What Would You Do: Patient Denies Being Suicidal, Collateral Says Otherwise

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Hypothetical scenario:

Mother calls the office in a state of panic because she thinks patient (24 yo M) will commit suicide. You speak to the patient and he says he has no idea, intention, or plan. You have no reason to suspect foul play from the mom. You are not sure if patient is telling the truth. No other information available.

How will you proceed?

 

[splik]

This is not the sort of thing we can we deal with in the office. If the mother is able to explain the reasoning, she can take him to ER to be evaluated if he is agreeable. Documenting that a patient denies SI will not protect you in a lawsuit if the patient subsequently commits suicide and you did not heed the family's concerns. There is a delicate balance and this also varies based on state civil commitment statutes. For example, in CA you could involuntarily hospitalize someone just based on decent collateral even if pt is denying all symptoms because our standard of proof is probable cause. Whereas in PA for instance, where the standard of proof is clear and convincing evidence you would not. In states where psychiatrists can't commit patients and it's up to the mental health professional (i.e. WA) or community service board (i.e. VA) this probably wouldn't fly either.

A while back I evaluated a patient in the ER who the psychiatrist was concerned about suicidality. The patient denied SI, intent, plan and all psychiatric symptoms (had a dx of schizophrenia). I placed the pt on a hold and had him admitted. He continued to deny symptoms during his hospitalization and was eventually discharged. Immediately after discharge, he overdosed (and fortunately survived but it was a significant OD).

I also had a situation in which the family lied about a patient being suicidal. It was obvious to me they weren't being truthful (not always easy to figure out) and so we did not act on it. However you need to take a good collateral history, consider historical features, and the patient's present mental state as well as recent life events in order to do a good risk assessment and figure out what the appropriate course of action is.

 

[Merely]

This is not the sort of thing we can we deal with in the office. If the mother is able to explain the reasoning, she can take him to ER to be evaluated if he is agreeable. Documenting that a patient denies SI will not protect you in a lawsuit if the patient subsequently commits suicide and you did not heed the family's concerns. There is a delicate balance and this also varies based on state civil commitment statutes. For example, in CA you could involuntarily hospitalize someone just based on decent collateral even if pt is denying all symptoms because our standard of proof is probable cause. Whereas in PA for instance, where the standard of proof is clear and convincing evidence you would not. In states where psychiatrists can't commit patients and it's up to the mental health professional (i.e. WA) or community service board (i.e. VA) this probably wouldn't fly either.

A while back I evaluated a patient in the ER who the psychiatrist was concerned about suicidality. The patient denied SI, intent, plan and all psychiatric symptoms (had a dx of schizophrenia). I placed the pt on a hold and had him admitted. He continued to deny symptoms during his hospitalization and was eventually discharged. Immediately after discharge, he overdosed (and fortunately survived but it was a significant OD).

I also had a situation in which the family lied about a patient being suicidal. It was obvious to me they weren't being truthful (not always easy to figure out) and so we did not act on it. However you need to take a good collateral history, consider historical features, and the patient's present mental state as well as recent life events in order to do a good risk assessment and figure out what the appropriate course of action is.

Damn it’s pretty crazy how variable state laws can be

 

[MacDonaldTriad]

And what is even more crazy is how variably the same state laws are interpreted by different counties. This judge doesn't allow this, the other judge insists that this be done....

 

[Bartelby]

I think you need to give a lot more context here. How well do I know the patient? What is my overall impression of this patient? Why is the mother in a panic that this patient will commit suicide? I think the information given is far too general to reach any kind of determination.

 

[Armadillos]

To me, the fact that parent thinks patient is risk for suicide is of little importance, HOWEVER why the parent believes that is of absolutely critical importance. So ask the parent why they are concerned, and depending what they say I would absolutely hospitalize patient regardless of what patient tells me.

Also, you don’t necessarily have to trust the parents medical judgement itself (that they believe pt is suicide risk), but in my opinion in crisis you absolutely have to believe the facts as parent tells them are true unless you have extraordinary reasons not to.

We aren’t the FBI, if mom says patient just gave away all his stuff, bought a gun and sent suicide Snapchat note, but the patient denies it completely and claims mom is being vindictive, (in my state) the patient will get to take up the argument with the probate judge.

And if you are unsure, in my opinion always error on the side of acutely assuring safety.

 

[PsyDr]

I'll just leave this here:

Belsher, B. E., et al. (2019). "Prediction Models for Suicide Attempts and Deaths: A Systematic Review and Simulation." JAMA Psychiatry.

 

[birchswing]

A while back I evaluated a patient in the ER who the psychiatrist was concerned about suicidality. The patient denied SI, intent, plan and all psychiatric symptoms (had a dx of schizophrenia). I placed the pt on a hold and had him admitted. He continued to deny symptoms during his hospitalization and was eventually discharged. Immediately after discharge, he overdosed (and fortunately survived but it was a significant OD).

This made me curious about the previous discussion of suicide increase during the promotion and airing of 13 Reasons Why.

If a person is hospitalized due to suspicion of suicide and is asked about it repeatedly, could it plant an idea? Especially in an unpleasant environment like a hospital. I really don't have any particular knowledge about schizophrenia but have heard that it's culturally informed (demonic vs pleasant spiritual experiences), which leads me to wonder if a person could take the idea of suicidality and internalize it.

 

[cara susanna]

This made me curious about the previous discussion of suicide increase during the promotion and airing of 13 Reasons Why.

If a person is hospitalized due to suspicion of suicide and is asked about it repeatedly, could it plant an idea? Especially in an unpleasant environment like a hospital. I really don't have any particular knowledge about schizophrenia but have heard that it's culturally informed (demonic vs pleasant spiritual experiences), which leads me to wonder if a person could take the idea of suicidality and internalize it.

Studies have repeatedly shown that asking about suicide doesn't increase risk.

 

[romanticscience]

Hypothetical scenario:

Mother calls the office in a state of panic because she thinks patient (24 yo M) will commit suicide. You speak to the patient and he says he has no idea, intention, or plan. You have no reason to suspect foul play from the mom. You are not sure if patient is telling the truth. No other information available.

How will you proceed?

Depends on the diagnosis. I've been in this situation with college student patients who have a personality disorder and who depend on family. The following would not apply if the patient's reality testing is impaired (psychotic, demented, intellectually disabled).

This could be an instance of a threat to the treatment frame (3rd party getting involved), maybe due to secondary gain or the patient attempting to control the therapy (not telling you he's suicidal but splitting dissociated anger at you by acting in such a manner as to have his parent call you). Without addressing in an initial contract (i.e., meeting/calling parents and having them agree to call crisis to maintain your neutrality / expecting the patient to maintain his safety), I'd discuss with the patient, sharing the difficulty of the situation (how it's more than just parents "over-reacting", its effect on treatment continuity, and re-contract around future instances (maybe meeting or calling the family).

Also, my question, what if you don't have the signed consent to talk with her? The most frustrating thing for me has bot been crisis calls from patients but from their significant others/family members.

 

[dl2dp2]

LOL I have patients who tell me repeatedly that they'll kill themselves and I don't hospitalize. The case history isn't sufficient to make a call one way or the other. Refer to ER in case of lack of clarity.

In *general*, one errs on the side of hospitalization if the family member tells you that they don't feel safe. Reason being: if the patient dies, the family will sue you. If the patient doesn't die and sues you for unlawful imprisonment, it's very unlikely a winnable suit if you documented your reasoning. In particular, there are other reasons for involuntary hospitalization in addition to risk of self-harm (i.e. lack of ability for self-care), which can be much more easily fudged in documentation.

In outpatient practice, the default and almost always right answer is ER eval. I have burned my rapport though by calling EMS on people. But rest assured, if you think things through, the harm of EMS pick-up and ER eval is almost always trivial compared to the possible risk of such a maneuver and can be easily convincingly argued in front of review panels or in a court of law. In particular, risk of harm of EMS/ER is much more related to non-community standard practice AT the EMS/ER (i.e. patient fighting EMS and getting injured), and if such things happen it's always easy to argue that you didn't do anything wrong, it's the fault of the EMS/ER not doing their job right. Your patient might hate you, but you can always say that you are concerned of their safety because of A B C. It's impossible to prove that such concern cause injury.

There are specific scenarios where clinically referring to ER isn't "right" and not evidence-based (i.e. BPD, suicide in the context of relapse/withdrawal to substances, etc.), and repeated ER referrals probably cause long term harm in recovery. But medico-legally, it's never wrong to refer BPD patients or substance users repeatedly to the ER, especially if you don't have any information.

 

[Bartelby]

Also, my question, what if you don't have the signed consent to talk with her? The most frustrating thing for me has bot been crisis calls from patients but from their significant others/family members.

Typically emergency situations override confidentiality concerns. I would consider calling the family member back and listening to what they have to say without disclosing any of the patient's information (aside from the mere fact that I am treating them, which the family member obviously already knows). If you will work with the family going forward try to get a signed release so that you can do so more meaningfully.

 

[sloop]

The answer to this is to bring the patient to the emergency department. If I have credible information that that my patient may commit suicide, they need to go to the ED. If they refuse to go, there is a legal process in my state where I can compel them to go to the ED. The fact that the patient denies the mother's report does not mitigate the concern if I think the report is factual or likely to be factual. The emergency department can then sort it out while the patient is means-restricted and relatively safe. It would be unsafe to try to get to the bottom of this without nursing care and supervision.

 

[Merely]

The answer to this is to bring the patient to the emergency department. If I have credible information that that my patient may commit suicide, they need to go to the ED. If they refuse to go, there is a legal process in my state where I can compel them to go to the ED. The fact that the patient denies the mother's report does not mitigate the concern if I think the report is factual or likely to be factual. The emergency department can then sort it out while the patient is means-restricted and relatively safe. It would be unsafe to try to get to the bottom of this without nursing care and supervision.

So the answer is to call 911 and tell them to go get the pt or have the mom do it?

 

[sloop]

So the answer is to call 911 and tell them to go get the pt or have the mom do it?

You can ask the patient to go to the ED. If they refuse and you think they are a danger to themselves or others, in my state you can fill out a petition and call the police. The police will send someone to pick up the petition and they will find the patient and bring them to the emergency department.

 

[Marasmus1]

Nowadays we are practicing defensive medicine. I would admit the patient regardless what the patient says and justify it with a strong note.

And please dont blame me. Blame the current healthcare system.

 

[hallowmann]

I'll just leave this here:

Belsher, B. E., et al. (2019). "Prediction Models for Suicide Attempts and Deaths: A Systematic Review and Simulation." JAMA Psychiatry.

Wondered if someone was going to bring this up.

This is one of those areas where we often err on the side of safety, but honestly, if I can't convince myself someone's rights should be taken away, its a hard pill to swallow. I agree with the rest, send them to the ED, consider a hold if they refuse, maybe get more collateral, but if you can't, that may be a red flag in and of itself. But yeah, as far as predictive models of who will actual commit/attempt suicide, they just don't work.

 

[clausewitz2]

Wondered if someone was going to bring this up.

This is one of those areas where we often err on the side of safety, but honestly, if I can't convince myself someone's rights should be taken away, its a hard pill to swallow. I agree with the rest, send them to the ED, consider a hold if they refuse, maybe get more collateral, but if you can't, that may be a red flag in and of itself. But yeah, as far as predictive models of who will actual commit/attempt suicide, they just don't work.

Agreed. If we are in a situation where we are considering hospitalizing strictly on considerations of medicolegal liability we are imprisoning someone for our own convenience and to protect our careers and finances. I think it is important to be clear-eyed about this. Different people will have differing intuitions as to how acceptable this is.

 

[Merely]

Agreed. If we are in a situation where we are considering hospitalizing strictly on considerations of medicolegal liability we are imprisoning someone for our own convenience and to protect our careers and finances. I think it is important to be clear-eyed about this. Different people will have differing intuitions as to how acceptable this is.

I mean it very acceptable because I’m more important than my patient

 

[deleted736562]

Someone who's denying everything is probably more concerning cause 90 percent of the time there's usually a fairly good reason why they ended up in the ER. The devil is in the detail. You'd need to get a very good account of family concerns, level of functioning, any recent triggers, depressive sx...etc, before trying to make a decision. Most of the time you will be able to get a more accurate picture of what is going on and then use your judgement accordingly. Holding and observing any changes in MSE is also important, though has to be said that some suicidal patients are able to hold it together pretty well.

As for OP, I think it's a similar process. This is entirely a case by case basis and depends on how much you know the family and the patient. If the family is reliable this is no brainer. You can also always advise the family to call EMS... There's really nothing stopping them.

 

[sloop]

Agreed. If we are in a situation where we are considering hospitalizing strictly on considerations of medicolegal liability we are imprisoning someone for our own convenience and to protect our careers and finances. I think it is important to be clear-eyed about this. Different people will have differing intuitions as to how acceptable this is.

Personally, I find it entirely acceptable. I am not taking away their rights without due process. They get brought to the ED and evaluated. If the ED finds new information or otherwise finds the petition insufficient, they get discharged. If not, they will have a hearing with a judge within an allotted time in accordance with state law.

The process is set up with protections for patients’ civil liberties. Are the protections perfect? No, but it is not reasonable for individual psychiatrists to bear the burdens and risks of trying to mitigate policy problems regarding due process.

 

[Stagg737]

Wondered if someone was going to bring this up.

This is one of those areas where we often err on the side of safety, but honestly, if I can't convince myself someone's rights should be taken away, its a hard pill to swallow. I agree with the rest, send them to the ED, consider a hold if they refuse, maybe get more collateral, but if you can't, that may be a red flag in and of itself. But yeah, as far as predictive models of who will actual commit/attempt suicide, they just don't work.

Agreed. If we are in a situation where we are considering hospitalizing strictly on considerations of medicolegal liability we are imprisoning someone for our own convenience and to protect our careers and finances. I think it is important to be clear-eyed about this. Different people will have differing intuitions as to how acceptable this is.

From an autonomy perspective I agree with this and I never really like making a patient involuntary. At the same time from a risk/benefit standpoint the decision is a lot clearer for me:

If I admit someone and the court rules they don't meet criteria then they spent a couple days being bored on our unit (in my state). Sometimes they do admit something is wrong and decide to stay. Sometimes we find something else on admission labs that we can address. Regardless, the overall risk of harm is relatively low.

If I chose to not admit someone and something does happen like they kill themselves or cause permanent injury, then I potentially lose my license and I lose the ability to help thousands of patients in the future. The risk is potentially very high for both the patient and myself.

The other point I keep in mind is that in my state if I am able to get more collateral and find out the patient really doesn't need to be on the unit, we can always drop the hold and discharge the patient after documenting the new information. When in doubt I ask myself, "Is this a decision I'm confident enough to risk my license on?", if the answer isn't a solid yes I take the safe route.

 

[Bartelby]

If I admit someone and the court rules they don't meet criteria then they spent a couple days being bored on our unit (in my state). Sometimes they do admit something is wrong and decide to stay. Sometimes we find something else on admission labs that we can address. Regardless, the overall risk of harm is relatively low.

While I agree with erring on the side of caution in very ambiguous situations, I don't think we should downplay the potential harms of involuntary hospitalization which can include:

-Loss of gun rights,
-loss of security clearance,
-loss of professional licenses,
-loss of trust / rapport leading to treatment dropout,
-missing work, bill payments, etc., sometimes with serious negative effects,
-difficulty caring for kids, pets, elders, other responsibilities,
-feeling humiliated or traumatized by the use of coercion.

Also if you (as the treating doctor who knows this person well) send them in on an involuntary hold most ERs will be very hesitant to drop the hold, presuming that your knowledge of the patient puts you in a better position to assess risk.

Again I agree with erring on the safe side if you have serious concerns, but I don't take the decision lightly and would not hospitalize simply as a CYA action when I thought genuine risk was low.

 

[Stagg737]

While I agree with erring on the side of caution in very ambiguous situations, I don't think we should downplay the potential harms of involuntary hospitalization which can include:

-Loss of gun rights,
-loss of security clearance,
-loss of professional licenses,
-loss of trust / rapport leading to treatment dropout,
-missing work, bill payments, etc., sometimes with serious negative effects,
-difficulty caring for kids, pets, elders, other responsibilities,
-feeling humiliated or traumatized by the use of coercion.

Also if you (as the treating doctor who knows this person well) send them in on an involuntary hold most ERs will be very hesitant to drop the hold, presuming that your knowledge of the patient puts you in a better position to assess risk.

Again I agree with erring on the safe side if you have serious concerns, but I don't take the decision lightly and would not hospitalize simply as a CYA action when I thought genuine risk was low.

Absolutely, and if this is a patient I'm familiar with or one of my own outpatients then that would shift things. I'd obviously try and obtain collateral if possible and then have them go to an ER first to be evaluated if it was still unclear. Like I said, I don't like placing people on holds and I was more speaking in situations where I do not know the patient and cannot obtain collateral. If I genuinely don't know what my level of concern should be though, then I'd definitely play it safe.

 

[phyonaphan]

In this circumstance (assuming you’re admitting involuntarily) you would document that your assessment of the patient has limitations as it is cross-sectional in nature, and whilst the patient is superficially denying acute thoughts of suicide the collateral information suggests concerning and compelling features indicating acutely high risk of suicide, and that admission is required for further longitudinal assessment on the basis of the inconsistencies in the patients and families reports, taking into account the patient may be guarded about their experiences. This is in order to exclude active major mental illness and for containment of immediate risks, and no less restrictive option is clinically indicated

 

[sloop]

While I agree with erring on the side of caution in very ambiguous situations, I don't think we should downplay the potential harms of involuntary hospitalization which can include:

-Loss of gun rights,
-loss of security clearance,
-loss of professional licenses,
-loss of trust / rapport leading to treatment dropout,
-missing work, bill payments, etc., sometimes with serious negative effects,
-difficulty caring for kids, pets, elders, other responsibilities,
-feeling humiliated or traumatized by the use of coercion.

Also if you (as the treating doctor who knows this person well) send them in on an involuntary hold most ERs will be very hesitant to drop the hold, presuming that your knowledge of the patient puts you in a better position to assess risk.

Again I agree with erring on the safe side if you have serious concerns, but I don't take the decision lightly and would not hospitalize simply as a CYA action when I thought genuine risk was low.

I don’t recommend being cavalier about sending people to the ED but I also don’t really think it’s reasonable to expect individual psychiatrists modify their practice because the legal process intended to assist in these situations is imperfect.

Perhaps I am simply more comfortable with paternalism, but I think that a situation where you are trying to predict how the ED is going to act or how the entire process will transpire after you send them to the ED is unfortunate and more likely to lead to not hospitalizing when it would otherwise be indicated than anything else.

I’m not saying that any of your concerns are not valid, but the ED is the appropriate setting to evaluate certain patients. Patients for whom it is no longer clear that outpatient care is safe due to collateral concerning for suicidal ideation should be evaluated in the ED.

In an ideal scenario where evaluation was quick, attentive to patient’s rights and impartial I think few would disagree that this is the appropriate setting. Although this is obviously not entirely the case, I cannot fix these problems myself or in that moment. I cannot invent a less problematic level of care that would be appropriate. I do not think it is justifiable to claim that a patient’s need for a certain level of care is modified by structural problems and potential unintended consequences.

 

[Nasrudin]

Predicting and preventing future behavior is a cyclical argument which never assumes responsibility for itself. If Beneficence is your starting and ruling premise there is no answer that doesn't lead to more intervention. You absolve yourself by passing the buck to someone else in the best case. But. If you start from Autonomy and use dialectics to overrule that only if you can prove imminent or acute risk, you make better decisions.

Predictive models fail with the first malingering person who complains, scattershot, the entire DSM cover to cover. Which is to say, a fair majority of patients in the psychiatric emergency room on an average Tuesday.

And yet. The Armies of the Beneficent will march us all over a cliff of stupidity en masse with their models of predictive behavior. Which ultimately result in an antisocial rapist, eyeing a defenseless, schizophrenic patient for a sexual assault opportunity. Because, he said..."I'm suicidal." But that score never gets kept. Because the Beneficent Behavior Predictors never pay the costs of their decisions.

I'll pay the cost. And break ranks. And argue from the position of Autonomy unless I can prove the utility of an admission. I may lose in the wrong situation, if all the cards stack up against me, or if I just get unlucky. But I can sleep well at night. Protecting the flock of actually mentally ill people who need a milieu that isn't traumatizing in the very least.

 

[thoffen]

Personally, I find it entirely acceptable. I am not taking away their rights without due process. They get brought to the ED and evaluated. If the ED finds new information or otherwise finds the petition insufficient, they get discharged. If not, they will have a hearing with a judge within an allotted time in accordance with state law.

The process is set up with protections for patients’ civil liberties. Are the protections perfect? No, but it is not reasonable for individual psychiatrists to bear the burdens and risks of trying to mitigate policy problems regarding due process.

I disagree vehemently. This would effectively be trying to punt just to protect yourself, but in reality you are heavily biasing those you punt to. If you send someone for further evaluation in the ED, it ought to be because your reasonable attempts at evaluation in whatever setting you are at are unable to determine whether commitment is needed and it is clinically appropriate that something they can do in that setting will clarify the picture.

As a primarily inpatient doc, I receive a lot of punts, and I don't think it's good for any patient, and I think it's particularly bad when the patient doesn't have any alliance with benefiting from inpatient care. Worst is when someone is harangued to check in voluntarily when it is clear they only relented to avoid an involuntary commitment process.

 

[Merovinge]

Worst is when someone is harangued to check in voluntarily when it is clear they only relented to avoid an involuntary commitment process.

You had me entirely until this point. Why is it worse for someone to go through a more pleasant (shorter/no courts involved) process even if they do only to avoid the less pleasant route? Plenty of patients lack the insight initially when making this decision but definitely improve in this area after a few days on the inpatient unit. I have had a number of patients thank me for forcing them to go after they leave even when they cry, fight, and argue tooth and nail to not go during the acute event.

 

[thoffen]

You had me entirely until this point. Why is it worse for someone to go through a more pleasant (shorter/no courts involved) process even if they do only to avoid the less pleasant route? Plenty of patients lack the insight initially when making this decision but definitely improve in this area after a few days on the inpatient unit. I have had a number of patients thank me for forcing them to go after they leave even when they cry, fight, and argue tooth and nail to not go during the acute event.

Well, this doesn't apply to all patients. I don't count the ones who don't want any hospitalization but do choose voluntary instead of involuntary with clear goals and idea that the hospital can accomplish something even if they would prefer no hospitalization at all. That is probably more the patients you are describing.

On the other end of things, if you are receiving a "voluntary" patient with no alliance whatsoever to any possible benefit to hospitalization who feels they have been coerced to be there, it can be really hard to accomplish anything productive. And in some cases they clearly lack capacity to have signed voluntary or were actually coerced. When someone has objectively valid reasoning to make psychiatric care the bad object in order to idealize their own self-care capacities to avoid confronting their need for help, good luck changing that.

 

[sloop]

I disagree vehemently. This would effectively be trying to punt just to protect yourself, but in reality you are heavily biasing those you punt to. If you send someone for further evaluation in the ED, it ought to be because your reasonable attempts at evaluation in whatever setting you are at are unable to determine whether commitment is needed and it is clinically appropriate that something they can do in that setting will clarify the picture.

As a primarily inpatient doc, I receive a lot of punts, and I don't think it's good for any patient, and I think it's particularly bad when the patient doesn't have any alliance with benefiting from inpatient care. Worst is when someone is harangued to check in voluntarily when it is clear they only relented to avoid an involuntary commitment process.

I think you’re attacking a strawman to some extent.

If one can resolve the issue without sending them to the ED, of course that is preferable for the reasons you describe. If you can determine the patient can be safely treated as an outpatient, that’s what should be done.

Part of the problem with this thread is that people are interpreting the initial question differently. I’m interpreting it as there being no other information other than a credible collateral source and a patient denying that account. This is an indeterminate case but the collateral is concerning. We’re talking about suicide and if the patient is potentially at high risk of suicide but you are unable to determine whether that is definitely the case while the patient is right in front of you or someone is observing them in such a way that could minimize the risk of suicide, I think that you need to send them to a setting where that can be done while they try to gain more clarity.

Basically, in this situation you need more time to determine suicide risk. Because this person might be a high suicide risk, they need to be closely monitored while you try to figure this out.

I never denied that there are problems with sending someone to the ED, especially involuntarily. My objection, fundamentally, is that a person’s need for psychiatric evaluation in the ED is logically separate from the problems arising from imposing this care. If you think there’s a decent chance a patient may be planning suicide, this is a reason for evaluation in a setting where there is 24 hour supervision. In most situations, the only viable option for this is the ED. If they need that level of care, it doesn’t matter that our system is imperfect. There is no logical way in which those imperfections modify the person’s need for evaluation. You almost make it seem like you view emergency evaluation of suicide risk as some sort of luxury service that you employ only if it’s not too onerous.