Poor Put Upon Psychiatrists

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MovieDoc is perturbed that patients who are contemplating suicide telephone.  Instead, he avers that they should be telephonally instructed to hang up and call another number.

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 don’t disagree that patients shouldn’t try to contact their psychiatrist, when they have one, but my disagreement is for different reasons. MovieDoc buys into many myths which have been exposed as such by Thomas Joiner. For example, the myth of impulsivity, selfishness and suicide notes are addressed:

To my knowledge, no study has reported a rate of note leaving among suicide decedents to exceed 50%. Moreover, most studies find rates between 0% and 40%4; a reasonable average rate would be approximately 25%.

 

Why are suicide notes so rare? Some have reasoned that because impulsivity is involved in suicidal behavior, suicidal persons often kill themselves before they have a chance to write a note. There are problems with this viewpoint, however. A major problem is that it draws on the distinct myth that dying on a whim is common. Another problem is the lack of empirical support that compares those who leave notes with those who do not. If it were true that note leavers are much less impulsive than those who do not leave notes, then this distinction should be easy to demonstrate in forensic studies that examine the lives, characteristics, and personalities of decedents. This difference has not been clearly demonstrated.

 

The relative rarity of suicide notes reveals the state of mind of those about to die by suicide. To say that persons who die by suicide are lonely at the time of their deaths is a massive understatement. Loneliness, combined with alienation, isolation, rejection, and ostracism, is a better approximation. Still, it does not fully capture the suicidal person’s state of mind. In fact, I believe it is impossible to articulate the phenomenon, because it is so beyond ordinary experience. Notes are rare because most decedents feel alienated to the point that communication through a note seems pointless or does not occur to them at all.

Suicide hotlines are staffed by people with all sorts of education, backgrounds and skill sets. There are no therapeutic standards of practice.  There is no accreditation, licensure or certification requirement for crisis hotlines or the people who staff them.  Caller beware.

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. Suicidality is obviously not safe for me to discuss with anyone, and until euthanasia is “on the table” I can’t foresee trusting any provider enough to discuss core concerns. Moreover, I have no desire to distress someone else, provider or otherwise, with my concerns.

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 (they call it containment), assaults and batteries (forced medication, restraints, isolation, refusal to allow patient chosen visitors to be present) and intrusive observation sans human interaction (unskilled people who do not speak to, touch or care for patients, but who literally remain in views at all times) is dehumanizing, demoralizing and confirms the extant hopelessness. It doesn’t ever address suicidality and its attendant concerns of thwarted belongingness and perceived burdensomeness.  It does nothing whatsoever to relieve the unbearable distress that predicates suicidality. It’s all about restraints, control and power.

Discontinuing mental health services and contacts was necessary to halt distressing assessments that were conflated with care and continuing trauma from a lack of effective care.  At least the iatrogenic harm stopped.

Like many others, I came out worse than before I received “treatment”.

So I find it ironic that the psychiatrist feels undue burdens in the theoretical situation of a patient contacting him or her with a perceived degree of unbearable distress.  Is it any wonder that the suicide rate is highest for psychiatrists?

When they remove the double speak and have that oh-so-critical insight into what will be done to them if they seek treatment for suicidality, psychiatrists, like most physicians, do not seek treatment and avoid seeking peer support or disclosing their “illness”.

The biggest walking, talking, suiciding ads for anti-psychiatry are distressed psychiatrists.

Treatment As Usual: Case Report

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Submitted without comment:

Outpatient psychiatrist: Patient came to her routine psychopharm visit expressing profound hopelessness and a desire for her life to end. She described recent incidents at the shelter where she is staying, including one where another guest took an overdose of medication and she (the patient) was distraught that she hadn’t recognized this (clinically) sooner.  She repeatedly said, “I can’t survive this…I want it to end.”  In addition to feeling overwhelmed and anxious about her state of homelessness, she expressed concern that she “would never feel safe anywhere.”  She denied suicidal intent but was unable to find any reason to continue her life and made numerous self-disparaging remarks.  She became increasingly distraught, crying and almost moaning in her chair.

Impression:

Since stopping her antipsychotic medication (intolerable EPS per patient) and decreasing her antidepressant medication on discharge from the hospital (to the street), the patient is faced with the reality of limited housing options and may likely face daily uncertainty about where she will sleep once she completes her time at current shelter – and is overwhelmed, panicked, despairing and hopeless about her life.  Her paranoid ideation has increased.  She sees no meaning in anything and wishes to die.  She denies immediate suicidal intent, but mostly due to lack of energy rather than lack of desire.

Plan:

With much persuasion, patient walked with me to the A(cute)P(sychiatry)S(ervice) where she will be evaluated for inpatient hospital admission.

APS psychology fellow note 4 hours after arrival:

Patient was tearful, depressed with poor eye contact.  Patient refused to talk to writer stating “I can’t talk, go away.” Writer was unable to complete full exam due to patient refusing to be evaluated at this time.  Patient is intermittently sobbing uncontrollably, saying nothing more than “I can’t” and “you have to let me go”, refusing medication and refusing to participate in interview. Perseverating on “you have to let me go” “nothing will help”  TP – perseverative -Insight poor Judgment poor Patient requires ILOC to establish safety, containment, and aftercare planning.

36 hrs later – Psychiatry fellow and attending consultation note:

Fellow: This patient was admitted for altered mental state with bradycardia and a serum diphenhydramine level of 489 mcg/l (toxic range).  Psychiatric consultation was requested for ? suicide attempt. The patient reports that she left the hospital yesterday, returned to the shelter at which she was staying to discover that her belongings (aside from medications) had been removed.  Pt reports having felt more hopeless and ingested unspecified number of her prescribed medications.  She reports that she did not want to hurt herself but hoped that this ingestion would kill her.  She denies having anything to live for at this point, denies intent to harm herself but feels “regret” for the outcome of this medication ingestion and reportedly “want(s) to die.”   Pt does report that much of her feeling hopeless is related to lack of shelter and job.  She attributes her “life situation” to being ostracized “for being a whistleblower” (related to prior living and job situation per medical record review).

Attending: I have reviewed the events/notes of earlier this week.  At present, she explains to me that yesterday, when she left here, she wanted to die and took pills in order to bring about her death and thought the pills she took would effect that outcome.  When she realized she did not die, she felt regret.  She still feels regret because she still wants to die and kill herself. Asked why she did not acknowledge this yesterday before she left here, she said that she knew she would be hospitalized psychiatrically if she had and she didn’t want to be.  I explained to her that caretakers are able to help her only to the extent that she is honest with them.  She is pessimistic that pharmacotherapy and psychotherapy can help her deal better with her problems even if they cannot take them away.  I explained further that both can help her to be more optimistic.  She denies any thought of wanting to hurt anyone else.  She denies that anyone here is trying to hurt her.  She feels her thinking is clear and in its usual state.

Impression: Delusional and depressive disorders.  She is pessimistic, despondent, and suicidal at present and meets criteria for involuntary psychiatric admission.  Continue suicide precautions.  Continue 1:1 observation.