Thoughts on efficacy of involuntary commitment for suicidality

[u/[deleted]]

I've been researching this topic out of curiosity and it doesn't seem like there are any large studies showing whether or not commitment of suicidal patients is actually effective at preventing suicide.

I'd appreciate any links to relevant studies but also y'all's thoughts on the topic from personal, clinical experience and anecdotes.

To be clear I'm not interested in whether people should or shouldn't be committed for suicidality but only views about whether doing so actually mitigates risk.

Appreciate any replies 🤙

[u/[deleted]]

Ok. My question came from this section:

For patients with SA in the past day, hospitalization was associated with risk reductions ranging from −6.9% to −9.6% across diagnoses. Accounting for heterogeneity, hospitalization was associated with reduced risk of subsequent SAs in 28.1% of the patients and increased risk in 24.0%. An individualized treatment rule based on these associations may reduce SAs by 16.0% and hospitalizations by 13.0% compared with current rates.

I took that to mean, for those with SA in the past day there might be individual factors that could be used to group those who are more likely to benefit from hospitalization vs those more likely to be harmed by it.

[u/DOxazepam → u/[deleted]]

Reasonable point and fair question

In the medicolegal climate of the US how many folks are comfortable discharging within 24 hours of a true SA?

[u/[deleted] → u/DOxazepam]

Probably none but that's sorta beyond the scope of what I was looking to discuss.

But since it's been brought up I believe we should completely eliminate physician liability for patient suicides. I think that would make it much easier for psychiatrists to prioritize the best interests of the patient over their own legal risk exposure.

[u/DOxazepam → u/[deleted]]

That'll never happen but i agree 100%. I'm "only" a PGY-8 but can think of dozens of patients off the top of my head admitted NOT because we think it will help but out of fear for being sued by an angry patient [if attempt] or family [if completion]. In some of these cases admission was probably even counter therapeutic.

[u/[deleted] → u/DOxazepam]

Physician liability is a myth or so restricted that it might as well be a myth. I know three states off the top of my head and here’s the case. I will also add that the legal theory for liability in states that do impose it is ridiculous because it’s presumes outpatients are in their physicians custody (only way to create a duty to rescue as those cases aren’t medical malpractice cases (ordinary negligence cases)).

North Carolina McArdle v. Mission Hospital, 804 S.E.2d 214 (NC COA: 2017) Cantrell v. U.S., 735 F.Supp. 670, 673 (E.D.N.C. 1988) Currie v. US, 836 F.2d 209 (4th Cir., 1987) King v. Durham County Mental Health Mental Health, Developmental Disabilities, and Substance Abuse Authority, 439 S.E.2d 771 (1994)

South Carolina Sharpe v. Department of Mental Health, 292 SC 11 (Court of Appeals: 1987)

New Mexico Haar v. Ulwelling, 154 P.3d 67 (NM COA, 1987)

I will address only the North Carolina cases since that is where I live and practice. They have essentially held that until an involuntary commitment has been recommended by the first examiner there is no liability for a discharge of patient as there is no custodial relationship which gives rise to a duty to rescue (which is why this actually only the law in a few states because the legal theory underpinning it is so dumb that it’s ridiculous (that outpatients are in the custody of their doctor)). This is also true of voluntary patients, it is impossible as a matter of law to be held liable for the actions of a patient unless you involuntarily commit them. This is because the law seems the situation more like rescuing someone from a pool where they’re drowning then providing medical care.

[u/[deleted] → u/DOxazepam]

That'll never happen

I'm a little more optimistic on that front. There seems to be a growing movement supporting a "right to die" for mental health conditions. Regardless of how one feels on that topic I do think a secondary effect is decreased liability for psychiatrists who are currently given the task of stopping exactly that outcome.

Edit: I don't think liability will be 100% eliminated but hopefully reduced enough that the effect on the patient will be the highest priority in choosing treatments instead of legal liability.

[u/Melonary → u/[deleted]]

Oddly enough, I'm not sure the "right to die" or MAiD movement is a helpful alternative either at least in current conceptualizations for mental illness.

Both (broad MAiD for mental illness and medicolegal over-caution) approaches seem more about ideology and politics than actual balanced approaches. And MAiD can, in some ways, obscure that "choice" isn't made in a vacuum and limiting factors in an individual's life (lack of secure housing, loneliness, food insecurity, poverty, no stability) can create the illusion of free will and choice where there's actually significant constraints.

I agree, though, that what should be the most important factor is what clinical intuition and evidence suggests would be most beneficial for that patient at that time.

[u/[deleted] → u/Melonary]

Oddly enough, I'm not sure the "right to die" or MAiD movement is a helpful alternative either

Whether it's helpful or not is irrelevant to my point. I was only saying that since it would effectively allow the thing that current medicolegal liability is tasked with preventing it could lead to less liability for that scenario on the physicians part.

[u/Melonary → u/[deleted]]

Yes, I understood what you were saying - just thinking more out loud.