Discharging Suicide Attempters

Many years ago a psychiatrist I respect told me he had implemented a policy of discharging any patient who survived a suicide attempt. This idea always seems to generate heated controversy among mental health professionals. I myself have regarded the idea with considerable ambivalence, but some weeks ago I discharged just such a patient.

When I raise the possibility of such a policy the most common response is, "How could you reject someone at such a low point in their life?" The answer to that question requires consideration of who represents the best professional to care for the patient. To me a suicide attempt in the context of psychiatric treatment represents a most emphatic declaration that the treatment and/or the professional have failed: "How could you continue working with someone who has told you in no uncertain terms your approach does not work?" While one can always rationalize hanging in there and trying a different medication or approach, a change of professional may provide the best real chance for success.

The logistics of implementation of such a policy may extend to the psychiatric hospital which may have admitted the patient. In my opinion the hospital staff should inform the patient of their outpatient provider's policy as soon as possible after admission to allow for processing feelings of rejection and to allow staff to arrange alternative aftercare plans. This may represent an adjustment for hospital staff in discharge planning which usually assumes the patient will continue treatment with their former provider. In my opinion we need to reverse this thinking, assuming instead that the hospital will refer the patient to a different provider with a different approach. Furthermore, hospital staff must initiate a discussion with the outpatient provider as near as possible to the time of admission, always a good idea anyway.

How will this impact psychiatric treatment, particularly where there are limited options available? Should we inform patients at the beginning of treatment of such a policy? How would such a policy affect risk of suicide attempt? How will this affect liability questions? Have you followed such a policy or seen others adhere to it? What might prevent you from implenting such a policy?

This kind of policy change may represent just one of many we should consider in light of our current apparent failure in our approaches to suicide prevention.

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