Ms. R, age 17, has a history of major depression, obsessive-compulsive disorder, and self-harm through superficial cutting of her arms and inguinal region. She reports that 10 days ago she ingested 7 times her prescribed fluoxetine dosage of 20 mg/d and aripiprazole dosage of 2 mg/d because she no longer wanted to feel emotional pain. She did not tell anyone she did this or seek medical attention.
Ms. R complains of chronic difficulties with her stepfather, who she describes as alcoholic. She feels her depression is worsening and support from her mother has deteriorated. Ms. R’s parents say they are trying to respond to their daughter, but she will not talk with them and some nights she does not return home. Ms. R admits to staying overnight in local mall parking lots to be alone. Her psychiatrist recommends acute inpatient care for Ms. R’s safety.
Admitting an adolescent such as Ms. R to a psychiatric inpatient facility may be necessary to address a crisis. Interdependent links among the patient, family, and support network complicate the determination of whether an adolescent requires inpatient care. To make the best decision, a psychiatrist needs to understand the youth’s difficulties within family, school, and community.
Who needs inpatient care?
Inpatient treatment remains an important part of the continuum of care for adolescent psychiatric treatment.1 Inpatient treatment typically is reserved for patients whose psychiatric disorder impairs multiple areas of functioning or poses a significant danger to self or others and for whom less-restrictive treatment resources are not appropriate or available.2 The number of psychiatric hospitalizations for adolescents is increasing, although lengths of stay are decreasing.3,4
Psychiatric inpatient care is appropriate for patients who require 24-hour nursing care and psychiatric monitoring to stabilize symptoms when they are in acute crisis and have a high risk of harm, and for initiation of treatments required for stabilization and integration into a less-restrictive setting.5 The decision to admit an adolescent rests on:
- the clinician’s ability to evaluate the risk of harm and functional status
- how much support the family and/or caregivers can provide
- the clinician’s knowledge of treatment resources available to the adolescent and family.6
Exploring suicide risk
Understanding potential lethality of suicidal thought and intent is complex and requires assessing suicidal behavior, the patient’s past and current intent, the risk of engaging in or repeating a suicide act, the underlying diagnosis, and protective factors. To quantify imminent suicide risk, directly address suicidality when interviewing an adolescent, progressing from past thoughts to current intent, plan, and ability to carry out such a plan (Table 1) .7
Planning and lethality. Also examine the patient’s degree of planning for a suicide attempt, efforts to avoid discovery and rescue, and his or her perceived lethality of a suicide attempt or plan. Patients who develop a coherent plan that would successfully avoid discovery clearly are at highest risk. Lethality of method is frequently misunderstood—especially among younger individuals—and thus their perception of the dangerousness of an attempt is more important than reality. Previous suicide attempts and chronic suicidality with recent escalation imply greater risk.
Motivation. Exploring the feelings that motivate a suicide attempt, intent, or ideation will help assess risk. Common motivations include:
- escaping from stress or hopelessness from perceived intolerable circumstances
- rejoining a dead loved one
- getting notice or attention from a parent, romantic interest, or other important individual
- injuring others around them.
Serious suicide risk may persist if the motivating feelings are not addressed satisfactorily.7
Unclear signals. An adolescent who expresses a clear intent to die, has a plausible plan, and is unable to work with or rejects caregivers’ attempts to help is at high risk and requires a secure setting, such as hospitalization. Typically, however, patients do not give such clear indicators; in these cases, consider other factors.
Unstable and unpredictable behavior implies serious short-term risk. Factors that indicate difficulties in a patient’s ability to maintain a safety plan include:
- a history of multiple suicide attempts or escalating seriousness of ideation
- inability to be truthful and form an alliance with the clinician
- difficulties in expressing and regulating emotions
- presence or likelihood of intoxication.
Psychosis, command hallucinations, high impulsivity, cycling associated with bipolar disorder, and substance abuse also are associated with high suicide risk.8
The clinician must determine whether an adolescent can form an alliance to report suicidal ideation, intent, or plan to a family member or other responsible adult, and if the family/caregivers are willing and capable of providing support, supervision, and compliance with future treatment recommendations that will ensure safety. If the answers are no, the patient requires hospitalization.