Suicide: Inadequate Treatment and Supervision/SSRI – Drug Prescription
This office has recently successfully completed the handling of a claim arising out of an unfortunate and most untimely death, as a result of suicide by an early middle-aged male leaving a wife and two young children.
There has been increasing scrutiny in recent years of healthcare provided by mental health professionals. Partly this is due to a growing willingness of people from all walks of life to discuss mental illness and its consequences. It is also the result, we believe, of the growth of managed care and the significant decrease of patients receiving mental health treatment in public facilities. Mental health professionals are increasingly and appropriately being held accountable for the failure to properly assess a patients’ risk for suicide and, concomitantly, for failure to take steps to prevent suicide.
Suicide is a well-recognized and known consequence of depression (Major Depressive Disorder), which is a specifically defined illness and disease, as set forth in the Diagnostic and Statistical Manual of mental health disorders, the bible of psychiatric diagnosis (DSM IV-R).
The standard of care presently requires a clinician to conduct a proper suicide assessment of each potentially suicidal patient. A clinician must consider all relevant factors and reach a reasonable conclusion, based upon those factors identifying the patient’s risk for suicide.
Although women are more likely to attempt suicide, the actual suicide completion rate is more than four times higher for men then it is for women, largely because men use more lethal methods for suicide. (Comprehensive Textbook of Suicidology, New York: Guilford Press, (2000) Page 151). Although suicide is relatively rare in the general population (a rate of 1 or 2 per 10,000 in the United States), it accounts for (in 1998 data) 30,903 suicidal deaths in the United States. That made it the ninth leading cause of death, ranking ahead of liver and kidney disease deaths and just behind pneumonia, diabetes and HIV deaths. In 1999 data, they rank suicide as the eighth leading cause of death, HIV deaths having been dropped to fifteenth. (ibid, p. 7).
It is significant to note that in nearly all major investigations conducted, it has been shown that 90-95% of people who successfully committed suicide had a diagnosable psychiatric illness. (Jamison, K. Redfield, Night Falls Fast: Understanding Suicide (New York: Alfred A. Knopf, (1999) Page 100).
The clinician must therefore reach a proper diagnosis of the patient’s condition to competently and accurately complete a suicide risk assessment. As noted above, the Diagnostic and Statistical Manual (DSM IV-R), considered the bible of psychiatric diagnosis, fairly well defines the various mental diseases and illnesses. Major Depressive Disorder, Bipolar Disorder, Schizophrenia, and substance abuse/dependency are four diagnoses which place patients at the highest risk for suicide. “In a clinical setting, assessment of suicide risk must precede any attempt to treat psychiatric illness or prevent suicide.”
Thus, prevention of suicide is only as good as the underlying foundation of medical assessment from which it proceeds. Thereafter, once a physician has made such assessment, there is an obligation or duty to take reasonable steps to prevent the suicide of that patient. (Jamison, K. Redfield, Night Falls Fast: Understanding Suicide (New York: Alfred A. Knopf, (1999) Page 237). Thus, proper diagnosis allows for proper treatment and proper treatment indirectly reduces the risk of completed suicide.
A clinician’s obligation is take reasonable steps to do the following:
(a) Remove access to firearms, having made every effort to inquire about same. (Flach, Frederic E.d., A Comprehensive Guide to Risk Management in Psychiatry (New York: Hatherleigh Press, (1998) Page 156);
(b) Involve the patient’s family and/or significant others in proactive prevention efforts;
(c) Evaluate the time and number of meetings with the patient; and
(d) Referral by a family practitioner to a professional mental health provider, such as a psychiatrist.
Their obligations may involve questions related to the need to modify or alter treatment, provide more close supervision, or even hospitalization. Question of hospital culpability arises once hospitalization has occurred.
Issues related to suicide create additional challenges for a trial lawyer in a medical malpractice setting beyond those that are normally experienced in what are generally difficult cases to begin with. There are numerous biases that jurors will bring to the case. Recent evaluation, by this office, has established that approximately twenty percent of the population may believe that suicide is an intentional act and if someone really wants to kill themselves they will eventually do it. As a corollary to that, the affects of an individual juror’s religious training or background may impute some type of intentional fault or “sin” upon the suicidal patient. This presents difficult bias issues for purposes of jury selection (or de-selection).
The facts are that suicide is not a rational process. Instead, suicide involves people that do not want to die but they want to end their pain. Thus, it is an irrational act chosen to reach an irrational result. (Bongar, Bruce, et al., Risk Management of Suicidal Patients (New York: Guilford Press (1998) Page 43).
There are numerous other myths about suicide. It is a complex issue and brings additional tragedy to what is otherwise tragic to begin with: an untimely death. When suicide occurs, the survivors suffer tremendous guilt and mental anguish, as well.
