September 23, 2007

What The Hell Kind Of Suicide Assessment Is This?

Do you know how many psychiatry journals there are?  A lot.  I get 8 peer reviewed journals mailed to my house, not to mention the shopping bag/week of "Insights" and "Reviews" and "Expert Series."   What the hell could be in all these journals, other than drug ads?  Is the field evolving that rapidly?  I mean, just how much info can there be about Lamictal?

But I'm happy to announce that the hundreds of articles are all top notch, cutting edge stuff.  Let's look at a recent one, about how to conduct and document a suicide assessment. 

I'm a busy man, with a lot to read-- what are the main, state-of-the-art points that I need to know about suicide?  


 clinical point 1


Also suggested was listening to patients, preferred over caning patients, which can sometimes be misconstrued as insensitive. 


How can I tell who's at risk?  Blood tests, cortisol levels, what? 

clinical point 2 

Crap.  Wrong again.  All this time I've been looking for breast implants.  Turns out, other signs include: frequent renting of Girl, Interrupted; being Anne Sexton; going through puberty in Ohio; mapquesting the longest way to the hospital; listening to rock music.

Keep in mind: these are the key points the editors and peer reviewers felt important enough to put in little sideboxes.  Aces.  Let's go on.  

What questions can be asked to help detect suicidality?



Wow.  Do the answers actually matter? 

Later the article discusses medico-legal risk.  That's what every psychiatrist wants to know: how to document a suicide assessment.  What should you write so that if, God forbid, the patient does kill himself, then it shows that you asked the right questions and did the best you could?    What advice is there for reducing medico-legal risk?  A sample write-up, perhaps?   

sample document

Great, finally-- this is exactly the kind of patient we want to know about-- complicated, but not currently suicidal.  Ok, what should I write in the assessment?  To reduce medico-legal risk?  I'm have a Moleskin, I'm taking notes:


sample assessment 

Does anyone in psychiatric journals ever get discharged?  Or are we in France?   The guy denies suicidality, and you're considering ECT?  This is like writing a pamphlet called, "Practical Tips For Driving In Snow" with only two sentences: "It's so much safer not to!  Have a Fanta!" (For a more practical, albeit not as well written, article on documenting the discharge of a suicidal patient, click there.) 


I didn't know those came in... (Below threshold)

September 24, 2007 6:23 PM | Posted by Jennifer Emick: | Reply

I didn't know those came in "dummies" versions...

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So what are the journals yo... (Below threshold)

September 24, 2007 7:42 PM | Posted by S: | Reply

So what are the journals you read? I'll take some guesses:

Archives, Psych Services, Am. J. of Psych, J. of Neuropsychiatry and Clinical Neurosciences, Focus, Academic Psych, JAPPL, and Current Psychiatry.

Am I right? Just curious.

Alone's response: mostly everything-- the big ones, also some forensic journals, occasionally I look through journals of other specialties (because they view issues differently-- consider SSRI/depression/cardiac studies from Circulation rather than J Clin Psych; I subscribe to a lot of boutique non-med stuff (Foreign Affairs, Washington Quarterly Nation, Wired, New Yorker, etc). I basically read until the coffee wears off/rum kicks in.

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it always seems strange to ... (Below threshold)

September 24, 2007 7:47 PM | Posted by andy: | Reply

it always seems strange to me that suicide is seen as the responsibility of the psychiatrist. at what point is the patient asked to take on some of the responsibility for their decisions?
of course this extends further than suicide and includes substance abuse, violence, child abuse and neglect. for some reason these are all something the psychiatrist has to worry about, and the patient is viewed as a passive player in the affair.
i once saw a sticker on a car that read "lord, help me to be the person my psychiatrist medicates me to be". it was supposed to be a joke.
Alone's reponse: You hit it on the head. In no other medical field is responsibility assumed almost totally by the MD. If you don't take your insulin, it's on you. The reason is that suicide is assume to be the result of an impairment in normal thinking. Is it? And if it is, what about any other kind of violence? (Whic, BTW, is also increasingly the responsibility of a psychiatrist-- try to discharge a guy who wants to beat his wife from an ER). This is the slow (fast) creep of paternalism-- i.e. communism.

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And something else. There's... (Below threshold)

September 25, 2007 3:27 AM | Posted by whatever: | Reply

And something else. There's plenty of people who have a plan or location, yet have no intentions of going through with them.

Forecasting is a risky business.

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at what point is the pat... (Below threshold)

September 25, 2007 6:31 PM | Posted by RussHy: | Reply

at what point is the patient asked to take on some of the responsibility for their decisions?
If you have the power to lock someone up against their will, I guess you'd better use it wisely.

Alone's response: responsibility I neither want nor think I (psychiatrists) should possess. The law limits us to commitment for recent dangerous behavior motivated by psychiatric illness (so wanting to kill your wife because she cheated on you wouldn't technically fall under that.) That's as much as I'm willing to accept.

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I basically read until t... (Below threshold)

September 26, 2007 12:37 PM | Posted by Stephany: | Reply

I basically read until the coffee wears off/rum kicks in.

My psychiatrist has never asked me if I felt suicidal.

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So many of your posts, I fi... (Below threshold)

September 28, 2007 9:03 PM | Posted by Janonymous: | Reply

So many of your posts, I find myself thinking, why have I never found a psychiatrist like this guy?

I tell any psychiatrist who asks, in general, I do not feel comfortable discussing with you whether or not I am "at risk". This is based on having been committed as a teenager, and discovering that the mental ward was one of the most traumatizing experiences; it seemed every action taken served the purposes of the doctors, and essentially nothing was done during my stay that in any way helped me with the *real life* problems that had led to my depression. Case in point, I had colleges requesting interviews (a couple Ivy leagues even), and the doctor refused to allow me a day pass to go to these, telling my mother that he saw college as a poor investment in me, and that she should instead be looking for permanent institutionalization for me. This did not make me less depressed. They gave me a lot of drugs there too.

Alone's response: that nothing happens on an inpatient ward is a common complaint. I would suggest to you, however, that discussing whether you are suicidal (or "at risk") with a psychiatrist can be more than a simple safety check, it can be kindling for insight. What is it about a specific situation or time that makes you suicidal? What is it about other situations in your life, that may have been worse, but did not make you suicidal? Etc.

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Pardon me, but I think you ... (Below threshold)

October 2, 2007 7:33 AM | Posted by Janonymous: | Reply

Pardon me, but I think you have missed the key point in what I wrote. I have indeed had suicidal thoughts at times in my life since the hospitalization years ago, but knowing that doctors have told me, by law, they are required to cover their own ass from legal action and so must err on the side of committing anyone they feel is at risk of harming themselves, I have long since decided, if I feel that way, the last person on Earth I'm going to tell is this asshole more worried about being sued than finding any "insights" in what I may be telling.

As for your suggestion, thanks. Yeah, I have had plenty of insights. Your point is vaguely condescending, implying that a suicidal person would not know why they were suicidal. It is the psychiatrists I have seen who have suffered an apparent lack of insight, seeing always symptoms, never a real life story. It is assumed suicidal feelings are crazy, aspects of distorted thinking and feeling. Any explanation to the contrary coming from the patient is dismissed (or, really, ignored) for this reason. Which is why, as in the article you cite, psychiatrists feel justified in thinking on behalf of patients. Sure, give him ECT; he says he's not that depressed but that's clearly a sign that his depression isn't allowing him to face reality.

Incidentally, I did eventually get out of that hospital, got my BA in psychology, and have done a fair amount of graduate coursework, though I'd really like at some point to go back for the PhD. To your point about "peer-reviewed" journals (I could not agree more with every one of these points), dissenting viewpoints are seldom listened to at all unless they're major academic players.

Alone's response: no, I think I got your point. My point is , who cares why they ask? Let them have their reasons, good or bad. (BTW, psychs rarely commit people simply out of fear of liability, thought they absolutely do admit people requesting hosp, even if they don't believe they are actually suicidal, out of fear of liability (which is obviously insane.)) But you (as the patient) need to do what you need for yourself, and if that means taking their silly "safety check" or pat answers to questions, etc, and using them for your own insights, so be it. In a sense, even if the psych sees you as nothing more than a fee, it doesn't mean you shouldn't use them-- and they can't help you-- anyway. And no, I wasn't trying to be condescending, but the questions are good ones for anyone to think about.

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you as one concerned with t... (Below threshold)

October 11, 2007 10:21 AM | Posted by yep: | Reply

you as one concerned with the essentially semiotic structure of psychiatry should surely see that "depression" and its "symptoms" and "associated" behaviours (e.g. suicide) are the fucking most obviously, most deeply, and most purely semiotic &, as such, are fundamentally unable to be logically deployed within the scientific scheme they have been placed in by psychiatry.... i would love for you to write a post on that.

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Re: Janonymous:Inv... (Below threshold)

October 18, 2007 2:08 PM | Posted by Nate: | Reply

Re: Janonymous:

Involuntary admits of non-violent people without history of self-injury occur. They are uncommon, but they occur. As to what the motivation of the committing psych is, who can say? "Why'd you commit that guy?" "Oh, just because I was scared of getting sued." Doesn't make it into conversation. Definitely doesn't make it into the chart. It's easy enough to document some crap about support systems.

(Sorry for late posting. Just discovered blog.)

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I'm with Janonymous. I've a... (Below threshold)

March 3, 2008 7:47 PM | Posted by Another Anonymous: | Reply

I'm with Janonymous. I've attempted suicide 7 or 8 times, with increasing seriousness. I nearly succeeded the last time (almost nine years ago). The only reason I do not try now is because I've made a commitment to my significant other not to hurt him that way, a commitment I take very seriously. I live daily with the unsettling knowledge that, should anything happen to him, all bets will be off.

Meanwhile, I am working diligently to use this time to find more positive reasons to stay alive. The best decision I ever made was to stop taking anti-depressants and the benzos that precipitated my last suicide attempt. Getting away from psychiatrists has been another really big help. As long as I had them picking me to shreds I had no hope of building anything that resembled a good self image.

In short, the very last person I would ever tell if I were suicidal would be any member of the mental "health" profession. What do they have to offer me? Let's see... incarceration, drugs that don't help but do hinder, oooohh--ECT, yep that's a great idea. Do something that may be helpful temporarily but causes permanent memory loss and completely stigmatizes me. Great idea. Not.

I'm actually making quite a lot of progress, doing better than I ever thought possible--and certainly better than any members of your most unhelpful profession ever deemed possible. Should I get into serious trouble again, I will not be looking for "help", for it only makes things much, much, much worse.

My significant other, by the way, totally agrees with me. He got to watch my experiences and totally gets why I would never divulge my intentions to anyone who might turn me in to the Mental "Health" Police.

I do enjoy your blog, though, and find it funny and thought provoking. I don't delude myself, however, that you're any different than your colleagues, although I'm sure you believe you are. I've known many really nice members of various branches of the mental health profession. They always think we disaffected former patients are talking about someone else when we express our feelings about our experiences in Psychiatric Land. Well, we are in one way. But the problems of power imbalance and medicalization remain no matter how nice the practioner. The nice ones are...nice. And that's, well, *nice*. But they simply can't tolerate the thought that they just don't get it.

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When are you guys going to ... (Below threshold)

June 14, 2009 9:54 PM | Posted by Christina MacKinnon: | Reply

When are you guys going to come up with a blood test for depression anyway? I'd like some lab results that say "YES there is a reason why you feel this bad" and also something I can point to to prove we're talking about a physical problem, not laziness or narcissism.

Research on what increases or decreases depression (as a physical illness would have more weight if you could link it to an objective serum level. (Fuck it, I'll let someone do an LP if they could measure the problem). Unfortunately, the more depressed the patient gets the more they place the fault on themselves. Hence the logic that if they could remove themselves everything would be OK. Give them something to measure, and it becomes just a matter of waiting until the body responds- not the spirit.

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Some people might not agree... (Below threshold)

February 6, 2010 6:43 AM | Posted by Ardath Martey: | Reply

Some people might not agree with what I have to say in general... that's fine but what I can say for sure is that everywhere I go people start flaming about anything. We're definitely in anger management need...Are we changing that fast ? I do recall things were a bit different just one decade ago. Or maybe when I was a kid stuff used to be more fun and I had no worries whatsoever.I think people need to find out more about marirea sanilor and themselves in general because only with propper education will we make a difference. My 2 cents.

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nice site. Good job.... (Below threshold)

December 7, 2010 11:01 PM | Posted by Louis Vuitton: | Reply

nice site. Good job.

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@Christina MacKinnon "When ... (Below threshold)

February 21, 2013 2:37 AM | Posted by Nonymous: | Reply

@Christina MacKinnon "When are you guys going to come up with a blood test for depression anyway? I'd like some lab results that say "YES there is a reason why you feel this bad" and also something I can point to to prove we're talking about a physical problem, not laziness or narcissism."

There will never be an accurate blood test for depression and thank goodness for that. Having such a thing would completely eschew personal and environmental responsibility. It's bad enough with all the "chemical imbalance = causation" mindset floating around. Having the "chemical imbalance bogeyman" makes it easy not to look at everything else. Everything else is you. And your actions and your thoughts.

If you blood test someone watching a scary movie and find them high in adrenaline, you don't say they have hyperactive adrenal gland and medicate, you say If you want your adrenaline levels to go down, you need to leave the movie. Likewise, if you blood test someone from a less-than-ideal environment and find they are low in serotonin and others, don't automatically say they have glandular problems and medicate, say Change and/or leave your environment and definitely change your way of thinking (mental environment).
Do some people truly have glandular problems? Yes. To the extent and in the numbers presently preached today? Decidedly not.

Medicating side, there is a reason the human is built with the ability to feel pain. It is an alarm; it lets you know something is wrong. Physical pain says that burner is hot and you need to get away from the stove. It also says you will need to interact with the burner in a different manner. Emotional pain says this person/environment/thought is causing you problems and you need to get away from it. It also says /if/ you are to interact with this person/environment/thought you will need to do it in a different manner.

~~~ The pain is not the problem. The pain is letting you know there /is/ a problem. ~~~

Put it this way: A person has a broken foot and keeps walking around on it just the same. It hurts, and over time it hurts so much the person would rather die just to get away from the pain. So they take pain killers. They no longer feel the pain, no longer hear the alarm, however, the foot is still broken. Every step they take further damages the foot. Eventually that foot is going to cause massive problems for them, regardless, whether they feel it or not.
Same with a fractured psyche. Say a depressed person takes emotional-pain killers, but changes nothing else. Going to the same places, thinking the same thoughts, interacting with the same people in the same ways, etc. They are walking around on a broken psyche that /will continue to get damaged/. Whether they can feel it or not.

Also, why is it, if not physical, automatically relegated to 'laziness' or 'narcissism'?
---"I'd like some lab results that say "YES there is a reason why you feel this bad""
You speak as if nothing found outside of a blood test could be a viable reason to become depressed. Abuse, being ostracized, neglected, feeling unloved.. None of these are viable reasons?

---"Unfortunately, the more depressed the patient gets the more they place the fault on themselves. Hence the logic that if they could remove themselves everything would be OK."

Fundamental Attribution Error. Guilt is only a major defining factor in /American/ depression. Other country's/culture's expression of depression involve the same amount of guilt the individual already had/didn't have. Furthermore, not all depressed Americans have guilt as a major factor. Sometimes it never enters their heads to be guilty, and they are still suicidal /for other reasons/.

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