Madden007

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Interesting case last night in the OPD. I saw a mother who appeared well at first but was actually psychotic. She thought her husband implanted listening devices in her hear, she was hearing disparaging voices, non-command, and felt old friends and characters in her life was after her. These symptoms are context of long hx of opioid use, PTSD, and some genetic loading of psychosis. What makes this case a bit hairier is the fact she had a 7 year old with her, who she lives alone with. I thought long and heard about calling child's protective services but I couldn't justify any neglect or abuse. I opted not to call. I still wonder whether that was the right call. Thoughts?
 

uname943

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If you have to ask, you know the answer.

You need to report suspicion of abuse/neglect. It is not your job to investigate whether the suspicion is true or not.
 
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ryerica22

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Although I would have called, I don't think much would have come out of it. They would definitely have asked you concrete questions about whether the child was in danger or not. This is a broken system.
 
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psych md jd

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Depends.

How are the mandatory reporting laws worded in your state?

What are the criteria? Abuse? Neglect? Vulnerable person?

Did you do a risk assessment?
 
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PsyDr

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If you do not report, something awful happens, you get sued and have to explain to a jury with no relevant education why you thought a reasonable person would not report a psychotic mother to protective services, and lose.

Alternatively, you report and someone else determines if an intervention is needed, and nothing happens to you if something happens or if nothing happens.
 
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WisNeuro

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If you are ever unsure. You can call and explain the situation and ask CPS if any further action is needed without giving PHI. Either way, document the hell out of what you did to CYA.
 
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Madden007

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I did a careful risk assessment. I documented well. Eventually, I opted to call the following AM. I guess the underlying question really is are we negatively biasing our patients because of mental health issues. Being psychotic doesn't equate to being an unfit provider. I understand the cya approach and being better safe than sorry-which I guess is why I reported- but for some reason it doesn't sit right with me, especially when there weren't signs of abuse or maltreatment which are usually the grounds for investigation.
 
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WisNeuro

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I did a careful risk assessment. I documented well. Eventually, I opted to call the following AM. I guess the underlying question really is are we negatively biasing our patients because of mental health issues. Being psychotic doesn't equate to being an unfit provider. I understand the cya approach and being better safe than sorry-which I guess is why I reported- but for some reason it doesn't sit right with me, especially when there weren't signs of abuse or maltreatment which are usually the grounds for investigation.

I'd get used to that. There are tons of times we have to let patients go who are on the border of self-neglect, non-decisional, etc; who we know are going into a bad situation, but legally we can't do much about it.
 

milesed

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I would and I make those calls with them in my office after explaining why. I want them to hear exactly what is said and the CPS staff usually have questions only they can answer.
 

HooahDOc

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I'd get used to that. There are tons of times we have to let patients go who are on the border of self-neglect, non-decisional, etc; who we know are going into a bad situation, but legally we can't do much about it.

This statement captures the nature of child psych very well
 

thoffen

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I hate that liability is a consideration here, but I'm not going to pretend it isn't. But I do think it's useful to look at these things without the idea of liability first.

I think, ethically, you'd have to way the patient's autonomy vs. the risk to the child. So, yeah, it would depend on your assessment of the risk and how reporting the case might affect the patient's treatment with you. No straightforward answer there.

From a liability standpoint, if you explained that ethical conflict and why you chose not to refer, I'd think that should offer protection unless somehow it could be argued that this didn't meet standard of care. If there was a clearly known risk to the child, that would be a problem. Also, you should obtain all available collateral and records to most accurately assess the risk.

Important also to note that CPS referral does not mean CPS action. It means assessment. So you're just reporting suspicion, not rendering judgment or consequence. That lessens the harm the referral does to the treatment but doesn't negate it.
 
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HarryMTieboutMD

Depends.

How are the mandatory reporting laws worded in your state?

What are the criteria? Abuse? Neglect? Vulnerable person?

Did you do a risk assessment?

/thread

Just a few questions--

1) What is OPD? (not our fav SDN poster obv)

2) You need to think about this diagnosis and come up with a good differential (not the point of this post but it's a great case). She is not just having "psychoform" symptoms (PTSD doesn't produce psychosis- what patients are reporting are intrusive symptoms- memories, etc), and opioids don't either (unless whatever she was ingesting was contaminated with a psychotogenic substance). She is experiencing a Schneiderian First Rank symptom (delusion of somatic passivity). How old is she? In appropriate age range for new onset SCZ? Affective symptoms? Details about other drug use? etc etc etc.
 
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deleted736562

Was the child in any way or shape involved in the delusions? Based on your descriptions, it's hard to see how he wouldn't be.

This is definitely a reportable case I feel. I think a more interesting question is whether involuntary hospitalization is an option here at all (if the kid somehow is part of the delusional system, you could argue a danger to others?) ? This sounds like a trainwreck waiting to happen.
 

Madden007

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/thread

Just a few questions--

1) What is OPD? (not our fav SDN poster obv)

2) You need to think about this diagnosis and come up with a good differential (not the point of this post but it's a great case). She is not just having "psychoform" symptoms (PTSD doesn't produce psychosis- what patients are reporting are intrusive symptoms- memories, etc), and opioids don't either (unless whatever she was ingesting was contaminated with a psychotogenic substance). She is experiencing a Schneiderian First Rank symptom (delusion of somatic passivity). How old is she? In appropriate age range for new onset SCZ? Affective symptoms? Details about other drug use? etc etc etc.
1. OPD, outpatient department
2. Diagnostically, the case is interesting. Besides the hallucinations/delusions there are no other symptoms [grossly disorganized or catatonic behavior; or negative symptoms; or formal thought disorder]. Diagnosis is psychosis, nos. Patient is older than 30 and younger than 60. History of schizophrenia [mother]. History of cocaine induced psychosis, treated with risperidone. History of depression and anxiety. History of PTSD symptoms [nightmares, flashbacks, etc]. On methadone, not currently using any drugs, but have to say that prolong intermittent drug use makes labeling with a diagnosis difficult.
 
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