{"id":1266,"date":"2017-07-24T12:18:35","date_gmt":"2017-07-24T19:18:35","guid":{"rendered":"http:\/\/blog.stevenreidbordmd.com\/?p=1266"},"modified":"2017-07-24T12:18:35","modified_gmt":"2017-07-24T19:18:35","slug":"the-high-risk-psychiatric-patient","status":"publish","type":"post","link":"http:\/\/blog.stevenreidbordmd.com\/?p=1266","title":{"rendered":"The “high risk” psychiatric patient"},"content":{"rendered":"

\"\"<\/a>A woman recently requested a medication evaluation at the suggestion of her psychotherapist. \u00a0The caller told me her diagnosis was borderline personality disorder. She hoped medication might ease her anxiety. \u00a0She also admitted that two other psychiatrists refused to see her because she was too “high risk.” \u00a0I asked if she was suicidal. \u00a0Yes, thoughts crossed her mind. However, she never acted on them, and was not suicidal currently. \u00a0I was curious whether my colleagues recoiled at the caller’s diagnosis, her suicide risk, her wish for anxiety-relieving medication, or something else.<\/p>\n

By definition, “high risk” medical and surgical patients face an increased chance of poor outcome. \u00a0According to a British study, high-risk surgical<\/a> patients are a 12% minority who suffer 80% of all perioperative deaths. \u00a0High-risk pregnancies<\/a>\u00a0threaten the health or life of the mother or fetus; they constitute six to eight\u00a0percent<\/a> of all pregnancies. \u00a0Various charts and algorithms identify the high-risk cardiac<\/a> patient.<\/p>\n

Historically, physicians and surgeons accepted high-risk cases. \u00a0As one would expect, these patients had poorer outcomes and higher mortality. \u00a0Doctors did the best they could, humbled by their limitations and occasional failures, spurred to treat the next such patient more successfully. \u00a0However, recent social changes conspire to blunt this acceptance. \u00a0Fear of lawsuits, stemming both from an active medical malpractice bar and patients’ high expectations, means that doctors, too, are at high risk. \u00a0Increased reliance on outcome data and online reviews by patients may likewise lead some clinicians to cherry-pick cases that won’t mar their results. \u00a0Patients at high medical or surgical risk now have a harder time finding a doctor who will see them.<\/p>\n

No single hazard defines the high-risk psychiatric patient. \u00a0\u00a0There is a robust literature on young people at high (and “ultra-high<\/a>“) risk for developing psychosis<\/a>. \u00a0 There are well established risk factors for addiction<\/a>. \u00a0Patients have also been deemed at high risk psychiatrically when they leave<\/a> institutional care without permission; when they are young unemployed women following discharge from medical ICUs;<\/a>\u00a0and when they are\u00a0youths<\/a> with “serious emotional disturbance” who receive public services.\u00a0 Having a psychiatric problem at all<\/a> may be one factor among many that signals high risk in non-psychiatric medical settings.<\/p>\n

However, “high risk” in psychiatry most often refers to suicide<\/a> risk<\/a>. \u00a0A large literature relates suicide to demographics, physical health, psychiatric diagnosis, behaviors such as substance use, and so on. \u00a0Unfortunately, a diagnosis of borderline personality disorder is associated with an 8-10% lifetime suicide rate. \u00a0This is significantly higher than the general population, and on par with schizophrenia and major mood disorders. \u00a0Did two psychiatrists refuse to see my caller due to her suicide risk? \u00a0If so, do they also refuse those with schizophrenia, bipolar disorder, and major depression?<\/p>\n

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. \u00a0Psychiatrists are rarely sued, and few of us even have such statistics or ratings. \u00a0However, a 1986 study<\/a> by Hellman et al found (unsurprisingly) that patients’ suicidal threats were stressful for their psychotherapists. \u00a0Perhaps the real question is: What kinds of stress should be expected in routine psychiatric practice, and what kinds are legitimately avoided?<\/p>\n

We must acknowledge that every decision about\u00a0joining insurance panels, setting fees, or limiting one’s practice in any way is a form of cherry-picking, broadly construed. \u00a0The stresses of running a business and providing for one’s family are not unique to psychiatry. \u00a0Everyone wrestles with balancing self-interest and other-interest. \u00a0Yet these trade-offs are particularly glaring in heath care, including mental health care.<\/p>\n

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. \u00a0This doesn’t resolve questions of ethics and professionalism though. \u00a0 I often turn down medication-only cases (although not the above caller) owing to my interest in psychotherapy. \u00a0I’ve also written<\/a> about avoiding private insurance contracts, and my mixed feelings about accepting Medicare. \u00a0Of 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.<\/p>\n

I think avoiding suicidal patients is different. \u00a0To 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. \u00a0Suicidal feelings are exactly why some patients seek our help. \u00a0Yes, they are at high risk for a bad outcome. \u00a0And I can vouch for the stress: in addition to being the target of numerous suicide threats and gestures,\u00a0I 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. \u00a0It’s no fun. \u00a0But in the end, the “high risk” belongs to the patient, not me. \u00a0I do the best I can.<\/p>\n

Come to think of it, a closer analogy is my declining to conduct ADHD evaluations in order to avoid being a gatekeeper<\/a> for stimulant-seekers. \u00a0I suppose here too the risk is theirs, despite my discomfort with gatekeeping and lie detection. \u00a0This confusion \u2014 whose risk is it? \u2014 is tricky. \u00a0Death, disability, hospitalization, and addiction are risks to the patient. \u00a0Lawsuits, adverse outcome data, regret at taking the case, and the stress of uncertainty<\/a> and self-criticism are risks to us. \u00a0Some of the latter risks have always been par for the course, some are newer. \u00a0Some are self-imposed. \u00a0When we speak of the high-risk patient, let’s be honest about whose risk it is.<\/p>\n

Graphic courtesy of\u00a0FreeGreatPicture.com<\/a><\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

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 […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[67,51],"tags":[36],"class_list":["post-1266","post","type-post","status-publish","format-standard","hentry","category-medical-practice","category-psychiatry-in-general","tag-risk","odd"],"aioseo_notices":[],"_links":{"self":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/1266","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1266"}],"version-history":[{"count":7,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/1266\/revisions"}],"predecessor-version":[{"id":1274,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/1266\/revisions\/1274"}],"wp:attachment":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1266"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=1266"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=1266"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}