One of our readers has commented that she's been involuntarily hospitalized for 'suicidal ideation,' presumably in the absence on a plan or any intention. Why is that? We hospitalize people involuntarily when we believe they may be dangerous, but the truth is, many people who feel depressed have suicidal thoughts, this is not at all uncommon, 'dark thoughts' are frequently mentioned during treatment, and the truth is that if we hospitalized every patient who thinks about suicide, umm...there would be no where to put them and no one to pay for it. Insurers put a huge amount of pressure on hospitals to keep people out and get people out. I remember the ER patient who was suicidal with a plan to shoot himself. The ER shrink called the insurance company to authorize the admission (it may have been voluntary) and the insurance company wanted to know if the gun was actually loaded!
It got me thinking, how does a patient get involuntarily hospitalized for thoughts, with no intention to act on them? I came up with a few ideas:
- The psychiatrist doesn't believe that the patient has no intention of acting on them. Why would that be? Somethings that might lead a psychiatrist to question a patient's word: A past history of a serious suicide attempt, especially a recent one. A friend or relative in the docs face saying they are lying. Another source of information that would indicate a lack of clarity about intent: a Facebook post saying "Goodbye, cruel world" a text message, something that makes the doc anxious. Indications that there is a plan: the patient has been giving away valuable possessions, has written a note, has mail ordered a noose.
- There is a mis-communication and the psychiatrist thinks the patient is having more active suicidal plans then the patient is actually having. This might be sorted out if more time is spent evaluating the patient or discussing options with the patient, but there are all sorts of other issues which may be playing out unrelated to the patient: the psych ER has 8 people waiting to be seen and there are too many things happening for the psychiatrist/ER staff to give them each enough attention.
- There are other risk factors which leave the psychiatrist feeling worried: substance abuse, for example, a history of repeated ER visits, a history of violence.
- The patient has a severe mood disorder and there is concern that the patient won't follow up with out-patient care and the psychiatrist makes a paternalistic decision that it would be in the patient's best interest to get intensive, aggressive treatment in the hospital.
- The psychiatrist has his or her reasons for being predisposed to being overly cautious: a patient is thinking of shooting up a school with no intent, but there was a high profile case similar to that all over the news yesterday.
- The psychiatrist has his own baggage: a lawsuit for a suicide has left him feeling it's best to 'play it safe and admit for observation,'-- the patient looks like his mother who died of suicide, another patient who swore they had no intent then suicided outside the ER door. All sorts of factors influence how a shrink thinks.
- A family member says, "He needs to be in the hospital, if you don't admit him and he kills himself, I'll sue your ass off."
- The patient refuses to commit to a safety plan.
- The psychiatrist is evil and loves power. (I had to throw that in here)