So it had been eight years since he'd seen anyone for his mental health issues. And then today, he decided to call up the clinic and ask for an appointment.
Oh sorry sir, but the next available appointment isn't for 2 weeks. Will that be okay?
He paused, counting the number of days til he could be seen in his head. Sure, he replied hesitantly. Go ahead and schedule me.
And what shall I say this is for? asked the receptionist.
Oh, well, I made a pretty major mistake at work a couple of weeks ago, and I've been feeling really kinda anxious and guilty about it. And I think maybe my depression is getting a little out of hand again. He was being forthcoming and honest about his feelings. So the receptionist wished him a good day and hung up.
He walked into the ER three hours later. Why was he here? He couldn't really say why. So the ER triage nurses flagged him as a psych patient, and the psych team went to go see him. Was he depressed? No, not really, he said. He had made a mistake at work a couple of weeks ago, and his boss yelled at him, but no one was hurt and everything turned out okay. Since then he had had some suicidal thoughts. But they were fleeting - nothing serious, he claimed. He had thought about jumping out his window, but he couldn't do it. He knew it was wrong, he said.
And now sir? Do you have any thoughts of hurting yourself now?
No, he replied. Not at all.
The patient had called up his sister and brother (who lived just a couple of towns over), and they were waiting for him in the waiting room currently. His dad was awfully sick, so he felt depressed about his dad's worsening health. But that was it.
Any firearms in the house?
No, sir.
The psych resident on call wasn't sure what to do.
He felt uneasy just letting the patient go, but the patient wasn't having any suicidal thoughts now. And his family was here and supportive. And the holiday weekend was coming up. Did he really want to hospitalize this patient, when it seemed like all he really needed was an outpatient psychiatrist? Really, there were far more patients he'd seen who needed to be hospitalized and weren't, so maybe this wasn't the best use of resources.
Sir, I think I'm going to let you go with your family on the condition that you see someone in clinic soon --
Oh, I have an appointment for next Wednesday! the patient interjected.
-- oh that's great! Okay, and I want you to realize that there are a lot of people out there who care about you, so if you ever feel like you might be thinking of hurting yourself, I want you to call 911 right away. Or come into the ER again, okay?
The patient promised.
Thanksgiving came and went.
And then Wednesday came and went.
The patient didn't show up to his appointment. The attending's secretary left a message on his landline - Hi sir! You were scheduled to be seen today in the Mental Health Clinic - please call back so that you can reschedule!
The attending got a call back later that afternoon. It was the patient's sister.
Tearfully, she informed the psychiatrist that her brother had killed himself two days ago - jumped out his window to his death 57 floors below. No one had seen it coming or thought he would do it. Her other brother had had lunch with him the day before he jumped, and he had seemed okay. Fine, even. And before he had jumped, he had called 911. But by the time help had come - no more than 4 minutes later - he had deadbolted the door, refusing to let anyone in to help him. They set about trying to tear down the door, trying to find someone with a master set of keys. But thirty seconds before they were in, he had jumped.
---
Our lecturer finished her story. And we, the students, sat there in shock, realizing that many of us would have done what the resident did. He didn't fill any criteria for major depressive disorder, he wasn't endorsing any suicidal ideation, and he had a great supportive family. We would have sent him home, too. Yes, there was that vague I don't know why I came into the ER bit and the whole prior psych history, but he seemed stable. He had seemed like he knew that he needed some help and had set the ball rolling with the psych appointments and calls to his family. True, we weren't there, so we couldn't pick up on minor body cues and such, but it seemed like the resident had made the right call. After all, who wants to be stuck in the hospital during the holidays?
Our lecturer was telling us the key clinical pearls from the story - that safety trumps any DSM-IV diagnostic criteria. That if you have a weird nagging feeling about something, you're probably right.
In every field, there's a fatal end point. Heart attacks for cardio, strokes for neuro. In psych, it's suicide. We might not have lipid panels or MRIs to go on, but we have our gut and our intuition. And that's what we have to trust.
