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kuntama

Suicidal patient and no mental illness

60 posts in this topic

Could I ask people what they would do in this clinical scenario?

Man in his mid-thirties with a history of depression; no previous admission; monitored in outpatients for past 3 years; last OPA 1 year ago.

2 months ago following a financial downturn he has decided to commit suicide; date has been decided and he won't divulge.

Cannot elicit any biological symptoms of depression; is not sectionable and has capacity.

What do you do?

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If you are really worried about the patient's risk of suicide and think with his history of depression, he could be depressed, he is already sectionable.

I mean, even if you suspect depression but can not prove it as there is no somatic syndrome you could still technically detain him for assessment upto 28 days and then take it forwards from there.

If I were the on-call consultant, I would advise my trainee to do the same. 8-)

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Hmm....

Well, he was sent home with an OPA the following week.

He returned, still stating he was suicidal and the clinician asked for a second opinion from a colleague; to be assessed at an OPA the following week.

Apparantly, he readily agreed.

What next? Brave clinician?

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I'm sure you've come across studies which showed that prior to the suicidal act patients visit their local service - you obviously don't want this to be one of those.

It's not clear from the brief description you have given whether he has any family, friends from whom you can get a collateral history. You don't want to find at a later date that he enjoys playing a game of pool with his friends before he visits you for the OPA.

It's also not clear what his expectation is of the service. The usual basic question - if he was last seen in the OPA a year ago why has this patient returned now. You also probably have his previous records so can check whether he has complained of these passive suicidal thoughts just to keep the professionals anxious for more attention.

Finally I won't section him if he is willing to engage and can discuss his thoughts. Feeling suicidal is not sectionable but if he has told you a particular date it might be worthwhile taking him seriously if he has never done this previously!!! ::)

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We definitely are taking him seriously.

LOoking through the notes, he has always expressed suicidal ideation but never given a date.

He is willing to engage, but apparantly not to be admitted. In fact, has requested psychology input.

Looking forward to assessing this gentleman next week.

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For me the interesting question is, why, having ruled out mental illness do you feel so much responsibility for this man. You gotta trust in your assessment. If you're not sure as to whether or not he's depressed, then obviously thats a different matter and a second opinion is a great way to firm up the diagnosis- I wonder if we do this often enough as psychiatrists.

But to come back to this case, if he's not depressed and he's admitted to hospital, then you really are on a hiding to nothing. He doesn't have a mental illness so there's nothing to treat in hospital, hence, no way of knowing when he's fit for discharge (well, technically he's fit for discharge as soon as he's admitted as he's not mentally ill). Somebody as manipulative as this guy sounds, is not likely to ever say he's not suicidal and it will be difficult to discharge him. When he is discharged, then he really will be at risk of suicide having become dependent on the ward environment (constant attention, reassurance etc etc etc) and feeling rejected and abandoned at having been discharged back to the very same reality that made him want to kill himself in the first place.

I personally don't think its any safer admitting someone like him to hospital and is probably more harmful. Its a short term strategy with little real benefit. I doubt very much there's any evidence that admitting someone without mental illness to hospital reduces their overall risk of suicide.

I can recall a case where we admitted someone to hospital with suicidal ideation. He was highly manipulative, had a borderline personality disorder, we felt he was not depressed. Eventually he started to say he felt better and was no longer suicidal. He took an overdose of insulin the night he was discharged and died a month later in intensive care having never regained consciousness. In fact, of the two suicides of patients that have happened who were under my care, one was that guy and the other, who also had a personality disorder and wasn't depressed, was an inpatient at the time she killed herself, having absconded from the ward earlier that day.

My strategy now is not even to discuss the whole issue of an admission as I do not see that as an answer to anything. I firstly seek to rule out mental illness. That done, I focus on the stressors leading the person to want to kill themselves and then attempt to problem solve with them, writing letters of support to various agencies etc if necessary. That has worked well to date and I feel its defensible practice. I document everything, including my line of thinking, and make sure I give them emergency contact info so they know that if they really reach a crisis point they can get help at any time.

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This patient has a past psychiatry history and was known to secondary services for a while. His experiencing low mood because of the credit crunch, might have incurred losses or is finding it difficult coz of job loss. And he has planned his suicide. I would offer him an admision. If he declines then will go for an MHA.

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Whilst i worked in Leed with the CRHTT, my consultant was particular about these suicidal patients. He argued that unless there is a defict of mind no one would go and commit suicide.

And as the evidence suggests that 90% of the completed suicides have a mental health background.

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Whilst i worked in Leed with the CRHTT, my consultant was particular about these suicidal patients. He argued that unless there is a defict of mind no one would go and commit suicide.

[highlight]And as the evidence suggests that 90% of the completed suicides have a mental health background.[/highlight]

Pray do quote the evidence please!

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He argued that unless there is a defict of mind no one would go and commit suicide.

Utter codswallop! So all suicide bombers are mentally ill? Everyone with a terminal illness who seeks euthenasia is mentally ill?

And your statistics are particularly shonky. Of the top of my head I think that out of the 5054 suicides reported in the National Confidential Enquiry, only 28% had had recent contact with mental health services. How you get a figure of 90% I have no idea. Perhaps you could back up your claims with some references?

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He argued that unless there is a defict of mind no one would go and commit suicide.

Utter codswallop! So all suicide bombers are mentally ill? Everyone with a terminal illness who seeks euthenasia is mentally ill?

And your statistics are particularly shonky. Of the top of my head I think that out of the 5054 suicides reported in the National Confidential Enquiry, only 28% had had recent contact with mental health services. How you get a figure of 90% I have no idea. Perhaps you could back up your claims with some references?

Are you saying that the other 72% were not in need of the mental health services? Not to mention open verdicts where suicide is suspected.

In debating whether or not someone has or hasnt got a mental illness mid threatening to take there own life, how can you use suicide bombers and those with terminal illness as a representation as to why you wouldnt intervene? Those examples of not having a mental illness are far removed from the case posted here.

Something has gone badly wrong in the psyche of joe bloggs when he decides to take his life. He may have lost hope of a positive change, he may have lost sight that his situation is transient, his thoughts may have become skewed or there may be physiological reasons. Whatever the cause do you not have a duty of care and a chance to help him through whatever it is thats causing such distress and loss of hope if he has presented to you?

If you seen a man bleeding at the side of the road would you not help. Just because the problem is not visable does not make it cease to exist.  

   :(

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cat - the examples I gave were a rebuttal to geeks statement that everyone who commits suicide has a mental illness. Not everybody who commits suicide does.

If someone has capacity and does not have clear signs of a mental illness then I still hold that we have no right to interfere with their plans. If you want to call it an acute stress reaction and get around it that way then that's fine. But what about the person who has reached a logical decision that their life is not worth living anymore over a period of days and no longer wishes to be a part of this world? Are you saying that their right to take their own life is something we should just over-ride? What happened to the GMC guidance that we should respect our patients' decisions, even if we hold them to be unwise? And does your approach then not extend to people wanting to discharge themselves from hospital despite there being a need for ongoing treatment? They know they are putting their life at risk, so does that mean they are automatically mentally ill, and that we should detain them too?

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In my limited experience I have tended to err on the side of safety when seeing such patients on call. I have always arranged for a M.H.A assessment. The act is intentionally vague and you can always make the case for detention based on your risk assessment and the fact that planning suicide is not 'normal' behaviour. You will always have a water-tight argument if you state that while there were no ICD 10 specific criteria at the the time of your assessment the patient's history and stated intention indicated mentally disordered thinking. Like a wise consultant told me many years ago, in these situations you have to suspend ICD 10 temporarily and apply the &quot:lol:aily Mail rule'. If the patient completes suicide and the Daily Mail gets hold of it and whips up public outrage against you, you will be surprised how quickly the Trust/Colleagues can turn on you. In situations were the M.H.O does not agree with a decision to detain you've got 100% cover if you send the patient home and he does decide to complete. No one can say you did not take all reasonable steps at your disposal to try to prevent the suicide. Call it defensive practice but hey better safe than sorry. In an outpatients set up ask for a consultant review.

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[highlight]Utter codswallop! So all suicide bombers are mentally ill? Everyone with a terminal illness who seeks euthenasia is mentally ill?

And your statistics are particularly shonky. Of the top of my head I think that out of the 5054 suicides reported in the National Confidential Enquiry, only 28% had had recent contact with mental health services. How you get a figure of 90% I have no idea. Perhaps you could back up your claims with some references? [/highlight]

I have read it somewhere i ll definitelypost the link or write down the reference.

As far as the suicide bombers are concerned You ought to read about the sociological causes of suicide . This one is called Altruistic suicide, read around it and the key word is Emile Durkhiem.

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and by the way contact with mental health services and having a psychiatric condition are two different things.

So many patients with the psychiatric conditions are in primary care and no body is taken up by secondary services unless they have an SMI.

So Chris, you got it totally wrong.

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So one advise Chris, donot shrug anything off without refering to a database.

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I just dont agree that anyone in sound mind would commit suicide, suicidal thinking itself is a strong negative thought/ emotion.

people who seem rational are those who have made up their mind and are at peace with their decision. But what has made them suicidal is the thing to consider.

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[highlight]I just dont agree that anyone in sound mind would commit suicide, suicidal thinking itself is a strong negative thought/ emotion.[/highlight]

read the sociology of suicide.

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cat - the examples I gave were a rebuttal to geeks statement that everyone who commits suicide has a mental illness. Not everybody who commits suicide does.

If someone has capacity and does not have clear signs of a mental illness then I still hold that we have no right to interfere with their plans. If you want to call it an acute stress reaction and get around it that way then that's fine. But what about the person who has reached a logical decision that their life is not worth living anymore over a period of days and no longer wishes to be a part of this world? Are you saying that their right to take their own life is something we should just over-ride? What happened to the GMC guidance that we should respect our patients' decisions, even if we hold them to be unwise? And does your approach then not extend to people wanting to discharge themselves from hospital despite there being a need for ongoing treatment? They know they are putting their life at risk, so does that mean they are automatically mentally ill, and that we should detain them too?

Yes, i realise your post was in response to Geek rather than in response to the original question. I realise too that this debate only raises more difficult questions. In which case its best not to generalise and take each case as it comes. Rather than posing more difficult questions focuss the answer to this one.

You cant do anything about the 72% who dont present and kill themselves anyway, either they dont want to be saved, have lost sight of any route that may lead to a recovery or have not been fortunate enough to receive the right or best care.

Those that do let you in on their plans are asking you to do something, some part of them that wants to survive are asking you begging you intervene. As a 'psych'iatrist your words read as cold and clinical washing your hands, stepping aside because you cant see clear signs of an illness. I hold that that does not mean it does not exist.

At the very least admitting would cover yourself as said by someone else and give that person time to rethink, recover and listen to a voice of reason for alternatives.

In answer to your question, yes i am saying that if you do have the power to override their decision to take their own life then use it.

If after all that could be done was done and they went ahead and killed themselves anyway then you did your best.

Going back to the original post it read that the chap has a history of depression and has set a date to kill himself, surely is enough to consider an admition??

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and by the way contact with mental health services and having a psychiatric condition are two different things.

So many patients with the psychiatric conditions are in primary care and no body is taken up by secondary services unless they have an SMI.

So Chris, you got it totally wrong.

I accept that, but in the same way having a psychiatric diagnosis and being detainable are also two different things. All of the people in the reference you gave had been 'diagnosed' by their families retrospectively by structured interview. Whilst attempts had been made to compare the results to a group with depression, the reliability of these accounts is open to question. And Durkheim published in the 1890's, so while there may be historical merit in reading 'Suicide' I am not sure about its application to modern psychiatry. I will have a look at it though. However does Durkheim not contradict the view you had posted that all people are mentally ill if they are suicidal? He seems to have a whole chapter about normal mental states and suicide...

cat - I agree that the original chap needed to be in hospital, and pragmatically of course you have to err on the side of caution with people. Yes, I would tend to use the mental health act to detain people who showed evidence of depressive illness and who reported suicidal ideation. I also think that we are to worried about ourselves and the risk of litigation these days. If someone has a truly awful life and no longer wishes to live it, and doesn't lack capacity or have significantly impaired decision making ability, then why do we step in to prolong their poor quality of life against their wishes?

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About the original post...

Why is this guy not fulfilling the criteria for an adjustment disorder... if not a major depressive disorder???

Clearly a large number of suicides are secondary to adjustment disorders...

And clearly the question is... Is there sociooccupational deterioration secondary to the disorder...

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and by the way contact with mental health services and having a psychiatric condition are two different things.

So many patients with the psychiatric conditions are in primary care and no body is taken up by secondary services unless they have an SMI.

So Chris, you got it totally wrong.

I accept that, but in the same way having a psychiatric diagnosis and being detainable are also two different things. All of the people in the reference you gave had been 'diagnosed' by their families retrospectively by structured interview. Whilst attempts had been made to compare the results to a group with depression, the reliability of these accounts is open to question. And Durkheim published in the 1890's, so while there may be historical merit in reading 'Suicide' I am not sure about its application to modern psychiatry. I will have a look at it though. However does Durkheim not contradict the view you had posted that all people are mentally ill if they are suicidal? He seems to have a whole chapter about normal mental states and suicide...

cat - I agree that the original chap needed to be in hospital, and pragmatically of course you have to err on the side of caution with people. Yes, I would tend to use the mental health act to detain people who showed evidence of depressive illness and who reported suicidal ideation. I also think that we are to worried about ourselves and the risk of litigation these days. If someone has a truly awful life and no longer wishes to live it, and doesn't lack capacity or have significantly impaired decision making ability, then why do we step in to prolong their poor quality of life against their wishes?

At last some sense regarding the original post.

Why would you step in to prolong their poor quality of life against there wishes?

Because life is precious, these people are precious. Remember the ones you thought you might be able to help all those years ago as a youg doc.

Poor quality of life compared to ??? The starving in africa or the sad lonely millionaire. I risk being accused of not respecting or listening to their wishes. I know very well that with some if they are going to kill themselves then thats what they will do, however there is always a chance that some wont and by changing their direction slowly begins to chance their perspective and so on.  

In buying some time may just help change the direction of someones life. Your question frighteningly puts a whole new meaning to our throw away society.

Personaly litigation isnt such a big issue but if by mentioning it moves someone into action to stick their neck out while covering themselves thats a good enough place to start.

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