Friday, October 13, 2006

Let's Talk About Suicide

[posted by dinah]

The post I wrote on Suicidal Students got a number of comments, some of them rather distressed and distressing, and while stirring things up is kind of the point of our Shrink Rap blog, I realized I created some unintended fallout: there is the impression here that what one says to a psychiatrist becomes public information that can be used against you. While we are a blog by and for psychiatrists, I don't want our patient, or would-be patient, readers to be spooked out of seeking help.

First, let me say that I believe strongly that students should be able to seek help for their problems without fear of consequences. Mostly. If a student goes to a psychiatrist and threatens to kill others, confides that they have been sexually abusing children, intends to murder the president, or is concocting a terrorist plot, the psychiatrist is obligated to report or warn others. So no, this isn't confidential, though hopefully the psychiatrist is able to weed out plan and intent from simple thoughts or fantasies and the student/patient gets helped before someone is hurt and the student's life is ruined.

In terms of suicide, oh gosh. A psychiatrist is obligated to do something about suicidal intent, be it hospitalizing the imminently suicidal patient, or intervening in a way to prevent the occurrence of the act--for example asking a family member to sit watch over the patient. Why do I differentiate between intent and ideation? Simply put, Major Depression is a common illness, and thoughts along the spectrum of WantingItToEnd-- starting with feeling hopeless and progressing through a range of passive death wishes to suicidal planning-- are Symptoms of the illness. I'd say many people have these feelings, but actually I believe that most people with Major Depression have hopelessness &/or death wishes with varying intensity at some point during their illness. I was surprised to read the comment of the doctor who had never had a patient admit to suicidal feelings. The majority of patients I see have at some time thought about hurting themselves; few have acted on them. Viewing it as a symptom, and a common symptom at that, it takes more than the confession of a Thought to get me nervous-- I have to have the sense that something has changed, that this is acute, that there is some imminent risk, before I start thinking about violating someone's confidentiality. This is all much easier with an ongoing patient whom I know, and I think clinicians are much more likely to err on the side of being too careful when they don't know a patient well and aren't sure how safe it is to let someone go home--the stakes here can be very high for someone's "best guess."

Oh, and yes, I worked briefly (during my residency) at a major university student mental health center where I saw suicidal patients and it never occurred to me to report anyone's thoughts to the administration. Simply put, suicidal thoughts and behaviors are so common in psychiatry, both as symptoms of Major Depression and in many other psychiatric disorders, that universities and student mental health centers can't possibly be tossing out every student who reports such ideas.

Universities have been successfully sued when students have committed suicide. This has led them to act defensively; they don't want the responsibility for suicidal students and some don't feel they can provide a careful enough level of supervision, especially in the dorms. Plenty of schools, however, have a protocol for managing students following hospitalization and yes, psychiatrists sometimes clear students for return to the dorms and to classes, even if The Last Psychiatrist doesn't believe it.

The two stories I linked to (that of the Hunter student thrown out of the dorm for a suicide attempt, and of the GWU student barred from the campus for suicidal thoughts) are provocative stories, I blogged about them because they caught my attention and got me riled up. Hunter College has re-evaluated their policy. In the GWU case, it's still in litigation and the university has not made any statements; the Washington Post article presented only the student's side, so I do believe there may be more to this story. Some of our commenters have also posted distressing student mental health stories; my hope is that these are the exceptions, otherwise I imagine that such clinics would be boycotted by all.

Am I sure it's safe to tell a Student Mental Health Center therapist about suicidal ideation without fear of dismissal? It seems reasonable to me that any new patient might ask who has access to his records (no, therapy notes shouldn't go to the dermatologist) and how sensitive information is handled. Anyone contemplating suicide should get help-- even if your school has archaic policies, it's better to have a semester off to heal than it is to end up dead.

I wish we lived in a world where it was all about doing the right thing and not the fear of being sued.