Suicide Risk Patient Is Prematurely Discharged From Psychiatric Hospital

This case involves a 23-year old male victim of human trafficking with a history of psychosis and multiple suicide attempts. He presented to the emergency room late one evening after overdosing on antidepressants. The patient was admitted to an internal medicine floor with psychiatry as a consulting service and was deemed a high suicide risk patient. After he was stabilized, the patient was transferred to a psychiatric hospital for additional treatment. The attending physician had intended to keep the patient at the hospital for a minimum of 4 weeks. After one week of treatment, however, the patient was discharged after allegedly showing remarkable improvement. The patient was discharged to his father’s home in spite of their fraught relationship. The night the patient arrived home, he hung himself in his bathroom.

Question(s) For Expert Witness

1. What is your experience managing patients with intentional drug overdoses in the inpatient setting?

2. Can you speak to why a patient like this would be admitted to medicine rather than psychiatry service?

3. Briefly, what factors weigh into the decision to have a suicidal patient admitted to a psychiatric facility?

4. Briefly, when deciding where to discharge a post-suicide-attempt patient, how do the home dynamics factor within the decision?

Expert Witness Response E-057103

I am a board-certified forensic psychiatrist. I work in a psychiatric prison facility on the high-security pod where I treat death row, ad seg, and other offenders with impulse disorders. I have additional training in treating psychiatric patients that present to the emergency room. I serve as an assistant professor of psychiatry where I teach trainees forensic psychiatry. In my free time, I conduct pro-bono human trafficking evaluations for a human rights advocacy organization. In the past, I have worked in a freestanding county inpatient psychiatric hospital where I supervised psychiatry residents.

I encounter the issue in this case very frequently. Many of my patients are on crush and float medications due to the risk of overdose. My pod takes in the offenders with the high-risk of self-injury and suicide and covers about 80% of state prisons. Initially, the patient may have been admitted to medicine for medical issues and could have been seen by a psychiatric consultant. In this case, the consultant should have recommended psychiatric hospitalization. If the patient refused, the psychiatrist or primary provider should have filed for involuntary commitment for inpatient treatment. If there was a good reason not to commit the patient, this should have been documented.

One would look for suicide risk factors both static and dynamic. Another issue is treatability. There may also be other issues outside of suicide risk (i.e. mood instability, inability to take care of oneself, thoughts of harming others, etc). One should look for the patient's consent. She could be admitted on a voluntary basis or involuntary. The family dynamics, relationships, and the situation at home are also very important factors. For example, if you discharge someone back home with an abusive partner, this could exacerbate the issue. Typically the social worker on the treatment team would contact the family. In my practice, I would find out if there are any contributing factors at the offender's home unit before discharging the patient back to his or her unit.