Thursday, April 12, 2012

Suicide risk? I don't want you.

Why do psychiatrists and other mental health professionals continue to accept into their practices patients who contemplate suicide? Do they want to be heroes? Do they feel too guilty about rejecting someone who "needs" their help?

Know that if a patient kills herself on your watch any survivors and their attorneys will very likely come after the money in your malpractice policy.

Know too that a colleague will gladly testify that if only you had done or not done something you should or should not have done the patient would still be alive today. Licensure boards will do the same. Never mind whether the patient's choice to die had anything at all to do with that for which you were treating them.

Because of these potential devestating consequences, including the emotional impact on yourself, once you know that the patient entertains thoughts of dying you will likely focus the preponderance of your efforts, not on providing the best treatment for the problem, but on preventing a suicide. Consider carefully whether you can keep someone from killing himself. In my community years ago a patient shot himself while in the office with the psychiatrist. Could you have stopped him? Patients kill themselves in psychiatric hospitals. If we cannot prevent those suicides, how can you imagine you have any control over someone between encounters?

Mental health professionals need not accept these risks. We can still ethically decide whom to accept and whom to reject as patients. If judges and juries continue to hold us responsible for the intentional acts of others we can choose not to accept the risk. Consider the consequences if we turned away potential patients whom we judged to carry an unacceptable risk of suicide. Patients would likely soon learn they must lie in order to obtain treatment. Might we add statements to our treatment agreements like, "I have never contemplated or attempted suicide." Would you demand to review prior records for evidence of past attempts or impulses to suicide? If you published on your Web site your policy of rejecting patients with unacceptable risk would they look elsewhere or simply be better prepared to lie.

Might such a change impact people contemplating suicide? Might knowing that mental health professionals might reject them as patients afterward (if the attempt failed) make them less -- or more -- likely to kill themselves? How might a patient react if after the initial evaluation you tell them you will not accept them as a patient? Who will accept them? Will they overwhelm those who do?

Consider making at least a small adjustment in deciding whom to accept as a patient. Maybe if more of us reject them, higher risk patients might not find anyone to treat them, and the courts or legislatures might do the right thing and stop blaming the treaters for the choices of their patients.


  1. The flaw in this logic is that it's not the courts or legislatures who will suffer, but the patients. But from your stance, I can only assume you'd be just fine with people eliminating the 'problem' by eliminating themselves. I thought this was a satire at first to demonstrate how absurd it would be to reject such patients. How sad.

  2. It is very sad, but there's no satire, and no flaw in the logic. As long as we enable them the courts will exploit our caring.

  3. I thought too, at first, that this was a satire. Perhaps the act of having that initial session will change the client's mind about suicide...unless they are rejected by the therapist or psychologist. Imagine being rejected by a person who, by profession, is supposed to care about you.....

  4. So you might feel like you must accept them into treatment to keep them from killing themselves? If you don't accept them, does that mean you don't care? Where does caring fit into a professional relationship. If they were thinking about killing you instead of themselves would you be as concerned about caring? Is your role to care or to treat?

  5. Agree that the courts think psychiatrists are omnicient and omnipotent in this one area, even as they think they are quacks and frauds in almost every other area, certainly not "real doctors." Anon #3

  6. I don't agree with Moviedoc's basic premise. My experience is that courts and juries do not generally think doctors are omniscient or omnipotent. It's the unusual exceptions to this generalization that tend to make the news.

    And, again with infrequent exceptions, if the patient's family thinks you were doing your best to help the patient and not villifying the family, blaming them, or ignoring them when they expressed concern about the patient, they tend not to sue.

    I taught my residents to immediately call close relatives after a suicide, offer condolensces, and offer to be of any help to them that you can. Doctors that hide from families in these cases can look like they are feeling guilty about something.

    If psychiatrists refuse to treat difficult or poor prognosis patients, who will?

    BTW, If docs start to get graded on their "results," many docs will start to avoid complicated patients. Pity.

  7. For the anonymous types here, I think you could go a long way to solving this problem.

    Enter into an agreement to indemnify any doctor who faces a lawsuit or Board action when a patient commits suicide. YOU pay for the doctor's losses in litigation. YOU pay for the doctor's defense in a Board action.

    Then the doctor knows he won't be bankrupted if one of his patients commits suicide, and you can show how much YOU care.


  8. I don't think it is a question of caring or treating. You treat suicidal and aggressive patients because you have the technical expertise to do it. In many (all?) APA guidelines the assessment of this problem is generally included in the the competencies for that particular diagnosis. In my practices it would not be possible to treat patient with severe mood disorders, schizophrenia or personality disorders if suicidal ideation or behavior determined of they were treated or not and those are the people I am interested in treating.

    I have never found that changing my practice to manage risk instead of adhering to the best clinical practice was worthwhile.

  9. Dr Allen says: "If psychiatrists refuse to treat difficult or poor prognosis patients, who will?"

    I just read that fewer med school graduates are applying for psychiatry residency spots. Maybe the question should be, "How can we attract more good people to psychiatry?" (People like Dr. Dawson?)

  10. I do think that suicidal behavior and aggressive behavior are deterrents to medical students going in to the field. I have had many tell me as much including members of my own family. I think that is addition to the fear of colossal failure (that is the conceptualization many students have about losing a person to suicide) and fear of litigation - stigma is a much bigger problem here than with mental illness in general. Aggression and suicide are both highly stigmatized behaviors in society rather than symptoms or problems to be solved. If our society moved forward to recognize that a lot of pain and suffering would be alleviated.

  11. So true George, even to the extent that the assisted suicide statute for WA (and maybe OR) stipulates that it not be called suicide!

    Blogger lockupdoc (sp?) used to say society has turned us into suicide police.

  12. As a former training director, I can tell you that the number of US applicants to psychiatry took a nosedive in the early 90's and since then has gone up and down somewhat, but has been relatively stable. It was a bit down this year. The spots in residency programs are easily filled with foreign medical school grads. My old program just filled with US graduates.

  13. Awesome, Anon tort-obsessors. Tell me, can that work 2 ways? I dropped my psychiatrist like a hot potato and not so much as an "It's been swell." once I learned he was licensed in my state to prescribe Suboxone and was on staff of a concierge addiction facility. Why?

    1) Because I didn't believe, what with the overregulation of his closet specialty, and the scrutiny of things like pain meds, that he would have my interests and my case foremost in his mind when he was making decisions about which meds (if any) to prescribe (as opposed to his quotas which are totally not "quotas").

    2) The discovery helped explain his fixation on getting me on an Atypical Antipsychotic. Even after being politely told by my LCSW that riding that hobby horse was getting us nowhere, because I wasn't going to budge, he (at what turned out to be our final meeting) again touted Seroquel.

    Now, I had suicidal ideation in my history, so maybe he was doing nothing more complex than what is suggested here: selfishly indemnifying himself against the tort risk.

    Perhaps on that theoretical agreement where we say we won't sue, the docs can somehow guarantee that they're in the room during sessions, and not mentally at the insurance agent's, or rehab facility supervisor's office, or doing lines of coke off the asses of hot sales reps.

    1. Telling you you needed to be on an anti-psychotic when you were, presumably, not psychotic? If you had listened to him and developed diabetes from, THAT's a tort!

  14. Here's a case that demonstrates the absurdity of which I speak:

    I never prescribe zolpidem, but this man's suicide resulted, not from his taking Ambien, but from his deciding to kill himself. We may never no what moved him to do so.