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Admitting Depressed Patients


jdog101

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Does anyone know if specific guidelines exist with regards to admittion patients that have depression or have had suicide attempts? For example, a young person overdoses but once they are medically stable no longer have suicidal ideations. Can you send them home with close follow up? Should everyone be admitted for monitoring for 24 hours? Thanks!

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This is probably super rudimentary but I've always just thought of the assessment as being a judgement on risk. A lot of people use the SADPERSONS mnemonic. From my experience its a mix of how big and huge the risk of suicide is in combination with how risk averse the attending is and in combination with how gridlocked the hospital is at that time

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We as a profession are terrible at predicting suicide.  It comes down to lots of static and dynamic risk factors - the presence of ongoing suicidal ideation is only one thing to consider, especially given how impulsive some people can be, and how quickly they can dysregulate.  The above poster is also right in that individual risk tolerance and bed situation also play a role.

 

That said, I think the only times I've EVER discharged somebody within 24 hours of an actual suicide attempt was if they had a chronic history of attempting and were documented not to benefit from hospitalization.

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We as a profession are terrible at predicting suicide.  It comes down to lots of static and dynamic risk factors - the presence of ongoing suicidal ideation is only one thing to consider, especially given how impulsive some people can be, and how quickly they can dysregulate.  The above poster is also right in that individual risk tolerance and bed situation also play a role.

 

That said, I think the only times I've EVER discharged somebody within 24 hours of an actual suicide attempt was if they had a chronic history of attempting and were documented not to benefit from hospitalization.

 

I've seen a fair number of quick-turnaround discharges in Peds Psych - classic example being a first attempt with virtually zero lethality to it, from a teenaged girl with significant parental or other interpersonal conflicts but otherwise living in a safe place. Admit them, let them sleep off the emotions, create a safety plan, set up community supports, discharge the next day often within 24 hrs. Often done to keep the kids from getting too comfortable on the floor (too supportive relative to their real life, which they need to learn to deal with). Actually really enjoyed these cases - they were heartbreaking in many instances, but it felt like the medical system actually rallying around a patient in short order.

 

But yeah, agree with the notion that suicide-prediction is not something we're good with... and the bed situation is something I've really had to wrap my head around. London's chronically short of beds and that means a lot of justifiable but less-than-reassuring discharges from the ER in order to keep space for those who absolutely need an admit  :(

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I've seen a fair number of quick-turnaround discharges in Peds Psych - classic example being a first attempt with virtually zero lethality to it, from a teenaged girl with significant parental or other interpersonal conflicts but otherwise living in a safe place. Admit them, let them sleep off the emotions, create a safety plan, set up community supports, discharge the next day often within 24 hrs. Often done to keep the kids from getting too comfortable on the floor (too supportive relative to their real life, which they need to learn to deal with). Actually really enjoyed these cases - they were heartbreaking in many instances, but it felt like the medical system actually rallying around a patient in short order.

 

But yeah, agree with the notion that suicide-prediction is not something we're good with... and the bed situation is something I've really had to wrap my head around. London's chronically short of beds and that means a lot of justifiable but less-than-reassuring discharges from the ER in order to keep space for those who absolutely need an admit  :(

 

Fair - that said, an attempt of virtually zero lethality - in those cases I wonder about intent and whether it was in fact a suicide attempt versus non-suicidal self harm or communicative function of behaviour.

 

If I'm convinced that there is intent to die, I'd have a very hard time discharging.

 

Children is also a little different because in most cases they have more social support, closer supervision, and somewhat better access to care.

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Fair - that said, an attempt of virtually zero lethality - in those cases I wonder about intent and whether it was in fact a suicide attempt versus non-suicidal self harm or communicative function of behaviour.

 

If I'm convinced that there is intent to die, I'd have a very hard time discharging.

 

Children is also a little different because in most cases they have more social support, closer supervision, and somewhat better access to care.

 

Fair point, though with adolescents, virtually zero lethality attempts can still signal an intent to die when they don't know what's lethal and what isn't.

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It is better to be safe.

 

On the other hand, it's also important to recognize that hospitalization, like any intervention, be it medication, therapy, or anything else, has not only benefits, but risks of harm, and unintended side effects.  This is something that can be really challenging to explain to patients and families when they request hospitalization but I do not feel that it is indicated.

 

Part of it is resource management, but a huge chunk is that hospitalization is not a zero harm intervention.  There are very real harms associated with hospitalizing people with mental illness - from re-traumatization to isolation from natural supports to stigma to short circuiting the person's own ability to cope and problem solve.

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