08 April 2009

Suicide Assessment on The North Shore: Why The System Fails.

The intent of using a picture of a coffin in this post is to drive home the point that half measures are no option considering the subject matter. I apologize for the discomfort to those who have been victimized by the suicide of a loved one but I believe you especially will understand the intent is to be as serious as possible when discussing this subject.

Here in the North Shore area of (Winnetka, Northfield, Northbrook, Wilmette, Kenilworth, Lake Forest, Glencoe, etc) Illinois the options for dealing with suicide (uncovering high lethality suicide
ideation and doing everything to prevent it) are covered by three basic occurrences: 1) your loved one verbally admits to thoughts of suicide, 2) you believe, for any of a variety of reasons, an attempt is possible/probable and/or 3) an actual attempt has been made.

Situation 1 is where lethality or seriousness of the contemplation begins to come into play. It's here also that the system begins to break down. There are some very well trained mental health clinicians who understand suicide and handle these sorts of situations competently and professionally. The vast majority of clinicians however are only minimally trained (if at all) to deal with death let alone suicide
ideation and the assessment of lethality. They often quickly suggest hospitalization and take action that is directed more to covering any possible liability issues and their own emotional discomfort than it is in dealing with the situation from a position of competency. I don't blame them and neither should you. All clinicians have comfort zones in terms of training and experience. The unfortunate fact is that death in general and suicide specifically, lies outside that zone for many.

The accurate assessment of suicide
ideation and lethality requires calm and focused intervention. Sending the person along the continuum of mental health care to more prepared clinicians (hospital emergency room personnel) is legitimate but also sets the stage for a breakdown of communication and the loss of valuable information. The situation can also become adversarial as the person being evaluated is now faced with possible psychiatric hospitalization or at least the use of medication, both of which carry possible physical problems and/or social stigmatization. Statistics on the exact numbers of people evaluated for suicide ideation and the outcomes of those evaluations are not available. Neither are accurate numbers of people who have been evaluated and then gone on to complete a suicide within the following year (some suggest 1 completed suicide per 100 to 200 attempts). What we do know is the majority receive anti-depressant medication and some are hospitalized for a short period of time. The period of time for hospitalization is now more a function of the person's insurance coverage (or lack thereof) then it is about the person's needs in general. The standard time is three to 5 days of hospitalization and then follow-up with a psychiatrist and other mental health clinicians for outpatient treatment. Along this continuum, patients drop out of care and/or stop taking their medications. Current Illinois Mental Health Law makes it very hard for all but the most determined family members to maintain the patient in the proper care necessary to prevent further crisis if the patient is unwilling. It's this frustration that wrongfully leads many to the mistaken belief that if someone is really determined to take their life that there is no way to effectively stop them.

In situation #2 people find themselves wondering about the possibility of a loved one taking their life. As a loved one you see problems such as financial, emotional or physical pain have over taken a persons life. You watch as they struggle, detach from life and generally become sullen. Their attitudes become negative and you suddenly wonder just what it is they are looking forward to, if anything. During heated conflicts they may voice statements that everyone would be better off if the person wasn't there or they describe life as meaningless and unnecessary. They haven't given you enough of a threat to force evaluation of some kind and they're resistant to therapy or psychological intervention. You're left in a position of constant fear and paralyzed from taking positive action because none seems available or a clear option doesn't appear to exist. Perhaps you're even feeling restricted or blocked from helping as the person is confined to a local jail or facility for incarceration due to some recent behavior. In such cases contact is often limited and regular correctional staff will not listen to your pleas for caution. The sad fact is often mental health services are lacking within jail settings even though the suicide rates within incarceration facilities are the highest among any group at approximately 38 per 100,000.

In situation #3 people often feel the most helpless to ensure the safety of a loved one. One or more attempts have already occurred. In some case the attempts were extremely serious and left no doubts as to the persons intent to end their life. It was only through some miracle that the attempt was interrupted in some fashion or that it was unsuccessful. As a loved one you know previous attempts are highly correlated with eventual suicide success. The mental health facility or hospital is about to discharge the patient and the only obstacle standing in the patients way of another attempt is medication and an appointment to see a mental health clinician upon discharge. These situations are perhaps the most dangerous for the elderly and adults between the ages of 45 and 54.

The mental health system fails in all three situations outlined above due to several breakdowns along the way (
http://www.chicagotribune.com/news/local/ct-met-northwestern-suicides-20120628,0,4291050.story). First, the system has become complacent with the idea that passing the patient along the continuum to a perceived higher level treatment provider (mental health facility, hospital or physician able to prescribe medication) who is assumed to be better able to care for the person, is the best option. This idea is neither accurate in reality nor based on anything personally and immediately relevant to the persons current life circumstances. At the extreme end of this continuum, the final option is to either physically or chemically (sometimes both) restrain the patient and attempt to provide mental health treatment and support. The obvious problems here are that during periods of restraint the person is totally unable to participate in any type of mental health therapy and there is no medication on the market (nor will there likely ever be) that is designed specifically to inhibit or prevent suicide. The outcome at this level of care (not that it can be correctly called care at this point) is simply to keep the patient still, quiet and docile; unable through restraint to harm themselves. At NISA we believe that once you've created this type of standoff with a patient, you've almost completely assured that the only viable option for the patient is to feign health until such point in time as they can safely achieve discharge and most assuredly attempt once again to take their life.

Second, by placing the patient into a conflictual position where their physical and/or emotional freedom could be taken away through hospitalization (at least the threat of) serves to insert a barrier between the patient and their treatment providers. Free will and choice are removed from the patients resources and thinly veiled coercion is introduced into the mix. It's only the most skilled and talented mental health clinician that can foster and develop a therapeutic relationship with patients under these circumstances.

Third, families and loved ones are often ignored in the treatment process due to preferences for individual treatment or inherent failures of privacy in medical care laws that allow adult patients to keep their medical care and information from being released to anyone except insurance carriers. In many cases loved ones are prohibited directly by the patient from knowing anything about their care or treatment. In these cases families are often left to hope for information about medication and/or the time of their loved ones next outpatient mental health care appointment and even who their mental health practitioner is. In situations involving suicide it seems illogical that disinterested third parties such as insurance companies should have access to information for treatment monitoring purposes while family members do not.

If you have any doubts about a loved one,
especially those being released from the hospital after either an attempt or threat of an attempt, we suggest a second opinion. Second opinions are obvious choices in any complex and life threatening medical situation. Shouldn't they also be an obvious choice in a mental health crisis as well, especially when a life is on the line?

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