On the unit, Mr. Z denies suicidal ideation, plan, or intent. Agitation and suspiciousness are prominent. He refuses to authorize staff to contact his colleagues, his ex-wife, and other family members. Mr. Z demands immediate discharge and forbids contact with his outpatient psychotherapist. He is placed on 72-hour hold as a conditional voluntary admission.
The clinician should:
a) contact Mr. Z’s family, as an emergency exception to confidentiality
b) e-mail his family members with questions
c) contact the patient’s psychotherapist as permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
d) try to develop a therapeutic alliance with Mr. Z
e) none of the above
The best response option is C
HIPAA permits psychiatrists and other health care providers who are treating the same patient to communicate with each other about medical treatment without obtaining permission from the patient.8 However, mental health professionals cannot share psychotherapy notes without a patient’s consent, except when legally required, such as reporting abuse or duty to warn. This is the most expeditious and productive way of obtaining essential clinical information. E-mail merely changes the mode of unauthorized communication with significant others.
Mr. Z is agitated and suspicious, and developing a therapeutic alliance would require time. It is necessary to gather information about his psychiatric condition as soon as possible. An emergency exception to maintaining confidentiality is another option.9 The definition of emergency varies among jurisdictions. Consulting with a knowledgeable attorney may be necessary, but it usually takes time. Ethically, it is permissible to breach confidentiality to protect the suicidal patient.10
Question 5
Mr. G, a 42-year-old engineer, is re-hospitalized after a failed hanging attempt. Initially, he is profoundly depressed but improves suddenly and requests discharge. The psychiatrist and clinical staff are perplexed. Is the sudden improvement real or feigned?
The treatment team should consider all of the following options except:
a) obtain records of earlier hospitalizations
b) check collateral sources of information
c) assess Mr. G’s compliance with treatment
d) obtain psychological testing to evaluate Mr. G’s honesty
e) determine whether behavioral signs of depression are present
The best response option is D
Short length of hospital stay makes it difficult to assess sudden patient improvement.11 Real improvement in a high-risk suicidal patient is a process, even when it occurs quickly. Feigned improvement is an event. Obtaining patient information from collateral sources is crucial. Sudden improvement might be caused by the patient’s resolve to complete suicide. Identifying behavioral risk factors associated with psychiatric disorders informs the clinician’s systematic suicide risk assessment of a guarded or dissimulative patient. Psychological testing will take critical time and is not a substitute for careful clinical assessment.
Question 6
In mid-winter, Ms. M, a 42-year-old homeless woman, is seen in the emergency room of a general hospital. She complains of depression and auditory hallucinations commanding her to commit suicide. Ms. M has 5 earlier admissions to the psychiatry unit for similar complaints.
The psychiatrist conducts a comprehensive suicide risk assessment. Acute and chronic risk factors for suicide are identified. Protective factors also are assessed. The psychiatrist weighs and synthesizes risk and protective factors into an overall assessment of Ms. M’s suicide risk.
The main purpose of suicide risk assessment is to:
a) predict the likelihood of suicide
b) determine imminence of suicide
c) inform patient treatment and safety management
d) identify malingered suicidal ideation
e) provide a legal defense against a malpractice claim
The best response option is C
Suicide cannot be predicted.12 The term imminent suicide is a veiled attempt to predict when a patient will attempt suicide.13 The process of a comprehensive or systematic suicide risk assessment encompasses identification, analysis, and synthesis of risk and protective factors that inform the treatment and safety management of the patient.3 The overall suicide assessment is a clinical judgment call that determines risk along a continuum of low to high. In Ms. M’s case, comprehensive suicide risk assessment will assist the clinician in determining the patient’s overall suicide risk and make an appropriate disposition. Without a systematic suicide risk assessment methodology, the clinician is at the mercy of the pejoratively labeled “frequent flyer” who is looking for sustenance and lodging. The frustrated clinician is left with little choice but to admit the patient.
Although not the main purpose, systematic suicide risk assessment can help provide a sound legal defense if a suicide malpractice claim is filed against the clinician alleging negligent assessment.14
Question 7
A psychiatrist is treating Mr. S, a 36-year-old computer analyst, with once-a-week psychotherapy and medication management for panic and depressive symptoms that emerged abruptly after the break-up of a romantic relationship. Mr. S is using alcohol to sleep. He reports occasional suicidal ideation but no plan. He finds the idea of suicide to be morally repugnant. A therapeutic alliance develops.