A few of our members are psychiatrists. Most are not. On rare occasion a surgeon will get a call or email from a patient suggesting they are considering suicide. Or they have a detailed plan to take their life. Or they’ve posted this nugget of info on Facebook or a doctor review site and you get an email from the site.
The conundrum is how a non-psychiatrist, now aware of your patient’s thoughts, can determine whether your patient is an imminent danger to himself or others.
There’s no easy answer. Still, the last thing a doctor wants is for harm to come to his patient. But, without background, training, and experience, how should one proceed? And it’s even more challenging given that some patients live in another town or even another state.
First, if you’re not a psychiatrist, don’t play a psychiatrist. The price of getting your diagnosis wrong may be a dead patient. There are always resources available.
If you know the patient is already receiving psychiatric care from a licensed professional, it is reasonable to bring that professional into the equation. The psychiatrist may simply state, “Thanks for the information. I’ll take it from here.” Of course, document that you had this conversation. But, you will have referred the patient to someone better equipped to address the problem.
What if you have no idea whether the patient is seeing a psychiatrist? You can ask the patient. Then, if the answer is yes, ask for permission to bring that doctor into the discussion. Or if you reasonably believe that the patient is an imminent risk (note: you CAN err on the side of caution), you can just make the call anyway. Again, document your actions and rationale.
Another excellent resource is the National Suicide Prevention Lifeline.
From their website:
It can be scary when a friend or loved one is thinking about suicide. Let us help. If someone you know has any warning signs we encourage you to call 1-800-273-TALK (8255) so that you can find out what resources are available in your area. Your call is routed to the Lifeline center closest to your area code. The local crisis center may have resources such as counseling or in-patient treatment centers for your friend or family member. Most importantly, please encourage them to call the Lifeline.
Finally, and most importantly, consider the option of calling the police in the locale where the patient lives. The police have a process called “Check Well Being” where they knock on the door and make an assessment as to whether your patient is at risk.
On one website, a former police officer detailed the different scenarios that triggers a “Check Well Being” visit.
- Disgruntled Teenager Seeks Attention: “Troubled and troublemaking teens with sensitive parents quickly learned that making cryptic or veiled comments with just the right phrasing elements (“Maybe you’d just be better off if I wasn’t around”) would induce panic and make for an orgiastic evening of unmitigated attention: emergency response, hand wringing, quiet weeping and lax discipline.” Most of the time the officer will offer resources to the parent(s)- such as Juvenile Office and Counseling.
- Impaired Caller: Most of the time the officer would find a drunk person or persons. If they were not surrounded by means of suicide, they were generally left alone. Sometimes the person had cognitive or communication deficits, which required a more sophisticated approach.
- Hotline Caller Who Says the Magic Words: These are often referrals from suicide hotline agents. Here, the agent cannot tell over the phone the seriousness of the threat, so an officer is dispatched to help make the assessment.
- Caller Directly Threatens Suicide to 911: This prompts an immediate dispatch while the dispatcher works to see if the caller has the means to carry the threat out – such as pills, knife, etc.
- Caller Directly Threatens Suicide with a Firearm: This changes how the call is responded to, how the location is approached, and how the scene is handled.
Once on the scene, the officer first ensures safety and containment. Then he investigates. If the officer believes the threat is not going to be acted upon, that may be it. If he believes the threat is real, they have the discretion to take the person to the hospital – even against their will – for a formal psychiatric assessment. This triggers paperwork the officer must complete (affidavit) requesting the hold. If the officer does not believe the patient will act on the threat, but the patient still wants to go to the hospital, the officer may give that person a ride. That might not trigger a mandatory hold.
When I was in training, one of my mentors said he’d rather have a resident at bedside making a diagnosis compared to Harvey Cushing (the father of neurosurgery) calling in from home. This same principle applies to patients threatening suicide (assuming you are not a psychiatrist). Better to err on the side of caution and have a professional – such as a police officer – lay eyes on the patient. Don’t forget about the National Suicide Prevention Lifeline. Finally, if your patient is already under the care of a psychiatrist, get them involved early.
What do you think? Have any of your patients communicated suicidal threats to you?
Helpful and well done.
Are most police trained in this? I get the idea that you’re analogizing the police officer to Cushing’s resident.
Granted there are certain tells that indicate seriousness of intent to commit suicide, but are these taught at police academies?
All this would seem to be discussing suicide from depression. I’m assuming that a patient in chronic pain from a terminal illness gets a pass here.
Thanks for reasonable suggestions. I can’t think of much more that would help. Everyone, even people trained in psychiatry and psychology struggle with the issue of suicide. Most of the time, you have no indication ahead of time, anyway.
My brother lost his job during the savings and loan crisis. He was a programmer for an S and L that closed. About that time our mother was getting more and more difficult and forgetful and would likely have to move out of their (shared) home to NH care. In order to pay for it we would have to sell her home. I told him he could come to stay with us. We would help him get another job. I told him he was my brother and I loved him. I thanked him for taking care of Mother and apologized to him for not doing more.
He had a huge argument with my sister that night and the next morning took a revolver to himself in Mom’s driveway. His suicide really pissed me off.
My point: There is no point “beating yourself up” about trying to prevent a suicide, even if you think you can. I would have called the police and had him placed under suicide watch if I had any idea. But I didn’t.
This damaged our family. My sister barely speaks to me. (It’s been over 4 years).
I appreciate the summary presented by Medical Justice. But if you fail to prevent a suicide, it is NOT your fault. Period. Even if you are a psychiatrist. It is almost impossible to stop that train once it has started rolling. In medicine we are trained to discount “anecdotal” points of interest as not being scientific. But in the case of suicide, anecdotal “evidence” may be the only logical way of looking at it. Every case is different. Your “control” of it is an illusion.
Michael M. Rosenblatt, DPM.
The police are there to make arrests and gather evidence. To expect more of them will be a mistake.
Sage advice. Excellent coverage and guidance for a potentially serious and nerve wracking situation. Thank you.