On this week's show, we take the mental health system to task for being
fairly inept at picking out those who really intend to kill themselves from
those who don't. We hear a tragic tale from a retired psychiatric nurse who misread
the signals of a teenage boy. And then there's the attending psychiatrist who says that psychiatric assessment tools are crude and that it often boils down to a gut feeling that can be quite wrong.
If I see a patient who I think is suicidal, I can refer them to a
psychiatrist for an emergency assessment. Often we do this with the
full agreement of the patient, which is called a voluntary assessment.
However, all physicians (not just psychiatrists) have the power under
provincial mental health legislation to order that the patient be
brought involuntarily to a psychiatrist and be held for up to 72 hours
for an assessment. In Ontario, an application for an involuntary
psychiatric assessment is called a Form 1.
According to provincial legislation here, for a Form 1 to be completed,
the physician, after examining the person, must have reasonable cause to
believe that the person has, or is threatening to, cause bodily harm to themselves or another person, or is
showing a lack of competence to care for themselves.
If in addition, the physician should be of the opinion that the said person is
apparently suffering from a mental disorder of a nature or quality that
likely will result in serious bodily harm to the themselves or someone else.
Check out an attached online version of the form here:
What concerns me is that even if I fill out a Form 1, and refer the
patient to a psychiatrist, the psychiatrist has the authority to rescind
the Form and send the patient home.
On this week's show, I tell the story of a patient who me and my colleagues placed on a Form more than once, only
the have the psychiatrist on call send the patient home, where he later
killed himself. What disturbs me even more is that with each referral
to the psychiatrist, we increased our pleas that the patient be admitted, all to no avail.
To me, there's something very odd about giving primary care docs like me
the authority to demand a psychiatric assessment only to neuter that
authority at the first opportunity. If you want to make a rule that
says I have to first discuss the Form with the psychiatrist before
signing it, fine. But once it's signed, it should be obeyed for the
full 72 hours.