thorough assessment (i.e., identified and documented all risk factors and all protective factors) and executed a plan that one of your peers would consider reasonable in light of the assessment.

MONEY!

 

[nitemagi]

I feel we should discuss this issue a lot more on this site. A thorough assessment is a moving target, and varies tremendously by situation, as does the intervention, it seems. Great points so far.

Other thoughts that have been brought up during my training--
-Should we be hospitalizing those with chronic suicidality if they don't seem to benefit from hospitalization? The suicidality doesn't go away, and all you've done is reduce their risk temporarily. But you can't hospitalize indefinitely.

-Should hospitalization be used for adjustment of modifiable risk factors, meaning factors other than age, gender, etc. But then this leaves the big gray area of the malingerer, and contingent suicidality. Yes they're suicidal because they're homeless. Putting them in the hospital gives them temporary shelter, but once out the hospital they're back in that situation. We're not a hotel.

-How much stock do you put in the idea of contingent suicidality? Classic study where they followed a group of I think 100 contingent suicidal patients, and zero of them committed suicide. I should dig that study up...

-Just like the turfing situation, all too often we fall into applying our honed rationalization skills to create a reason for not doing something. Where should we draw the line? Medicine uses the "well we're not doing anything but observing them" all too often to rationalize discharging or transferring them, and we could do the same to create rationale for not admitting. But should we?

-Is there any data out there on diagnosing malingered SI? There is for so much other pathology, but not for SI for some reason.

 

[Therapist4Chnge]

I'm not sure there is a more frustrating case than the frequent flyer borderline patient. What is considered a "thorough" assessment in this case? Does your documentation change if they have a prior attempt? And if so, why should that information not be included anyway?

The above is by far the most frustrating consult/evaluation.

 

[nitemagi]

I'm not sure there is a more frustrating case than the frequent flyer borderline patient. What is considered a "thorough" assessment in this case? Does your documentation change if they have a prior attempt? And if so, why should that information not be included anyway?

The above is by far the most frustrating consult/evaluation.

Totally!

And maybe we should be declaring risk in terms of chronic high risk and poor prognosis, really recognizing there are some people who will always be high risk and they will very likely eventually do something. Especially borderlines. But we shouldn't be hospitalizing them every time they come into the ED. I try to emphasize this in assessments, and use the idea of chronic high risk d/t non-modifiable risk factors, and that it is/is not advisable to hospitalize them because of the presence/absence of modifiable risk factors. A prior attempt recently may raise acuity. An attempt 20 years ago is technically a risk factor, but isn't going to change whether they're sitting in the ED in crisis or in a starbucks sipping coffee.

 

[whopper]

-How much stock do you put in the idea of contingent suicidality? Classic study where they followed a group of I think 100 contingent suicidal patients, and zero of them committed suicide. I should dig that study up

I read that study. In fact I think I gave a link to it on the board about 2 years ago. I forgot who wrote it but I believe he was in TX and he replacated the study a few years later with similar results. Nuts, I can't find the study right now! In those studies, contingent suicidality was actually a protective factor!

While those two studies were very good and it did change my mind on how to handle these patients, the author of those two papers specifically wrote that more research needs to be done.

(After years of reading a great study, putting it my mind, but not being able to remember the source when it actually showed up in clnical practice, I started habit of saving the "landmark" studies I read that changed the way I practice but seem out of the ordinary. E.g. most people encountering someone contingently suicidal usually allow them to manipulate them. Unfortunately I started the practice long after I threw the article away.)

I'm not sure there is a more frustrating case than the frequent flyer borderline patient

Linehan mentioned that inpatient hospitalization is usually not effective for borderline PD. The best way to handle chronically suicidal borderline patients is to have an effective DBT treatment team that can provide 24/7 services. In those cases, if the patient is suicidal, they are supposed to contact the DBT therapist on duty that can prevent the person from needing to go the hospital. The therapist does provide support but in a drill-sergeant type of way. They enforce boundaries and do not allow the person to emotionally hold others hostage.

Now the problem here is that many areas usually do not have ANY DBT TREATMENT WHATSOEVER! Then you got the psychiatrist that allows borderlines to manipulate them, keep them as an inpatient without any real effective treatment for their disorder, give them substances of abuse, ineffective polypharmacy, etc.

Of course, and it's unfortunate, there is a borderline of the type of extreme where they are chronically suicidal but they are and willing to act on it. In that case, you might have to hospitalize the patient. In that case, IMHO they need to be transferred to a long-term facility (not the usual facilities most of you residents are in that only hospitalize on the order of a few days). There, in the long-term facility the patient can get DBT and in addition be in a safe environment that is difficult to commit suicide.

 

[whopper]

Aha...

http://psychservices.psychiatryonline.org/cgi/content/full/53/1/92

http://ps.psychiatryonline.org/cgi/...ce&volume=47&firstpage=871&resourcetype=HWCIT

 

[CaMD]

Thanks Whopper! Thats gonna be my down-time reading for tomorrow.

 

[DrGachet]

I'm not sure there is a more frustrating case than the frequent flyer borderline patient.

I do not appreciate your attempt at humor. Though I realize it creates distance which is necessary if that is your line of work, it dehumanizes the person and is presumptuous.

Too many people with repeated suicidal ideation/attempt get labeled BPD, and unfortunately, that only makes things worse, specially for those whose feelings were never validated as a child and are suffering because they were dehumanized and their lives devalued over and over again in the past. Self-fulfilling prophecy can be a scary thing.

I have great respect for those who work with traumatized people, with those with BPD, put up with their rage and soothe their fears, yet remain optimistic and compassionate, are prepared for the worst but constantly expect and wish for the best.

*end of rant*

 

[whopper]

Not a defense or a criticism of any of the above posts. When I was a resident, no one in the program provided DBT. The way the program handled borderline patients was simply to discharge them ASAP with some non-compassionate words (e.g. condescending attitude, "stop manipulating us," "we know your game") or the other attending let the patient manipulate him in apporpriately (e.g. give out medications of abuse, longer lengths of stay, etc).

Then in outpatient they got a another psychiatrist that again didn't know how to do DBT and didn't know any of the tactics you mentioned (validation, understanding that borderline is often from prior trauma, etc).

And the cycle continued on and on and on.

Attendings never fessed up to the residents that they basically were contributing to a bigger problem, partly out of ignorance/narcissism and partly because few attendings want to admit they know little on something that is so desperately needed in modern psychiatry.

That in turn puts a lot of frustration on residents. The fact that several attendings and staff members saw borderlines as troublemakers and not people in need only validated the less than stellar response.

As bad as that is, from what I've seen my residency program was not below the standard. It was the standard. I see few programs teaching DBT. Most psychiatrists I know believe all they have to know about it is that it's the answer you give on the board exam when it asks for the first-line treatment for borderline PD. Why? Because that's the message they're given. It's not taught, few psychiatrists mention it, few programs even have mental health professionals trained in it outside the psychiatrists, and the only time it the system demands knowledge of it in a manner where the psychiatrist actually is held responsible is when it appears on the exam in that level of simplicity.

And for you people thinking that this means give a borderline PD patient anything they want, no. Proper DBT also means enforcing boundaries. Yes, treatment teams in general, with some exceptions, should be getting out a borderline PD patient out of the inpatient unit quickly, but that patient should also be referred for proper psychotherapy. From what I understand, being a good DBT psychotherapist involved being part drill-sergeant and part listener.

 

[The Long Way]

Thanks for the replies.

The discussion regarding borderline patients reminds me of a patient that I recently saw, where I felt stuck admitting, even though I was not sure that it was justified, and the patient definitely did not want to be admitted.

She was a young woman with previous diagnoses of Bipolar d/o and Borderline PD. She had not had any psychiatric care in a number of years, and was recently started on an SSRI by her PCP for labile mood. I saw her three weeks after the SSRI was started and she was probably becoming manic. In addition, she was really struggling with mood dysregulation, had very intense emotions, and had a strong personality component that seemed to emerge during the interview.

Three days prior to my evaluation, she had had some potentially lethal suicidal behavior, which she aborted. She stated that she did not know if she had any intention to die on that night. During my interview, though, she denied any SI, had questionable social support, no close mental health follow up (1 month out), and was going to return to the same stressful situation that brought her to the ED. She had sought help on the day of interview, was future oriented, and had a mother that committed to watching her, denied EtOH/drugs, and denied previous suicide attempts.

My gut feeling was that she was probably safe to go home, but with her impulsivity and intense emotions and worsening manic symptoms, I felt that she would benefit from a short inpatient say. After staffing with my attending, it was decided that she would go inpatient (involuntarily if necessary).

While I agree with the end decision, I recognize the potential harm that inpatient admission (especially involuntary) can do. Many of our patients are struggling financially to begin with, an admission adds to that stressor in the realm of lost wages and added hospital costs. In addition, with this patient, she was essentially given an ultimatum to go voluntarily, or she would be forced to go involuntarily.

I'm OK with involuntary admission when it is clearly warranted, however, I struggle with the appropriateness and ethics of taking away a person's freedom to choose when I am not strongly convinced that it is absolutely necessary and for the reason of "better safe than sorry."

I'm still learning here, and appreciate the perspectives expressed on these boards. Thanks again for your insight and experiences.

 

[nitemagi]

Thanks for the replies.

The discussion regarding borderline patients reminds me of a patient that I recently saw, where I felt stuck admitting, even though I was not sure that it was justified, and the patient definitely did not want to be admitted.

She was a young woman with previous diagnoses of Bipolar d/o and Borderline PD. She had not had any psychiatric care in a number of years, and was recently started on an SSRI by her PCP for labile mood. I saw her three weeks after the SSRI was started and she was probably becoming manic. In addition, she was really struggling with mood dysregulation, had very intense emotions, and had a strong personality component that seemed to emerge during the interview.

Three days prior to my evaluation, she had had some potentially lethal suicidal behavior, which she aborted. She stated that she did not know if she had any intention to die on that night. During my interview, though, she denied any SI, had questionable social support, no close mental health follow up (1 month out), and was going to return to the same stressful situation that brought her to the ED. She had sought help on the day of interview, was future oriented, and had a mother that committed to watching her, denied EtOH/drugs, and denied previous suicide attempts.

My gut feeling was that she was probably safe to go home, but with her impulsivity and intense emotions and worsening manic symptoms, I felt that she would benefit from a short inpatient say. After staffing with my attending, it was decided that she would go inpatient (involuntarily if necessary).

While I agree with the end decision, I recognize the potential harm that inpatient admission (especially involuntary) can do. Many of our patients are struggling financially to begin with, an admission adds to that stressor in the realm of lost wages and added hospital costs. In addition, with this patient, she was essentially given an ultimatum to go voluntarily, or she would be forced to go involuntarily.

I'm OK with involuntary admission when it is clearly warranted, however, I struggle with the appropriateness and ethics of taking away a person's freedom to choose when I am not strongly convinced that it is absolutely necessary and for the reason of "better safe than sorry."

I'm still learning here, and appreciate the perspectives expressed on these boards. Thanks again for your insight and experiences.

I think there's multiple sides to this situation. I agree with whopper that DBT should be taught, and IMO is more important than CBT. I also know there are many situations where the patient essentially escalates to get an admission, not in a malicious way but because frankly it's their coping mechanism. The problem I think with admitting them is it reinforces that hospitalization is the way to deal with their crisis, rather than guiding them through using their resources/skills/etc. to handle the situation on their own. Of course this leads to multiple further arguments that if they had the resources to deal with things differently then they would have already, but I'm not so sure. I think people go the way of either routine/habit or of least resistance. Working on yourself fits neither.

I've sadly had a few borderlines who I see in the ED and response very well to some pacing and guiding them through relaxation exercises, calming them, and then suddenly the crisis feels a lot more manageable for them. And then suddenly they're not begging for admission.

 

[whopper]

IMHO the best way to prevent and stop the phenomenon of the chronic manipulative person that tries to put the ER (or psychiatrist crisis center) hostage is to implement DBT (I already beat that horse to death), implement malingering testing and start prosecuting patients.

DBT already has it's own problems all of which boil down to money and politics. Hospitals can make money from someone coming in all the time and implementing DBT requires people to be trained in it. While the state and health management companies will save much more than the money spent and earned by hospitals, the system is not built that way. There's no incentive to hospitals to implement these systems other than the pure satisfaction of helping society.
Kinda like people with high cholesterol, a smoker, and overweight and I'm a cardiologist. I could spend hours trying to fix the person's unhealthy lifestyle and only get paid the $75 for the office visit or I could give the guy a triple bypass that makes me thousands of dollars.

The problem with malingering testing and prosecution is that we are not supposed to do "harm" to our patients. Some interpret that as getting the law after them. Another problem is you're supposed to respect their privacy. Am I supposed to tell the police officer what the patient told me during the interview? While I agree that allowing them to get away with terroristic manipulation is causing harm, no one in the profession nor organizations have put forth clear guidelines on how to handle this. The problem here is part political, monetary, and ignorance.

You find out a patient is not truly mentally ill in the Axis I sense, you think medicaire/medicaid is going to pay for the bill when you write there is no mental illness and you kept the person in the hospital for days? I sometimes get people telling me they will but I do get more telling me they will not. I can tell you the medicaire/medicaid billing person in the hospital I work in tells me they will not pay.

As for the ignorance component, general psychiatrists do not know well how to handle malingering. The forensic psychiatrists that do (and they are not common, most FPs don't know how to do malignering testing), are not going to have the time and likely not the desire to do it in an ER setting. Good malingering testing requires days of observation and psychological testing.

As for the law, even if I did find someone to be malingering, am I supposed to call the police and have them arrested? Again, that is something not clearly established and many hospitals will tell the doctor to just let it go because they don't want to get involved in a possible legal quandry. I can also tell that is it my personal belief that unless very good testing and evidence is documented, several doctors will abuse their power if given it to have patients taken away by the police.

IMHO, the best way to handle it is for a doctor, if he believes the patient is malingering, to be able to consult a forensic psychologist or psychiatrist to do malingering testing on the person. There would also have to be legislation stating that such a practice is legal and allowable. Doing so would create guidelines in this area that has not been defined. For the protection of patients, they should only be held accountable for malingering if the evidence is overwhelming because the testing can sometimes yield grey data. A judge could also be involved in the decision making process because that would shift responsibility to the Court and away from the doctor.

The above will likely never be done. Some areas have a mental health court and that is a step in the right direction, but even they are no where near close to establishing the above.

And even if it is done, I could see further problems down the road. If a patient is truly malingering, the patient could attempt self-harm, not becuase they want to die but out of anger. That sometimes happens when psychiatrists kick out patients suspected of malingering. The person in these situations (assuming they are malingering) may cut himself knowing full well that now the hospital has to take them in. In many cases where this happened I did not believe the person was suicidal at all. E.g. the person held a piece of glass in front of staff and with a smile on his face the guy starting cutting his wrist even saying "now you have to take me in *****hole!" Such a thing can happen in a legal situation and do you think a judge without mental health training is going to want to touch this sore subject? In most cases heck no.