Contingent Suicidality-a protective factor?

[whopper]

I posted about an article that researched this a few months ago, but I couldn't find it.

I'm studying for my boards, and turns out a copy of the article was stuck in one of my old books I was referencing.

Found it online after finding the physical article.
http://psychservices.psychiatryonline.org/cgi/content/full/53/1/92

And this one...but this one you got to pay money for it.
http://ps.psychiatryonline.org/cgi/reprint/47/8/871

Patients in the contingently suicidal group were more likely to have diagnoses of substance dependence and antisocial personality disorder, to be unmarried, to be homeless, and to have legal difficulties. Patients in the noncontingently suicidal group were more likley to have a diagnosis of major depression.

Overall, seven confirmed suicides and three highly suspected suicides were identified. All ten occurred in the noncontingently suicidal group. Among the 137 patients in the study, 20 died from any cause, including suicide, during the seven-year period. Of these, 18 were in the noncontingent group, whereas only two patients in the contingent group died, and their deaths were from causes other than suicide.

Something to think about next time you got someone in the ER saying with a smile on their face, "if you don't give me a place to stay tonight, I'll kill myself. If I happen to survive, I'll sue you. Now get me my sandwich bitch.

Of course despite the above data....

The findings reported here should be considered tentative, given the methodological limitations of the study. The sample is too small for definitive conclusions to be drawn.

Reminds me of the night I was on call at the ER, had a contingently suicidal person who stated she did not like the rescue mission shelter because it wasn't up to her standards and demanded to be admitted as an inpatient. I told her I wouldn't admit her, and she left the ER, took off all her clothes and lay flat on the street naked yelling "you got to give me a place to stay tonight!" The cops refused to arrest her and brought her back in saying she was mentally ill. I wrote a note saying she wasn't mentally ill & was malingering, and discharged her again. She then repeated the same thing, the cops brought her back to the ER saying she was mentally ill.

I guess a cop has more ability to diagnose someone as mentally ill vs a psychiatrist.

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[Pershing]

Only skimmed the first article. It would be interesting to see how the contingent vs. the noncontingent groups were managed. Was there a difference in the rate at which they were admitted to the psych service or the aggressiveness of the management? Some of the contingent cases may be blatantly obvious, but wouldn't the more ambiguous contingent cases perhaps benefit from an admission to sort things out if it couldn't be done satisfactorily in the ED?

 

[whopper]

but wouldn't the more ambiguous contingent cases perhaps benefit from an admission to sort things out if it couldn't be done satisfactorily in the ED?

I agree.

I mentioned this in the previous thread where I brought up this article.

IMHO, an ER/admitting psychiatrist should have a heavy amount of caution with any suicidal patient, even when continengtly suicidal, and even more caution with a patient that's never been seen by the hospital system.

My general way of handling this type of situation was if we never saw that patient before and the person was suicidal, admit them. Figure it out later. Social workers are going to have to get enough collateral information for malingering to be ruled out, and that can take days.

However if the patient has enough factors to reasonably justify malingering (homeless, history of pulling suicidal threats, not showing objective symptoms of mental illness, the classic "show up to the hospital when the welfare is spent" scenario), that's when more drastic measures need to be taken.

Where I did residency, I did not see much of an organized attempt. There was a lot of disagreement between the ER attendings/ER psychiatrists, inpatient psychiatrists, and there wasn't a consensus among them on how to tackle the problem. I've seen that happen at several other places as well.

I am glad this study is out because these 2 are the only ones I've seen so far where someone tried to gauge this phenomenon that several people do not want to touch with a 10 foot pole.

When working in an ER, in a poor urban area, this is a constantly recurring problem, but very few people have attempted to tackle this issue in an organized & evidenced based manner.