In a large practice, trust your instincts to detect life-or-death depression
Depression, in its most severe forms, carries the risk of suicide or even homicide. But sorting life-or-death cases from less serious ones becomes complicated when your patient base covers a large geographical region or several thousand persons. In a large practice, many patients may be relatively unfamiliar to you, and you have limited time to make critical triage decisions.
As a psychiatrist with experience following a large outpatient practice and managing an inpatient unit, I believe the following advice can help you identify which cases require emergency treatment.
Pay attention to immediate signals from the first-time patient. Psychiatrists working with large patient bases often receive new patients, and the feelings, circumstances, and symptoms surrounding initial visits warrant special attention. Check for signals that the patient is at risk for homicide or suicide and for signs of acute depression, including obvious psychomotor retardation, physical agitation, and preoccupation with nihilistic themes or death.
Your suspicion threshold should be high when patients are involuntarily brought in by concerned friends or relatives. In such cases, it is often prudent to interpret the situation as an emergency.
Remember that symptoms of serious mental health problems can be deceiving. Acutely depressed patients often exhibit slow movement and speech, but what looks like lack of cooperation may signal conceptual disorganization, paranoia, or catatonia—all severe symptoms that carry a high risk of suicide and warrant hospitalization.
If a patient insists he or she will be OK, proceed with caution. Your toughest cases will be patients who acknowledge that they feel suicidal but assure you they can remain stable as outpatients. Ask targeted questions to sort out whether their reluctance to accept inpatient care could lead to an emergency. For example, does the patient have a recent history of making suicidal plans, or do any of the risk factors listed below apply?
Keep in mind that most patients will not disclose a concrete suicide plan if they do not wish to be hospitalized. You may need to rely on information from those who brought the patient to you. When a patient is unfamiliar to you, no “safety contract” between you and the patient is sufficiently secure.
Of course, things are different in an outpatient, nonemergency scenario. In “cooperative” triage situations, many patients can be believed when they say they are not acutely suicidal. The easiest clinical decisions are made when patients come to you with the expectation that you will help them.
Watch for risk factors in familiar patients. Some established patients may become highly depressed but do not exhibit signs of an impending emergency. Be aware of the usual risk factors:
- previous psychiatric hospitalization(s)
- current emotional instability
- comorbid personality disorder
- history of substance abuse
- lack of adequate support from family and friends
- presence of psychosis
- family history of suicide
- gender (women make more frequent suicide attempts, but men are more likely to succeed). 1
Finally, even if you’ve never met the patient before, you can negotiate varying levels of contact, such as daily office visits or telephone conversations. You can also encourage family and friends to monitor the patient’s behavior and provide emotional support, as long as you are careful not to draft them into caregiver responsibilities they may not be equipped to handle.
1. Roy A. Psychiatric emergencies—suicide. In: Kaplan HI, Sadock BJ, eds. Comprehensive Textbook of Psychiatry (6th ed). Balitmore: Williams and Wilkins, 1995;1739-47.
Dr. Vuckovic is medical director of The Pavilion, a residential psychiatric evaluation unit at McLean Hospital, Belmont, MA. He is an assistant clinical professor of psychiatry at Harvard Medical School, Boston.