Thursday, October 6, 2011

If you're suicidal hang up and call the crisis line.

Despite the ubiquitous "If this is an emergency, hang up and dial 911" message I wonder how many patients who are sufficiently ambivalent about ending their lives to call their psychiatrist would call 911 instead. There seems to be an expectation (standard of care?) that psychiatrists can somehow talk them out of it over the phone, or attempt to stop the patient by involving 911 or other resources. I find it ironic that many argue that video conference (eg, Skype) is inadequate for even routine psychiatric encounters and yet expect psychiatrists to, on the spur of the moment, handle a life or death situation over the phone. Why not send these calls to the people who handle them all the time, crisis lines, and stop trying to be the hero like one of those movie psychiatrists? In Sybil Dr. Wilbur goes to her patient's apartment to rescue her. How far should one go to stop the patient from killing herself? Why stop with a telephone call?

Should we pretend to do something we cannot do? Does providing access outside of an appointment encourage or reward dysfunctional and potentially dangerous behavior?

"If you're suicidal, leave a message and you'll get a free telephone session with your physician who wants to be your hero and rescue you and provide you with attention and make you cared for, warm and fuzzy."

I am challenging an irrational myth which has become to some degree standard of care, at the very least an expectation, just because we perpetuate the illusion, a myth that interferes with providing appropriate after-hours assistance to patients. Does the fear of malpractice suits force us to do what may not be in the best interest of the patient, practicing what I call make-believe medicine?

As a physician I want to provide access by telephone after hours, but talking to me by phone is no substitute for going to an emergency room. I don't pretend to be capable of talking anyone out of any kind of bad behavior. Is there any evidence that any of us is capable of doing that? (other than in the movies)


  1. Have any patients ever called emergently expressing suicidality?

    FYI, suicide hotlines are staffed by people with all sorts of education, backgrounds and skill sets. As a caller, I've been treated to someone chewing his food and multiple hang ups ("I'm sorry I can't help you. I have to go now." Click. That was verbatim, and so must be in the script for getting rid of undesirable calls)

    I refuse to ever have contact with any aspect of hospital based psychiatric services, as do I suspect a majority of people with past suicide attempts. The trauma and harm that caused is something I won't expose myself to again.

    But I would not contact a psychiatrist either since the power to force treatment is an ongoing threat.

    All this to get to the point that I hypothesize that there really isn't a big patient population that would be likely to call their psychiatrist with lethal suicide intent.

    Just as most people who commit suicide don't leave notes, I doubt that they make impulsive "save me and be all warm and fuzzy about it" phone calls, either. I certainly learned that no one is interested, nor can help, via that route. Indeed, I learned that there is no useful therapeutic treatment for suicidality. The current standard of incarceration and intrusive observation is dehumanizing, demoralizing and confirms the extant hopelessness. It doesn't ever address suicidality. It's all about restraints, control and power. Discontinuing mental health services and contacts was a relief as far as distressing assessments and lack of care went. At least the iatrogenic harm stopped.

  2. I haven't had a psychiatrist or therapist who takes calls outside office hours for many years now. I had forgotten that it used to be different.

    I wouldn't want to interrupt some doctor's or therapist's family time to talk about killing myself anyhow.

    Where I see a need is when a person gets extremely concerning side effects, and the crisis line and nurse helpline (that many insurance plans provide) can't help with that type of issue. I doubt I ever called a doc after hours or on weekends with such a concern, but it's possible.

  3. Catlover: The thing about side effects is that I know enough about the patient and their meds to handle a question in minutes. What a waste it would be for someone to even call a helpline. Forget about a costly (in time and money) visit to an ER. It just makes sense.