The high-risk psychiatric patient

A woman recently requested a medication evaluation at the suggestion of her psychotherapist.  The caller told me her diagnosis was borderline personality disorder. She hoped medication might ease her anxiety.  She also admitted that two other psychiatrists refused to see her because she was too “high risk.”  I asked if she was suicidal.  Yes, thoughts crossed her mind. However, she never acted on them, and was not suicidal currently.  I was curious whether my colleagues recoiled at the caller’s diagnosis, her suicide risk, her wish for anxiety-relieving medication, or something else.

By definition, “high risk” medical and surgical patients face an increased chance of poor outcome.  According to a British study, high-risk surgical patients are a 12% minority who suffer 80% of all perioperative deaths.  High-risk pregnancies threaten the health or life of the mother or fetus; they constitute six to eight percent of all pregnancies.  Various charts and algorithms identify the high-risk cardiac patient.

Historically, physicians and surgeons accepted high-risk cases.  As one would expect, these patients had poorer outcomes and higher mortality.  Doctors did the best they could, humbled by their limitations and occasional failures, spurred to treat the next such patient more successfully.  However, recent social changes conspire to blunt this acceptance.  Fear of lawsuits, stemming both from an active medical malpractice bar and patients’ high expectations, means that doctors, too, are at high risk.  Increased reliance on outcome data and online reviews by patients may likewise lead some clinicians to cherry-pick cases that won’t mar their results.  Patients at high medical or surgical risk now have a harder time finding a doctor who will see them.

No single hazard defines the high-risk psychiatric patient.   There is a robust literature on young people at high (and “ultra-high“) risk for developing psychosis.   There are well established risk factors for addiction.  Patients have also been deemed at high risk psychiatrically when they leave institutional care without permission; when they are young unemployed women following discharge from medical ICUs; and when they are youths with “serious emotional disturbance” who receive public services.  Having a psychiatric problem at all may be one factor among many that signals high risk in non-psychiatric medical settings.

However, “high risk” in psychiatry most often refers to suicide risk.  A large literature relates suicide to demographics, physical health, psychiatric diagnosis, behaviors such as substance use, and so on.  Unfortunately, a diagnosis of borderline personality disorder is associated with an 8-10% lifetime suicide rate.  This is significantly higher than the general population, and on par with schizophrenia and major mood disorders.  Did two psychiatrists refuse to see my caller due to her suicide risk?  If so, do they also refuse those with schizophrenia, bipolar disorder, and major depression?

To the best of my knowledge, psychiatrists do not shun high-risk cases in order to avoid lawsuits or to improve their outcome statistics or online ratings.  Psychiatrists are rarely sued, and few of us even have such statistics or ratings.  However, a 1986 study by Hellman et al found (unsurprisingly) that patients’ suicidal threats were stressful for their psychotherapists.  Perhaps the real question is: What kinds of stress should be expected in routine psychiatric practice, and what kinds are legitimately avoided?

We must acknowledge that every decision about joining insurance panels, setting fees, or limiting one’s practice in any way is a form of cherry-picking, broadly construed.  The stresses of running a business and providing for one’s family are not unique to psychiatry.  Everyone wrestles with balancing self-interest and other-interest.  Yet these trade-offs are particularly glaring in heath care, including mental health care.

The law allows doctors to refuse service to anyone, as long as that refusal isn’t based on membership in a legally protected class, e.g., race or religion.  This doesn’t resolve questions of ethics and professionalism though.   I often turn down medication-only cases (although not the above caller) owing to my interest in psychotherapy.  I’ve also written about avoiding private insurance contracts, and my mixed feelings about accepting Medicare.  Of course, patient misbehavior may also lead a psychiatrist to turn down or refer out a case: inability to keep or pay for appointments, calling incessantly, making too many demands, etc.

I think avoiding suicidal patients is different.  To me, a psychiatrist who avoids suicidal patients is like a surgeon who can’t stand the sight of blood, or an obstetrician who doesn’t like to think about where babies come from.  Suicidal feelings are exactly why some patients seek our help.  Yes, they are at high risk for a bad outcome.  And I can vouch for the stress: in addition to being the target of numerous suicide threats and gestures, I have had one confirmed suicide in my practice, another that was equivocal (it may have been an accident), and likely others I don’t know about.  It’s no fun.  But in the end, the “high risk” belongs to the patient, not me.  I do the best I can.

Come to think of it, a closer analogy is my declining to conduct ADHD evaluations in order to avoid being a gatekeeper for stimulant-seekers.  I suppose here too the risk is theirs, despite my discomfort with gatekeeping and lie detection.  This confusion — whose risk is it? — is tricky.  Death, disability, hospitalization, and addiction are risks to the patient.  Lawsuits, adverse outcome data, regret at taking the case, and the stress of uncertainty and self-criticism are risks to us.  Some of the latter risks have always been par for the course, some are newer.  Some are self-imposed.  When we speak of the high-risk patient, let’s be honest about whose risk it is.

Graphic courtesy of

7 comments to The “high risk” psychiatric patient

  • Jenna

    What you don’t know is how many psychiatrists turn out high risk due to suicide patients. As an ivy league educated PhD employed, with a family, etc etc etc…..and a history of severe depression including a couple of suicide attempts (though none for more than a decade), ECT, DBS, etc when my psychiatrist of 8 years who did meds and therapy decided she could no longer treat individuals with a history of suicidality, I contacted more than 60 psychiatrists in NYC before I could find one who was willing to see me for medication — and she is more or less incompetent. So while perhaps you are the bigger person and don’t do such a thing, those 60 private practice psychiatrists made it clear that they were not taking patients with a history of suicidality.

    So whose risk is it, really? Well, if no one is willing to prescribe my anti-depressants, it’s mine. But it’s those psychiatrists’ faults. And if I can’t find anyone in NYC — outside of such a a major metropolitan area, I can only imagine how difficult it must be. I don’t know whose risk it is, but I do know who loses out. And that, that is on all of your heads. What exactly are you in this field for — truly, just to murmur to the worried well?

  • Jenna

    Quite curious if even you could come up with a list of 5 psychiatrists willing to take new patients with a history of well controlled suicidality, those who had not had an attempt in more than a decade, who were compliant with medication and therapy. Bet you couldn’t!

    • Hi Jenna,

      I didn’t reply earlier because you made my point better than I did. I’m amazed and saddened that 60 NYC psychiatrists all refused to see you with a distant history of suicidality. I’m also astonished that your psychiatrist of eight years terminated with you because she could “no longer” treat formerly suicidal people. I have to admit, I wonder if something aside from your history was at play — it’s hard for me to picture dropping a stable patient whose history, after all, hasn’t changed.

      New patients calling me for an appointment rarely even offer such historical details before I see them. I’ll know they seek treatment for depression, have a long and sometimes severe history, and are not currently (acutely) suicidal… and they’re in. Only in the first visit do I learn about past suicide attempts and treatments.

      I’d like to think that most of the psychiatrists I know would work with a patient such as yourself. I know I would — again, assuming there are no other “gotchas” you’re not mentioning. But I can’t provide a list, because I don’t honestly know for sure. If the situation is really as plain as you say, the problem is far worse than I imagined. Thanks for writing.

  • Jenna

    Nope, no other gotchas. I’m smart, funny, compliant and flexible. I don’t screw around with suicide or make suicidal threats and I’m honest when things get bad. I have a solid, good therapist who I see regularly and have an excellent relationship with. We’re talking about looking just for medication management. And prior to this experience I wouldn’t have dreamed of giving such details on the phone – major depression, recurrent would have been the extent – but I now offer those details on the phone because I’m not prepared to pay $500 for an intake only to be told that Dr X is so sorry, but he doesn’t work with patients with a history like mine. I’m a quick learner, you see, and one or two waste of time intakes like those taught me not to waste my time or money. The part that’s most laughable is that they all refer to so and so and so and so and even their own referrals say the same thing. It’s sad, that the people who have the experience that is needed – as they gain more and more experience – they charge more and see easier patients. It’s something that an NYC psychiatrist once told me and I laughed at – but it’s sadly incredibly true. I’ve had friends in the field post to their professional listserves and get the same results there. And forget about anyone who takes insurance. It’s a really serious problem, even here in NYC, the Mecca of Psychiatry. I shudder to think what it must be like elsewhere.

  • Esskay

    The risk averse psychiatrists are not to be blamed, blame the lawyers who cash in on. Bad outcome, despite the doctors following or exceeding standard of care.
    In most cases if suicide occurs, the doctor is blamed since the patient is no longer there to defend their doctor. Greedy lawyers with no other intention but to take their 40% share of the bounty, are the winners in most cases. They rely on wearing out the doctor being sued since most settle due to the uncertainty of facing a lay jury, and spending countless hours with depositions and court appearances.
    My recommendation in an ideal world would be patients sign an arbitration clause like many other industries do , and you’ll see how many psychiatrists will go back to helping patients with so called “ High Risk “ histories. From what I am told the lawyers have made sure no such contracts are valid.
    Most of us trained taking care of high risk patients, but them as residents we were protected by our esteemed institutions and our attending supervisors.
    I share many of my colleagues guilt in turning down patients, and fo me it isn’t the hassle factor or demands, it’s the unfairness of our legal system that allows these ambulance chasers with no contributions to society at large, on cashing in on someone’s bad outcome.

    • Hi Esskay,

      While I did mention “an active medical malpractice bar,” I apparently was mistaken in assuming “psychiatrists do not shun high-risk cases in order to avoid lawsuits.” Fear of lawsuit may best explain Jenna’s inability to find a willing psychiatrist in NYC, of all places.

      Psychiatry ranks dead last in malpractice claims among medical specialties. Literally every other physician accepts more legal risk than we do. I’m sorry if this sounds insensitive, but it seems we psychiatrists enjoy the luxury and privilege of avoiding this comparatively modest legal risk, whereas our colleagues in neurosurgery, obstetrics, and other fields routinely accept much higher legal risk as the cost of doing business.

      While there is no obligation to accept any such risk, risk-free clinical practice is, if not a contradiction in terms, at least a rare bird. Thanks for writing.

  • Michelle

    Yes, Esskay, the risk-averse psychiatrists do deserve some of the blame, AS WELL AS lawyers that might cash in on it. It is unethical to refuse high-risk patients. High-risk patients are clearly the ones who require specialty mental health care most of all! Do you know what happens when psychiatrists refuse these patients? They either get no medical care or they get whatever their general practitioner is able to offer them. In the paltry 15 or 20 minutes that is alotted to them….while also managing their high blood pressure or diabetes. While receiving pay that is less. So we do the best we can in the time we have, and sometimes it’s enough, but many times it might not be. And God forbid you miss another serious medical concern, because the patient wants to focus on their anxiety.

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