Saturday, May 07, 2011

A Cry for Help

When Roy and I were on Talk of the Nation this past week, a called phoned in to ask about her sister. The question was about care in the Emergency Room/Department, so it was a perfect Roy question and he fielded it. I've been playing with it since, and wanted to talk more about this particular scenario, because the scenario was very common, and the question was more complicated than it seems.

From the transcript of the show:

ANN (Caller): Hi, thank you very much. I would like to ask Dr. Roy (oh, I gave him his blog name here) a question: My sister was admitted to emergency when she cut her wrists, and the doctor on call pulled me aside and said, do you think she was trying to kill herself?

And I said - because my sister is very intelligent - I said, if my sister really wanted to kill herself, she would have done it. I think she's asking for help.

And so he said - and so he had her see the psychiatrist who was on call, or on duty. And she spoke with him for a while. And he sent her home, saying: Well, if you need me, I'm here.

What I would like to ask Dr. Roy is, what protocol was going on there? Why did they allow that to happen? And what would you change, if you could?

Roy did a great job touching on issues of voluntary versus involuntary hospitalization and the importance of hooking someone who is looking for help in to outpatient care.

If this were more of a two-way conversation, I'd want to ask more questions. What did the caller think should have happened? Was the sister given a referral for outpatient care? Was she asked if she wanted one? Was she already in treatment? My sense --and I could easily be wrong-- was that the caller thought the patient should be admitted to the hospital. She was desperate and ready now for help. The doctor asked the sister if she thought the patient wanted to commit suicide; hopefully the patient was asked that as well.

So if the caller thought her sister should have been hospitalized, there are things about the 'system' she isn't aware of. Hospital inpatient units are a place that people go to be kept safe. In many ways, they are a holding place and the goals there do not include treatment back to wellness, but treatment back to safety. It's a very low bar, and it ends up that only those who are imminently dangerous, or so disorganized as to be at risk, get admitted from an ER. There are some exceptions: if the ER doc doesn't believe a patient who says he's not suicidal/homicidal, he may err on the side of safety and admit the patient, or if the patient's behavior seems unpredictable, he may get admitted. At a community hospital, a typical length of stay is only a few days, very little actual psychotherapy occurs in the hospital, and while medications may be started, people are generally discharged before those medications can take effect or even be brought to steady-state levels. Gone are the days of long-term hospitalizations. And because of the acuity of illness in those people who are admitted to the hospital, psychiatric inpatient units are often not very restful places. If you want peace and quiet, you're better off in a hotel where you can order room service, have a massage, sleep peacefully, and it costs a whole lot less.

Sometimes people are admitted to specialty units where more intensive treatment does take place which may take longer and may have a goal that goes beyond imminent safety. There are special mood disorder units, eating disorder services, pain units, trauma disorder services, or inpatient stays for ECT...but one doesn't typically get admitted to these from the Emergency Room and often issues of payment limit who can be admitted and for how long. Of course, there is Clink's favorite place, The Retreat, where you can get help in a very pleasant environment, and I imagine they would be happy to have the sister of the caller from the radio, but that is self-pay.

"Getting help" usually means going to an outpatient therapist/psychiatrist and it's not something that necessarily gets started while the moment is ripe. If there is a clinic associated with the hospital, they may have emergency slots for the ER to offer fast appointments, but other times, it can take many weeks to get a first appointment. Private practice varies a good deal-- I know shrinks who can get you in within the week, and others with a 6 week wait, and many who are simply too booked to take new patients.

I didn't write these rules, I'm just letting you know what they are. How do you think it should all work?


Sarebear said...

My suicide attempt, in '96: I took some Nyquil and a bunch of Tylenol, then 5 minutes later called 911. I do not know if I intended to call when I took these things; I am pretty sure I did not, that I wanted to show my damn sister who was in charge of the house and everyone in it despite us being adults because my parents were out of the country, I wanted to show my damn sister that I seriously wanted to die, and I couldn't cope with the pressure she was putting on me to get a job, because I had become incapable of holding one down, proved over and over a year before.

Well, as the EMT's are wheeling me out, my aforementioned damn sister, and you will see here why I refer to her that way, told me, "If you'd wanted to kill yourself, you would have not called for help and died." Or something like that. I was stunned that someone could be so inhumane, and to this day it echoes inside me when I contemplate suicide, that if I REALLY am serious, that I would reach out to no one. In effect, what she said has increased my danger. It hurt more than anything I've been told in my entire life.

Sarebear said...

Then, at the hospital, after getting my stomach pumped and charcoal given, I talked to a mental health person not sure of what type. Years later, when going through my Social Security process of getting medical records for my hearing, I read the records from this incident and became extremely angry.

They asked this same damn sister if I would receive support at home, and she said yes. She's about as supportive as a spider's web.

I also seemed exceedingly happy at the hospital because I thought this meant I'd finally be getting help. Even knowing how the process of being determined to be in enough danger to be admitted to hosp. works nowadays, I still think I'dve stood a chance seeing how I actually TOOK stuff, if my sister hadn't said there'd be support.

Upon getting home, there was, of course, no support, and in fact my damn sister called my and her favorite aunt to come up to stay for a few days to a week, to help in this situation. I thought, "Oh good, I'll have someone caring and empathetic to talk to," but NO, my DAMN SISTER hogged all her time with I suppose dealing with what I'd done. Well, if it bothered her that much why the hell did she tell me that I should've not called for help and just killed myself????

So I was more alone than I'd ever been in my life. I came close to trying something again. Especially with her words stabbing into my soul.

Sarebear said...

I guess one thing I'm saying is, that I wish the question about support that was asked of my sister, wasn't a "secret" from me, and that they'd asked me if I expected to get any support (though since I'd called 911 on myself maybe they figured I'd say anything to get in the hospital . . .) If I had been in a supportive situation, I wouldn't have done what I did. They didn't consider this at all, it seems . . . I just feel betrayed by the system, not to mention my damn sister.

Of course, through this blog and comments on it I've learned that going inpatient for suicidal reasons would be possibly something I'd never want to do.

Dinah said...

I don't want to discourage anyone from getting help. Even if a psychiatry unit in a hospital is not a fun or restful place, a few days there to have some distance from stressors, to maybe get a change of meds, to reflect and stabilize, is a whole lot better than being dead for eternity.

Sometimes even just the conversation/evaluation with the ER staff is enough to help a person regain their composure, come up with a plan, and regroup.

But it's not about fun, it's about survival.

Anonymous said...

i tried to commit suicide in my early 20's. I took pain killers that I'd saved up and lots and lots of aspirin. A friend called soon after I'd swallowed the last pill and I answered the phone. I confessed, she came and took me to emergency.
One of the docs there asked me if I had a "headache"? He was sarcastic and rude and contemptuous. Whatever my problems at the time (now long since healed but not forgotten), I did not deserve that treatment.

I hope young docs are better prepared to handle emergency psychiatric problems. I would hope they would at least delve deeper.

Mental health problems should take the same priority as other health emergencies.

Anonymous said...

"A few days" is pretty hilarious to me. I got to spend four weeks, with another six as a very real possibility, based on about 30 minutes of conversation with a real doctor. Why then did they think I might need to spend 10 weeks in a locked ward? Apparently I was not forthcoming enough with a psychologist who was continually insulting me and enjoyed making me cry in public places. Stay classy, guys!

jesse said...

It was clear that the caller, Ann, had not been interviewed by the psychiatrist. She relates, "And she [the patient] spoke with him for a while. And he sent her home, saying: Well, if you need me, I'm here."

What would lead the psychiatrist to say that to the patient (we do not know whether the Ann heard the psychiatrist saying this, or whether it was the recollection of the sister)? Did he suggest an outpatient psychiatrist to the patient, but she refused?

The model of medical care that is discussed often involves teamwork. One doctor handing off treatment to another. But psychiatry does not fit the model as well as other branches of medicine. If a patient broke her wrist she might readily accept a referral, but a psychiatric patient is different. If the caller's sister had actually had an engaged and connected interview with the on-call psychiatrist she might not at all have wanted to continue care with someone she did not know. And if she had not had an engaged interview she would be even less likely.

It does appear that the patient did not subsequently cut her wrists again. But I find it hard to construct why the psychiatrist would not have wanted to talk with the sister.

Anonymous said...

Some of these rules you list depend upon the state you are in and the mentality of the ER and the hospital. I am a court appointed attorney for involuntary mental health commitments and in my state a good number of people get admitted as involuntary patients and forced to take meds into psych units from the ER for at least the statutory 96 hour hold - if they want to hold the alleged incapacitated person longer, it requires a court hearing. Most people are released within the 96 hours (which does not include holidays and weekends in the computation of time).

Sarebear said...

I hope I didn't alarm anybody. While I wouldn't WANT to go inpatient psych, after some comments I've read here, it's more if I NEED to even if I don't WANT to.

If I ever end up not going when needed, it's more about my fear of being trapped which I had long before I read anything here.

moviedoc said...

1) Even a luxury hotel is probably way cheaper than a night in a psych unit. Imagine how a patient feels on discharge with a $10,000 - $20,000 hospital bill on top of whatever illness + situation made suicide seem like a good option.

2) Unless the "hospitalist" psychiatrists refer to their own clinic after discharge they have little incentive to manage the patient's treatment in such a way that optimizes for outpatient follow up. It's very different when you admit, attend the patient in hospital, and discharge them back to your own practice.

Sunny CA said...

When I heard the woman pose the question on your NPR interview, my first thought was that the suicidal sister left the hospital and successfully killed herself. Recall that she said "Why did they allow that to happen? And what would you change, if you could? ----". Allow that to happen implies to me that there was a bad result. With a good result she would not still be thinking about it. Neither of you asked the outcome. It did not sound to me as though the caller thought the outcome was good. Also, the caller's thinking her sister is intelligent is not necessarily a medically correct assessment of the suicidal sister's emotional state. Do you know anyone who thinks slicing both wrists with a razor is a great way to get attention? There is purple hair and nose rings to accomplish that. I don't understand the hospital doctor not taking sliced wrists as a suicide attempt without needing to question the sister of the patient. People who make an unsuccessful attempt are very distressed about their life, in my opinion.
The doctor who was assigned to me in the hospital inpatient unit did not accept Blue Cross and so I had to pay his entire $480 per session (usually about 10 minutes) in full by check. That was over $10,000 just for the psychiatrist with no insurance to pick up any part of that tab. When I tried to change doctors I was prevented from changing.

Dinah said...

SunnyCA, interesting take on it! I thought "How could that happen?" was simply a question of how could someone who attempted suicide be sent home...I did assume that if the story ended with a successful suicide, then the caller would have said so, but as I said, there were a lot of unanswered questions here. The format did not allow for us to have a back and forth.

Dinah said...

Oh, it would have been a really different discussion if the final result was that the sister did indeed commit suicide that day.

People often have good outcomes and feel distressed with the process, and this is not unique to psychiatry.

Sunny CA said...

You may be right that the caller would have said her sister had died after being released. I know I would have said so.

I have a 16 to 17 year old high school student I teach in my biology class who was admitted to a psych unit a few weeks ago (when he was not at school) because he felt suicidal. About 2 weeks later he fell out of his seat in another class, but before he did he told a fellow student he had taken 4 sleeping pills. Emergency responders took him to the hospital, but he lied about the circumstances of taking the pills and was immediately released. Wednesday of last week, the next week, his eyes started rolling back in his head and then he started to vomit. Finally he admitted taking 15 sleeping pills and once again was taken to the hospital. I assume this time he was admitted since he did not return to school Th., Fri. (His father is angry at the teacher for suggesting the school call 911.) These 2 outcomes were at the same hospital, same student, similar time of day. If the patient does not tell the doctor they are suicidal, then I assume the doctor does his/her best to assess if the patient is a danger to him/herself or if the emergency is the result of an accident.

Anonymous said...

Wow. Well written and I think, fairly accurate assessment of how it all works. My dear best friend had a serious suicide attempt a year ago - she ingested over 100 pills, combination of Tylenol, Klonipin, xanax and who knows what else. She did reach out in time, and ended up spending 3 days in the ICU with a Picc line iv in her to flush out the toxins. Then another 5 days after that in the psychiatric unit. Good support from family, friends, therapists in the months to follow. Unfortunately, she attempted again 6 months ago and was successful and I lost my best friend and it hurts to lose someone that way.
The psychiatric units at the hospital are always at capacity and those that have extended stays (here) seem to fall in that small percentage of patients that are schizophrenic or psychotic and have completely lost touch with reality.
I've had my own brief stay in the hospital due to severe postpartum depression a decade ago... it was no picnic. If it weren't for my spouse and Dr. insisting that I needed to go in, it wouldn't have happened. It was because of their insistence and support. I ache for those that don't have that understanding from family/friends.
It is about a 4-5 week to get into a psychiatrist here as a new patient. And around a 3 week wait with a therapist if they are any good and taking new patients.

On my end, it absolutely sucks having a mood disorder. I hate how it affects my family and I hate feeling this way... once again, I can't imagine not having a good support system or having family members that won't advocate for me even when I don't want to be advocated for.

Anonymous said...

They will discharge you very quickly after a suicide attempt involving pills esp if you say that you were just upset and didn't really want to die even if that is a lie.
If you are psychotic they will keep you longer but like you said not long enough for the meds to fully start working. I don't know why anyone would talk about a hotel and a psych ward in the same sentence. Well people check into spas and hotels and not so well people get admittd to hospital. I have known people who feel crappy and think that a hopsital will admit them for a therapeutic experience but that is not what hospitals do. they are set up for crisis care and even if you swallow a truckload of pills, you can be let go very quickly once they see you are not dead. if you are dead, they will keep you in the morgue. Rule of thumb is walk around the streets naked and you will get admitted. OD,not likely. Anyhow, these places are not fun and are about the worst place to get better. They serve their purpose as a holding pen if you are a danger but no criminally so in which case you go to a different sort of jail.

Robert Lindeman said...

Roy, what DID you say about voluntary vs. involuntary treatment. The distinction is crucial, perhaps the most important feature of this case study. Please explain to us how you justify committing a woman against her will on the basis of "dangerousness" and especially on the basis of "disorganization" as you say in your post

Dinah said...

Interesting that most commenters want to tell us about their experiences. I was interesting in knowing How you think the system should work.

RL: in this story, we did not have the impression that involuntary commitment was at the heart of the issue, it seemed the sister had come to the ER voluntarily, and I thought would sign in voluntarily if that was recommended. Since the sister did not speak to the psychiatrist, we don't know if he recommended inpatient treatment, we can assume, however, that he chose not to certify the patient as someone who was at imminent risk.

Roy mentioned the voluntary vs involuntary issue because that often does become an issue.

Remember: we didn't know the questions beforehand and we had no time to think about them--not even seconds. And we had very little information to go on in terms of the facts of the case.

S said...

I'm somewhat confused; was it determined that her cut wrists a suicide attempt? Personally i never cut on my wrists (too visible; i injured pretty much everywhere other than forearms) but i knew plenty of girls who did, and it had nothing to do with suicide. Of course if it _was_ a suicide attempt, that would be something that requires immediate attention; i'd guessed that's what the extended conversation between the patient and the on-call shrink was intended to discover. Nonsuicidal cutting as a release also, of course, does eventually require long-term attention, as it's an indication of significant distress and lack of coping skills, but if that's what was happening, then i'm not sure i see what a hospital stay would accomplish.

TruthHurts said...

Let me see if I can post the truth without tripping your "ad hominem" and "slander" standards(eye of the beholder of course).
First of all, any individual can be and are routinely admitted to an inpatient facility if someone--and this could mean anyone no matter how credible they may be in their lives or what their motives may be--decides that someone else is a "danger to self or others". No actual evidence of this "danger" is needed, and indeed, the patient is very often "convicted" without being either given a "fair evaluation" or provided with ANY rights under the applicable state statutes nor recent federal civil rights rulings. Period. Once a person winds up as an inpatient, all civil rights of that person in practice END. Some states have agencies in theory charged with protecting such rights but they routinely fail to enforce such rights and are in fact thus part of the entire hospital system. Next, the staff usually decide to at minimum "embellish"/twist the record--and often falsify the record--and this is sometimes(such as by E. Fuller Torrey, MD, a Psychiatrist who thinks these practices are "lifesaving" thus necessary)a process that is vocally advocated by Psychiatrists(and always accepted by same). So this is the basic situation we have--and this exists for the very reason many other things exist in the American Marketplace--there is a huge profit to be had by too many players(hospitals, pharmaceuticals, staff).

TruthHurts said...

I just want to add something for the benefit of the "court-appointed attorney" who posted(and those who may be inclined to think this sort of process is at all fair).
Court hearings are held however all judges refuse to listen to patients and instead accept routinely the opinion of the Psychiatrist--whatever this may be. This is in part due to the fact that Psychiatry has injected itself wholly into the law and thus perverted it for the most part. Thus, judges feel obligated to operate this way, although patients in such a process are never afforded any notable civil or human rights either according to established law or according to international standards of law on such matters--that's a fact.

Sarebear said...

I felt compelled to post my experience because in showing what I felt DIDN'T work, it might show where improvements could be made, even without specifically saying what changes, it would at least show what I thought was wrong which meant I thought they should have done something different. I even say what I thought should be different at the end of my second post, but I still think posting the experience in response to your request for more concrete ideas about what to do, is an innate response to your query, because I (and it seems others) feel that explaining our unpleasant and even seemingly to us problematic care or lack thereof in one or some aspects, that I or we felt that through our experience you'd see where we thought the problem was . . . It's not too hard to imagine what could change our perceived problems. It's not like I thought through all this before posting, rather I just really FELT that sharing my experience would highlight the problem areas which is practically the same thing as me telling you what I think needs to change, although perhaps not HOW it needs to change or WHAT it needs to change to.

Understand what I'm saying?

Anonymous said...

I don't know, I think in the end of the day the major issue is lack of resources, and the "how" problem is a direct result of that. If patient A tried to kill herself, received medical care to ensure she was in no longer in physical danger, and was no longer endorsing suicidality, then yea, I do think that the bed she would have held would better serve someone who perhaps did not yet try to commit suicide but came to the ER actively suicidal. Do you both need help? Undoubtedly. But resources are limited, and you can go home without killing yourself, even if you hate your sister and she hates you, and the second patient hasn't tried to kill himself and perhaps has the best sister in the world, but can't stay alive independently...well, it's an issue of resources. It's cruel and unfortunate, but in the end of the day life simply counts more then comfort. Comfort and stress and emotional pain can be treated and handled outpatient. Inpatient resources are limited and should go to those who are truly a danger to self or others - and in the present, not as having been either in the past.

Anonymous said...

I think the system should do a better job of educating people about how it all works - the difference between voluntary and involunary, the standard for involuntary, how long a person has to stay, etc. I certainly don't know how any of it works. I even read the relevant statutes for my state and I still don't understand it. I imagine that if I were in danger, I would agree to a day or two or three in the hospital, if I knew that I could leave should I change my mind. But I have no idea if it works that way.

Battle Weary said...

Like "S" above, I immediately wondered if this was a suicide attempt at all. It very easily could have been self-injury/harm, which is NOT suicidal ideation. Inpatient treatment would do very little to help this issue, long-term (or short-term, depending) therapy is the way to go. Not knowing the full story it is difficult to judge how this happened, why it happened, or if this was appropriate treatment.

Anonymous said...

I think the hand-off should be better. In my health system, we would never give someone a cancer diagnosis and then hope they follow up with their PCP. We schedule the follow up appointment the same day with the patient. In fact, for breast cancer we have a special clinic where the patient comes in, watches a video about breast cancer and then sees the radiologist, oncologist, and surgeon all in one visit without leaving the exam room (the docs come to them). They leave knowledgeable about their disease with a treatment plan in place.

ERs are rotten places to get mental health care or any kind of care other than keep-me-alive-right-now acute care. What would be better would be an integrated system that had a way to refer clients out for therapy the next day which dovetailed into a more permanent placement that was compatible with the patient's insurance / ability to pay.

In a county south of mine, one group of hospitals threw together a pot of money and worked with the county to set up a suite of services for their frequent fliers in the ER. This was a CYA move on the part of the hospitals - an effort to get reimbursement. But they found that by assigning their FFs to a team that included a social worker (who evaluated support systems for the patient and their need for rehab), patient advocate (who helped the patient sign up for medicaid) and hooking them into welfare and housing services helped keep people out of the ER and basically paid for itself. By extension, a resource team that consisted of a psychiatrist, psychologist or MFT, and patient advocate would be the perfect follow up for those with mental health issues that required follow up but not hospitalization. They could do two to four weeks of follow up and transition the patient to regular care.

Anonymous said...

Sounds like they did the right thing by letting her go. Now, she won't have traumatic hospital memories to work out in therapy or a large bill to add to her list of problems. The ER visit is going to be pricey enough.

Anonymous said...

I was admitted to the psych ward a few months ago. It was the worst experience ever! It was basically a prison. All we could do is take our meds, go to group therapy (the lessons seemed to recycle a lot),eat, and watch tv/play card games. I could barely sleep because the workers would check in our rooms every 15 minutes with flashlights. The only cool thing about the experience was the people I have met. All the patients knew that in order to get out, we had to act happy in front of the workers and psychiatrists, not argue with them, and just basically do nothing. I didnt really want to be at the place, but they induced guilt on me about what would happen if i didnt volunteer my admittance. I was in the ward for 9 days and ive only seen my psychiatrist twice. I wish there were things to do because most of the time I ended up thinking negatively and coloring/watching tv/playing cards didnt distract me that much.