Thursday, March 8, 2012

Tried to kill yourself? You're fired!

The mythical psychiatrist or psychotherapist accepts and understands everything. Or does she? Years ago a respected colleague told me of his policy. If a patient in his practice attempted suicide he would discharge them. The more I think about this the more I like it. Assume that either the patient's care has been transferred, likely to a hospital, and that the psychiatry has given the requisite thirty day notice in writing, not only to the patient but to the hospital. Ethics might obligate the original psychiatrist to continue providing care for the remainder of the thirty days, but the hospital should probably take the opportunity to refer the patient to a new provider for a fresh start.

One would likely invoke such a policy on a case by case basis with exceptions as indicated. Would ethics require the provider to notify all patients of the policy before starting treatment?

Many will balk at this idea, perhaps in part related to the professional's feelings of failure, anger, and perhaps fear of recurrence. But does a suicide attempt not represent the ultimate breach of treatment contract as well as a clear statement that the treatment has failed? Does rejection of the patient after the attempt not offer the possibility of more effective treatment?

From the psychiatrist's perspective such a policy also sets a limit, expressing the position that she will not accept society's misguided attempts to hold her responsible for the acts of another.

If all psychiatrists and psychotherapists refuse to work under such circumstances, who will take care of the patients. Perhaps society needs to answer that question.


  1. ...While I do agree with you that a suicide attempt is a clear indicator that treatment has failed...I hope that the doctor you describe at least offers a referral to another doctor or a counselor, etc.

    Also, what if the person did not even have suicidal feelings prior to taking the medication? What if the person had OCD, took a med, and then became psychotic on the med? Does the prescribing doctor have any obligation to help stabilize that patient?

  2. It's easy to "offer" a referral Jane: Google or your insurance company or the local medical society. I would never foist off a patient who had attempted suicide on a colleague I like and respect. Golden Rule and all that.

    What if? What if? Bottom line is don't do it on my watch. The prescribing doctor can end her obligation with 30 days notice, or less, depending on the situation.

    1. ..but what about the other part of my question? What if the patient completely loses it on the med? Isn't that a mitigating factor? What if the patient became that way (suicidal) only after being on the medication. It's possible to become manic, suicidal, psychotic, whatever on psychiatric drugs. Especially children. We hear about 7 year olds trying to kill themselves when put on 5 different psychiatric drugs. Shouldn't the doctor recognize that his treatment failed and try to remedy the situation? Or at the very least refer the patient to a psychiatrist who may have more experience in such things and who can try to fix what happened.

      I hear these terrible stories of children, especially children, being put on a stimulant, an antipsychotic, a mood stabilizer, an antidepressant, and a benzo and then all of a sudden they try to take their own lives (and sometimes it is only one med). I saw that thing on the news a long time ago about foster kids on psych meds. They would go on the drugs and try to kill themselves or go totally nuts...until the foster parent finally blew off Medicaid and paid out of pocket for a private psychiatrist to reduce the meds or just completely pull the kids off.

      If kids can flip out like that then why not adults...1boringoldman was writing about that a long time ago. He volunteers in a free clinic and he would see these messed up little foster kids on five different psych meds...and he had no clue what to do with them. So whenever he met a kid like that, he would just take him off of all his meds one at a time. And the scary thing is, once the kids were over discontinuation syndromes, only some of them in his judgment actually needed the meds. They were acting so nuts cuz they were overdrugged. Only some of them had ADHD, and then a few really were psychotic. The rest were normal kids who were flipping out on the drugs.

      Don't you think the original doctors of those kids should have tried to remedy the situation or refer those kids to a doctor who might have been better equipped to help them? Why would a retired doctor like 1boringoldman, who only works once a week, have to pick up the pieces?

    2. "I would never foist off a patient who had attempted suicide on a colleague I like and respect. Golden Rule and all that."

      Could you really say that to a six year old girl who tried to kill herself after you just put her on an antidepressant and an antipsychotic because her father raped her and she is depressed about being in foster care?

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  4. Jane, when you use the word "mitigatin" you make it sound like sentencing for a crime. IMO in the situations you describe the patient would be better off with a new psychiatrist, preferably one they found themselves. I'm not sure I buy the idea that meds make people kill themselves, but if it seems the med is making them worse instead of better they should almost always stop taking it, and maybe the patient should fire the psychiatrist.
    Nobody is making 1boringoldman "pick up the pieces," but it sounds like he's performing a great service. As for the original doctors it would be best all around if they just stopped prescribing benzos altogether and learned how to operate more like 1boringoldman instead of adding another drug every time a new problem seems to pop up.

    1. Actually, it kinda is like sentencing someone sometimes. I felt bad for the foster kids cuz they were all on medicaid, so they really didn't have any options. It seemed like they either got stuck with a terrible psychiatrist, who would actually make them worse, or they would get lucky with a generous foster parent who would just pay out of pocket for another psychiatrist (who was actually competent) to treat the kid. And I know what your thinking, you probably think that if the psychiatrist is really that incompetent, and the drugs were messing up the kids that much, then why did the foster parents not just take the kids off the drugs. According to the foster parents, they would be told by social workers that if they stopped the drugs then it would be considered child abuse and they could lose the foster kid and not be able to adopt....Hence why they just ended up paying for another doctor in some cases. Or they would sadly continue on with the meds. After all, a doctor ordered those meds for that kid. He needs it! If the foster parent disobeys, that means the foster parent is a bad parent. I know that in my city, there are only two psychiatrists that accept Medicaid...and I hear they are terrible.But that's where there needs to be some accountability. i don't like that there are all these little kids who have to be treated by Medicaid doctors who overdrug them. Especially cuz there are so few doctors who will treat them and accept Medicaid. I think if a doctor takes on that burden of helping a foster kid, they should be forced somehow to revise their treatment until they get that kid better...even if it means pulling them off the meds. The kids have already been through so much. I'd hate for anyone to bail on them. There aren't too many psychiatrists who will help them.

      And I know that probably sounds unbelievable too...that the foster parents would be told it is child abuse if they didn't drug the kids. But actually...something kinda similar happened to me when I was young. I was tested for a learning disability by my school. And my scores were all messed up. So the school called my Dad and told him that I wasn't actually learning disabled. My IQ scores were so off because I was traumatized because my mother was dead and I probably have ADHD. If he did not get my psychiatric help then it would be considered child neglect. And I actually didn't believe that when he told me that later on. I thought that was diffusion of responsibility for not getting me any accommodations for me intellectual deficits and he was just covering up for his choice to drug th heck out of me as a kid...But then I heard all of these stories from parents online who say their kids struggle in school, so they have them tested for a learning disability, and then all of a sudden, they get called in for a meeting at the school, the school has called a social worker, and they are being told that if they do not put their kid on some kind of stimulant and get psychiatric help for their child's learning problems that it will be considered child abuse :/ I know that sounds nuts, and totally unbelievable, but I think he might have actually been telling the truth.

      I'd like to take in a foster kid someday...but I hear there's all kinds of bullying from social workers, and paperwork, and about a hundred reasons not to do it. I don't think I could take in a foster kid on tons of psych meds unless I could afford to find the kid good care. I would hate to be in a situation where I felt like i had to needlessly drug a kid because I might be labeled a child abuser :/

    2. Sadly I do believe it, Jane. There's a lot that needs changing.

  5. Good point about kids Jane. My post and comments about firing patients after a suicide attempt refer to adult patients only.