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C H A P T E R 16
Inpatient Treatment
Copyright 2020. American Psychiatric Association Publishing.
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
Richard L. Frierson, M.D.
The vast majority of psychiatric treatment typically occurs in the outpatient set
ting. The development of inpatient psychiatric treatment was guided in part by the
need to prevent persons who were viewed as a danger to themselves from dying from
suicide or engaging in serious self-harm behaviors. Inpatient 24-hour observation
was believed to be superior to routine outpatient treatment in suicide prevention. In
order to maximize patient autonomy, psychiatric treatment should normally occur in
the least restrictive setting possible, provided that the treatment setting is likely to be
efficacious while ensuring patient safety (Lake v. Cameron 1966). However, when
patients are at significant suicide risk due to the severity of their mental illness, a lack
of insight, or inadequate outpatient resources (including family or other support sys
tems), inpatient hospitalization has become the standard of care (American Psychiat
ric Association 2003).
Inpatient psychiatric treatment in the United States is facing multiple challenges in
the twenty-first century, most notably a significant shortage of available public and
private inpatient psychiatric beds. Deinstitutionalization and cuts to state public
funding for mental health services have shifted some of the burden of behavioral
health treatment to emergency departments (Medford-Davis and Beall 2017). In some
jurisdictions, patients are held in an emergency department for days without ade
quate treatment or a hospital room (see Chapter 14, “Emergency Services”). This cri
sis has recently come to the attention of the court system, which may force increased
state funding for inpatient beds in the future (Appelbaum 2015).
Alternatively, patients who need inpatient treatment but for whom beds cannot be
found are sometimes released back to the community, with disastrous consequences
(Bursiek 2018). Because of inpatient bed shortages, patients who are actually hospi
talized may have more severe mental illness and may be at increased risk for inpatient
suicide. In addition to its impact on general hospital emergency departments, the cur
rent shortage of psychiatric beds has also resulted in a greater probability of jail de
tention for minor charges among persons diagnosed with severe mental illness (Yoon
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et al. 2013). Jails are often poorly equipped to handle persons with severe mental ill
ness, including those at risk of suicide (see Chapter 21, “Jails and Prisons”). Finally,
this critical decline in psychiatric beds may have contributed to the recent increase in
the overall suicide rate in the United States (Bastiampillai et al. 2016).
This chapter reviews inpatient treatment of suicidal patients, including the deci
sion-making process for hospitalizing patients with suicide risk, the incidence and
epidemiology of suicide in the inpatient setting, the risk factors for inpatient suicide,
and the principles of risk management. Specific strategies in risk management, in
cluding observation and staffing levels, are reviewed as well as newly proposed en
vironmental requirements from the Centers for Medicare and Medicaid Services
(CMS) through The Joint Commission (formerly the Joint Commission for the Accred
itation of Healthcare Organizations). Finally, through presentation of a malpractice
case involving an inpatient suicide death, the interaction between patient and envi
ronment, including inpatient unit design, is discussed.
Making the Decision to Hospitalize
The decision to hospitalize a patient can only be made after a thorough evaluation of
the patient’s clinical condition, including the presence or absence of a psychiatric dis
order, the severity of current symptoms (including hopelessness and impulsivity),
past suicide attempts and their severity, overall functioning, and the availability of
outpatient support systems. The clinician should also explore activities that give the
patient a reason to live. In situations with a high potential for dangerousness to self
or others, inpatient treatment may be warranted even if additional history is not
available or the patient is unable to meaningfully participate in a psychiatric exam
ination due to agitation, psychosis, or other factors.
The decision to hospitalize must also include an examination of the possible nega
tive effects of hospitalization, including disruption of employment, financial hard
ship caused by hospitalization, and other psychosocial stress (e.g., inability to care for
a dependent child or adult due to hospitalization). It should also include an evalua
tion of the patient’s ability to provide self-care and to manage a crisis and seek appro
priate help (e.g., family members, emergency care). Thus, the degree of suicide risk
should be balanced with these various elements when making a decision about treat
ment settings. Guidelines for decision making can be found in Table 16–1.
Once the decision to hospitalize a potentially suicidal patient is made, the psychi
atrist must next decide whether the hospitalization should occur on a voluntary or in
voluntary basis. Voluntary admission is always preferred, because it upholds the
principle of patient autonomy, but the psychiatrist must consider civil commitment if
a patient refuses admission. All states permit civil commitment for patients who pres
ent a danger to themselves, and most states allow for civil commitment of persons
deemed “gravely disabled” (Kapoor 2018; see Chapter 17, “Civil Commitment”). Fi
nally, if the psychiatrist is concerned about possible elopement or if the patient has a
history of elopement from psychiatric facilities, hospitalization should occur on a se
cured unit. A significant number of inpatient suicides have occurred immediately fol
lowing elopement (Madsen et al. 2017).
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Inpatient Treatment
TABLE 16–1.
203
Guidelines for selecting a treatment setting for patients at risk for
suicide or suicidal behaviors
Admission generally indicated
After a suicide attempt or aborted suicide attempt if
Patient is psychotic
Attempt was violent, near lethal, or premeditated
Precautions were taken to avoid rescue or discovery
Persistent plan or intent is present
Distress is increased or patient regrets surviving
Patient is male, older than age 45 years, especially with new onset of psychiatric illness or
suicidal thinking
Patient has limited family or social support, including lack of stable living situation
Current impulsive behavior, severe agitation, poor judgment, or refusal of help is evident
Patient has change in mental status with a metabolic, toxic, infectious, or other etiology
requiring further workup in a structured setting
In the presence of suicidal ideation with
Specific plan with high lethality
High suicidal intent
Admission may be necessary
After a suicide attempt or aborted suicide attempt, except in circumstances for which
admission is generally indicated, such as in the presence of suicidal ideation with
Psychosis
Major psychiatric disorder
Past attempts, particularly if medically serious
Possibly contributing medical condition (e.g., acute neurological disorder, cancer,
infection)
Lack of response to or inability to cooperate with partial hospital or outpatient treatment
Need for supervised setting for medication trial or electroconvulsive therapy
Need for skilled observation, clinical tests, or diagnostic assessments that require a
structured setting
Limited family or social support, including lack of stable living situation
Lack of an ongoing clinician–patient relationship or lack of access to timely outpatient
follow-up
In the absence of suicide attempts or reported suicidal ideation/plan/intent, but evidence
from the psychiatric evaluation or history from others suggests a high level of suicide risk
and a recent acute increase in risk
Release from emergency department with follow-up recommendations may be
possible
After a suicide attempt or in the presence of suicidal ideation/plan when
Suicidal thoughts and behaviors are a reaction to precipitating events (e.g., exam failure,
relationship difficulties), particularly if the patient’s view of situation has changed since
coming to emergency department
Plan/method and intent have low lethality
Patient has stable and supportive living situation
Patient is able to cooperate with recommendations for follow-up, with treater contacted if
patient is currently in treatment
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Textbook of Suicide Risk Assessment and Management, Third Edition
TABLE 16–1.
Guidelines for selecting a treatment setting for patients at risk for
suicide or suicidal behaviors (continued)
Outpatient treatment may be more beneficial than hospitalization
Patient has chronic suicidal ideation or self-injury without prior medically serious attempts,
if a safe and supportive living situation is available, and outpatient psychiatric care is
ongoing
Source. Adapted from Jacobs DJ, Baldessarini RJ, Conwell Y: Practice Guideline for the Assessment and Treat
ment of Patients With Suicidal Behaviors. Arlington, VA, American Psychiatric Association, 2010. Available
at: http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf
Accessed September 8, 2018. Used with permission. Copyright © 2010 American Psychiatric Association.
Incidence of Inpatient Suicide
The inpatient setting allows for the implementation of constant observation, seclusion,
or physical or pharmacological restraint, which are all modalities designed to prevent
a patient from acting on suicidal impulses. However, inpatient suicides occur at a sur
prising rate, accounting for between 5% and 6% of all suicides in the United States
(Busch et al. 2003). Psychiatric inpatients have a suicide rate that is 13 times higher
than the annual global age-standardization suicide rate (Madsen et al. 2017). The esti
mated number of hospital inpatient suicides per year in the United States ranges from
48.5 to 64.9, which is far below the previously widely cited figure of 1,500 per year (Wil
liams et al. 2018). Additionally, the prevalence of inpatient suicide attempts is 10-fold
that of inpatient deaths from suicide, and many attempts involve serious injury
(Brunenberg and Buijhl 1998).
The Joint Commission considers inpatient suicide a sentinel event, defined as a pa
tient safety event that results in any of the following: death, permanent harm, or se
vere temporary harm with intervention required to sustain life. Inpatient suicide was
the second most common sentinel event reported between 1995 and 2005, and 1,100
voluntary reports of suicides occurred in health care settings in the United States be
tween 2010 and 2014 (Knoll 2012; Stempniak 2016). More importantly, about 21% of
The Joint Commission’s accredited behavioral health care organizations and 5% of its
accredited hospitals are noncompliant with The Joint Commission’s recommended
practices to identify patients at risk of suicide. Inpatient suicide is not unique to the
United States; a study in the United Kingdom found that nurses, on average, were
confronted with a death from suicide of one of their patients suicide every 2.5 years
(Nijman et al. 2005).
Epidemiology and Risk Factors for Inpatient Suicide
Out of all types of suicide, inpatient suicide should be viewed as the most avoidable
and preventable due to the proximity of patients to hospital personnel, including
mental health professionals. For that reason, courts and juries in malpractice claims
attribute a greater responsibility to inpatient facilities to prevent suicides. Whereas
about one in four outpatient suicides will result in a malpractice claim, about one in
two inpatient suicides will result in a claim (Knoll 2012).
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Identifying risk factors for inpatient suicide is difficult because suicide, although
the tenth leading cause of death in the United States, is a rare event occurring at a base
rate of 13.5/100,000 population (Centers for Disease Control and Prevention 2017).
Studies attempting to secure robust risk estimates on the more restricted and smaller
population of inpatients are even more difficult. Additionally, the evidence-based
suicide risk factors used for suicide risk assessment in the outpatient setting are not
correlated with inpatient suicide. For example, outpatient risk factors such as age,
sex, marital status, unemployment, and lower educational level are not necessarily
risk factors in inpatient settings (Busch et al. 2003).
Similarly, whereas depression is the most common diagnosis in outpatient suicide,
schizophrenia and psychotic disorders are just as likely as mood disorders to be
found in patients who died from suicide in the hospital (Spiessl et al. 2002). In a 9-year
review of all inpatient suicides in Germany, identifiable risk factors included history
of being a victim of assault, personality disorder, previous suicide attempt, psycho
pharmacological treatment resistance, suicidal thoughts on admission, schizophre
nia, depression, female sex, and length of stay (Neuner et al. 2008). However, a
systematic review and meta-analysis demonstrated that the most established risk fac
tors for inpatient suicide are depressive symptoms during admission, a diagnosis of
a mood disorder or schizophrenia spectrum disorder, and a history of deliberate self
harm (Large et al. 2011). Additionally, meta-analyses have identified a family history
of suicide or mental illness, high levels of hopelessness, feelings of worthlessness or
guilt, prescribed antidepressants, and longer length of hospitalization as inpatient
suicide risk factors (Madsen et al. 2017).
Many studies have found that inpatient suicide is most likely to occur outside of
the hospital when a patient is on leave or has absconded from an inpatient psychiatric
unit (Madsen et al. 2017). Among suicides that occur inside the confines of a psychi
atric unit, the vast majority occur by hanging. In one large study, hanging accounted
for 73% of all suicides that occurred on the inpatient unit; most occurred in a private
area (e.g., bedroom, bathroom) using a door corner as an anchor point (Meehan et al.
2006). More than 90% of inpatient suicides took place in private spaces, such as the
bathroom, bedroom, closet, and shower. In a multiyear review of suicide attempts
and completions at U.S. Department of Veterans Affairs (VA) inpatient facilities,
hanging accounted for 76% of deaths from suicide, with most using a door, door han
dle, or wardrobe/locker as an anchor point and sheets, bedding, or clothes as a liga
ture (Mills et al. 2008). In one review, case fatality after attempted suicide by hanging
was 70%, but the majority (80%–90%) of those who reached medical treatment alive
survived (Gunnell et al. 2005).
The risk of inpatient suicide is highest in recently admitted patients, with as many
as one-quarter of inpatient suicides occurring during the first week of admission
(Madsen et al. 2017). This is particularly true when a readmission to a psychiatric hos
pital has occurred within 30 days of the last discharge (Madsen et al. 2012). Inpatient
suicides occur even while patients are under observation. In a 6-year study in En
gland and Wales, 16% (n=113) of all inpatient suicides (N=715) occurred while pa
tients were under observation (Flynn et al. 2017). Of the suicides that occurred while
patients were under observation, 96% of the patients were under intermittent obser
vation and 4% were under constant observation. In 65% of these cases, the patient
died on the inpatient ward; in 35%, the patient had absconded from the hospital while
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Textbook of Suicide Risk Assessment and Management, Third Edition
on observation. Finally, most occurred when less-senior staff (e.g., student nurses or
health care assistants) or staff members who were unfamiliar with the patient (e.g.,
pool nurses, staff agency nurses) were performing the observations.
Inpatient Treatment and Suicide Risk Management
The first goal of inpatient treatment is patient safety. Because the risk of suicide is great
est in the first week of hospitalization, patients should be placed on an appropriate
level of observation. Many hospitals have developed written policies regarding man
datory observation levels for newly admitted patients with suicidal ideation. Patients
at high suicide risk should be placed on direct intensive psychiatric observation (i.e.,
one-to-one observation) for at least the first 24–48 hours. Observers performing this
level of observation should be freed of other clinical duties. Patients at mild to moder
ate risk may be placed on continuous observation where one observer is responsible
for watching two or three patients. Although some hospitals use “15-minute check”
schedules, 15 minutes is more than enough time for a patient to die from hanging, and
many hospital suicides have occurred while patients were under this observation
level. Camera monitoring of patients also is not recommended because observers can
become bored or distracted or be called away to other tasks.
The observation of psychiatric patients as an intervention to mitigate risk of sui
cide requires a complex, sustained interaction between the patient, observer, psychi
atrist, nurse, other treatment team members, and the psychiatric unit environment.
Staff members who are directly responsible for observing a patient should be active
members of the patient’s treatment team (Janofsky 2009) and should be trained in car
diopulmonary resuscitation (CPR) and suicide prevention, including means restric
tion. Interdisciplinary collaboration is also needed when making the decision to
discontinue direct observation and institute some form of intermittent observation.
The observer and nursing staff supervisors should have direct and open communica
tion regarding any unusual changes in an observed patient’s behavior. Finally, psy
chiatrists and other staff should conduct a suicide risk assessment before decreasing
levels of observation. Once an observation level has been decreased or discontinued,
the onset of new stressors during hospitalization (e.g., the ending of a romantic rela
tionship, loss of employment due to hospitalization) should lead to reassessment for
the need to maintain or increase levels of observation.
After the management of safety issues, the main goal of inpatient treatment is to
establish a therapeutic alliance and to initiate appropriate biological and psychosocial
therapeutic interventions. The provision of a supportive inpatient environment can
also help relieve stressors, strengthen and develop coping skills, and instill hope for
the future. In inpatient settings, treatment is administered using a team approach,
typically with a psychiatrist leading a group consisting of nurses, social workers, psy
chologists, and other mental health workers (e.g., activity therapists, mental health
technicians), with each member providing input. Communication in team meetings
can be improved by adding to the agenda a specific discussion of patients identified
as a potential suicide risk. Psychiatrists should remain aware at all times that al
though a collaborative approach is used in patient treatment, treating psychiatrists
ultimately bear the responsibility for critical decisions.
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The patient’s underlying suicide risk factors and clinical condition govern the treat
ment modalities used and the length of hospitalization. Modifiable suicide risk factors
such as an underlying mental illness (e.g., depressive disorder, psychotic disorder, bi
polar disorder or anxiety disorder) may be treated with appropriate pharmacotherapy
and supportive psychotherapy (see Chapters 7, 8, 10, and 11). For patients with a con
comitant or primary substance use disorder, management of potential withdrawal
symptoms and further referral or transfer to a facility for substance use disorder treat
ment should be considered (see Chapter 9). For those patients with borderline person
ality disorder, the duration of hospitalization may be intentionally limited to avoid
regressive dependency. These patients may receive more effective treatment through
relatively quick transfer to an intensive outpatient program once the suicidal crisis has
passed, particularly a program that employs dialectical behavioral therapy (Linehan
et al. 1991). For patients with severe depression and persistent suicidal ideation, elec
troconvulsive therapy (ECT) should be considered because it is accompanied by a
rapid reduction in suicidal drive (Fink et al. 2014).
In addition to initiating treatment of underlying psychiatric disorders, inpatient
hospitalization affords time to identify and mobilize outpatient treatment resources
and support systems. The era of managed care and the requirement to obtain insur
ance preapprovals for inpatient treatment have resulted in pressure on both patients
and hospitals to discharge patients as quickly as possible. Since the 1960s, the length
of stay for psychiatric inpatient care has decreased from months to days, and the sole
focus of psychiatric inpatient treatment has become safety and crisis stabilization
(Sharfstein et al. 2008). As a result, discharge planning actually begins at admission.
Prior to discharge, psychiatrists should make certain that they conduct a suicide risk
assessment and that the team has developed a safety plan. This plan may include ar
rangements for the patient to initially stay with relatives or friends (if they normally
live alone), scheduling of an outpatient visit within days of discharge, and education
of the patient and family about how to access emergency services.
Lethal means restriction may be a critical element of a discharge safety plan. For ex
ample, removing or limiting a patient’s access to firearms prior to discharge to home
may be essential (see Chapter 29, “Suicide and Firearms”). If the patient has a history
of suicide attempt via overdose, soliciting family involvement in medication adminis
tration may be warranted. Patient and family education about the role of medication
in treatment and the importance of compliance can be reviewed. Finally, a safety plan
should include concrete steps that patients or family can take if the same stressors that
led to admission were to reoccur or if the patient’s condition worsens. This is especially
true for patients who made definite plans and underwent extensive suicide prepara
tion prior to admission, because they may be at highest risk for subsequent attempts
(Jordan and McNiel 2018).
Patients are at increased suicide risk during transition points, including the week af
ter hospitalization and the weeks after discharge. Unfortunately, a significant number
of psychiatric inpatients—as many as 65%—fail to attend scheduled or rescheduled
mental health appointments following psychiatric hospitalization (Boyer et al. 2000).
Risk factors for failure to comply with scheduled outpatient treatment include having
a severe and persistent mental illness, having been involuntarily hospitalized, having
had no prior public hospitalizations, and having a longer length of stay. However, three
clinical interventions have been shown to triple the odds of successful linkage to out
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patient treatment: 1) communication about discharge plans between inpatient and
outpatient clinicians (i.e., not merely administrative staff), 2) patients starting outpa
tient programs prior to discharge, and 3) family involvement during the hospital stay
(Boyer et al. 2000).
Inpatient Environment
One of the most effective ways of reducing the rates of death in suicide attempts is means
restriction (Sarchiapone et al. 2011). On the inpatient unit, means restriction generally
involves the minimization of ligature risk (Centers for Medicare and Medicaid Ser
vices 2017). In assessing potential ligature points on an inpatient unit, it should be noted
that more than 50% of hanging attempts are not fully suspended and that ligature points
below head level are commonly used (Gunnell et al. 2005). In 2017, The Joint Commis
sion issued recommendations stating that inpatient psychiatric units in both psychiatric
hospitals and general/acute care settings must be ligature resistant in patient rooms, pa
tient bathrooms, corridors, and common patient areas (The Joint Commission 2017).
Doors between patient rooms and hallways must contain ligature-resistant hardware
including, but not limited to, hinges, handles, and locking mechanisms.
Additionally, the transition zone between patient rooms and bathrooms must be
ligature free or ligature resistant. This may require removal of bathroom doors or use
of special doors designed to prevent using the top to support a ligature. Patient rooms
and bathrooms must have a solid ceiling (i.e., no drop ceilings), although common ar
eas and corridors may have drop ceilings as long as all aspects are fully visible to staff
and no objects are present that patients could use to climb up to a drop ceiling.
On high-acuity units, means restriction interventions may also include the prudent
restriction of access to ligatures, such as belts and shoelaces. Finally, hospital administra
tors, clinical staff, and building maintenance personnel should conduct periodic safety
inspections of the inpatient unit, known as “environmental risk assessments,” with the
goal of identifying environmental hazards that could be used in a suicide attempt.
Medical Management of Suicide Attempts
Case fatality after suicide attempts by hanging is high; firearms are the only com
monly used means of suicide with a higher lethality rate (Spicer and Miller 2000). One
U.S. survey of hangings in general (not limited to those on inpatient units) found that
78% of people were pronounced dead at the site of discovery, but of the 22% referred
to the hospital, 64% survived (Gunnell et al. 2005). Survival is possible even after sus
pension for more than 5 minutes. After medical hospitalization, most deaths are due
to bronchopneumonia, pulmonary edema, or adult respiratory distress syndrome.
Because survival of a suicide attempt is generally contingent on arriving at a medical
facility alive, all inpatient clinical staff should be trained periodically in CPR and the
use of an automated external defibrillator. Routine drills to simulate medical emergen
cies should be held, and policies should outline the procedures to be followed when
outside medical assistance is needed, including assigned responsibilities for calling
911, directing and assisting the responding emergency medical technicians, ensuring
unit security during medical emergencies, and managing other patients on the unit.
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In the case that follows, a medical malpractice action was brought against a psy
chiatrist and a general hospital after the death of a patient from complications of a sui
cide attempt while receiving inpatient psychiatric treatment.
Case Example
A 21-year-old female college student was brought to the emergency department at a lo
cal hospital by family members after expressing suicidal thoughts and a plan to drive
her car off of a bridge. She had a history of treatment for persistent depressive disorder
but had dropped out of treatment approximately 2 months prior to her presentation.
She had been hospitalized 7 years earlier at age 15 after an antidepressant overdose. She
had been treated successfully with antidepressant medications over the years in outpa
tient treatment.
She had no history of alcohol or illicit substance use. Her medical history was re
markable for Graves’ disease (for which she was receiving thyroid hormone replace
ment) and hyperprolactinemia secondary to a pituitary adenoma that was being
followed by a neurologist. Her family history revealed that her mother had a history of
schizophrenia and that the patient had actually been born in a state psychiatric hospital
and raised by an aunt and uncle. At age 7 months, her mother died from suicide while
on a holiday pass from the state psychiatric facility. The patient also had two maternal
uncles who had been diagnosed with bipolar I disorder, and one of them had attempted
suicide. The patient was sexually abused as a child by another uncle. She had delayed
speech as a child but was a bright student who did well in school and, in addition to
attending college full-time, worked at a health facility transporting patients. She had
never been married and had no children. The emergency department physician re
ferred her to the inpatient psychiatry unit for admission based on her untreated mental
illness and high risk of suicide.
On admission to the psychiatric unit, she reported that her “whole body hurt” and
that she had not slept in 3 days. She was initially placed on direct observation. Daily
nursing assessments indicated that the patient reported feelings of hopelessness
throughout the hospital stay, but she denied further suicidal thoughts to the nursing
staff on a daily basis. The treating psychiatrist did not document his own suicide risk as
sessment or his review of the patient’s family history of suicide, prior attempts, or other
standard risk factors. He also did not document a request for her outpatient records,
which were never obtained.
Two days after admission the psychiatrist discontinued direct observation, and the
patient was moved to a private room after she signed a “no-suicide” contract. The private
rooms in this hospital had a wall-mounted telephone with a cord. The psychiatrist doc
umented that both the patient and her family rejected the use of psychiatric medications
for treatment of her depression. Three days after admission the patient was described as
“very upset today” in nursing notes, and on day 4 she was described as “not ready for
the outside world.” On hospital days 3, 4, and 5, the psychiatrist documented “no sui
cidal ideation, no homicidal ideation, no paranoid ideation, contracting for safety.”
On hospital day 5, she was found in her room 15 minutes after receiving a phone call
from a friend. She was unconscious and hanging from the receiver hook, with the wall
mounted telephone cord tied around her neck. She was transferred to the medical ser
vice and died 15 days later of complications from hypoxic brain injury.
Discussion
In this case, the psychiatrist failed to conduct systematic suicide risk assessments both
at the time of admission and at the time the patient’s level of observation was decreased.
He therefore failed to identify numerous significant suicide risk factors: 1) untreated
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mental illness, 2) suicidal ideation with a specific and potentially lethal plan prior to ad
mission, 3) a prior suicide attempt requiring psychiatric hospitalization, 4) a significant
family history of suicide (mother) and suicide attempts (uncle), 5) complicating medical
illnesses, 6) expressed continued hopelessness during hospitalization, and 7) a child
hood abuse history. The psychiatrist did not document that he ever inquired about sui
cidal thinking other than his brief “no suicidal ideation” and “contracting for safety”
notes. The reliance on a “no-suicide” contract rather than a formal suicide risk assess
ment may have led to a false sense of security on the part of the psychiatrist.
Although the treatment team viewed the patient’s family as supportive, they did
not document any family discussion about the recommended standard of treatment
for depression, including antidepressant medication. Because outpatient records were
not obtained, the psychiatrist was not aware of the patient’s positive response to prior
antidepressant pharmacotherapy and did not relate to the patient or her family that
this would predict a favorable response to antidepressant medication in the future.
The record also did not reflect if she had been offered ECT or alternative treatments.
Finally, the presence of a wall-mounted telephone in a private room on an inpatient
psychiatric unit is concerning. A patient with suicidal ideation might foreseeably use
such a telephone and cord as both ligature point and ligature. Therefore, the hospital
as well as the psychiatrist may very well have some degree of liability.
Conclusion
Inpatient hospitalization, from its initial development to the present day, continues to
serve a vitally important role in suicide prevention. However, in the current climate
of medical economics, the sole focus of psychiatric inpatient treatment has become
safety and crisis stabilization. Therefore, with potentially suicidal patients, the goals
of inpatient treatment are to ensure safety through observation, to initiate appropriate
treatment strategies to address the underlying mental illness, and to provide a sup
portive inpatient environment where coping skills can be strengthened and devel
oped and where hope for the future can be instilled. Finally, inpatient treatment
affords time to develop a comprehensive safety plan prior to discharge through the
mobilization of outpatient supports and the development of contingency plans
should suicidal thoughts recur in the future.
Key Points
•
A current shortage in the number of inpatient psychiatric beds in the United
States has led to many persons with mental illness being diverted to emer
gency departments and jails or prisons.
•
The decision to hospitalize a suicidal patient involves an evaluation of the de
gree of suicide risk balanced with a consideration of the negative effects of
hospitalization and an evaluation of the patient’s ability to provide self-care,
manage a crisis, and seek appropriate help.
•
Inpatient suicide risk factors may differ from recognized evidence-based out
patient suicide risk factors.
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•
Inpatient suicide is one of the leading sentinel events reported to The Joint
Commission. Most inpatient suicides occur via hanging in private areas (bed
room or bathroom) using a door or door handle and a ligature made from
sheets, bedding, or clothes.
•
Potentially suicidal patients should be placed on an appropriate observation
level immediately after admission and a suicide risk assessment should be
completed.
•
Prior to discharge, a safety plan should be developed that focuses on means
restriction, using outpatient supports, and developing a contingency plan.
•
Periodic environmental risk assessments of inpatient units should be conduct
ed to identify potential hazards that could be used in a suicide attempt, and
policies should be developed outlining appropriate and coordinated respons
es to medical emergencies such as suicide attempts.
References
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