A quarter of adults in the United States meet the criteria for a diagnosable mental illness. More than 1,069,000 people in the country attempted suicide in 2014 alone, according to the American Association of Suicidology.

Americans spent as much as $69 billion on mental healthcare services back in 1999 and while there is no current accurate data, experts suspect the spending is significantly higher today than it was almost two decades ago. Unfortunately, despite the massive spending and the significant need for effective inpatient and outpatient treatment, the system designed to treat people with mental health issues is fraught with problems in the United States.

Pacific Standard recently published an in-depth report of some of the issues with mental healthcare services in the United States. The report highlighted problems with inpatient care facilities in particular – and suggestions for positive change.

Until more effective solutions are identified, however, patients will continue to be at the mercy of care providers who  likely are not  equipped to actually fulfill their role at treating illness and preventing death by suicide. When a death occurs either under the care of an outpatient care provider or while a patient is receiving inpatient mental health services, family members of the victim should consider pursuing litigation  to hold the care providers accountable and, importantly help change conditions in the mental health industry

Problems in the U.S. Mental Healthcare System

Pacific Standard Magazine reported on one situation in which the mental health commissioner for the state of Virginia took a trip to an inpatient psychiatric care facility run by the state. The commissioner saw a facility which appeared very functional, as he saw impressive presentations and met with residents. However, the entire system seemed so perfect the commissioner suspected a Potemkin village had been constructed for his benefit.

He was proved right when he dropped by unannounced several weeks later. Residents suffering from behavioral problems smelled of unwashed clothing and urine. Patients requiring intensive treatment were alone in rooms as staff members chatted with each other in hallways. Overmedicated patients were also everywhere, slouched on the couch in front of the television.

When the commissioner tried to take steps to fix conditions, he discovered quickly there was little he could do to improve things and he also discovered similar problems existed nationwide in care facilities. He has since written a book focused on the problems with the mental healthcare system in America as well as focused on suggestions for making positive changes.

Unfortunately, the problems he identified with inpatient care are only the tip of the iceberg when it comes to nationwide issues with mental health services. Some of the many issues include psychologists and psychiatrists relying on outdated treatments and insurers who refuse to pay for the care patients need.

Less than 15 percent of mental health care consumers actually receive care based on evidence, and those who don’t can suffer greatly from ineffective treatments.  When this poor care is provided to patients and suicide or other serious consequences result, it is important to pursue claims against those responsible to ensure there is at least accountability within the ineffective patchwork system for providing care.

Suicide is the second leading cause of death among young people between the ages of 15 to 24 in the United States. According to the American Association of Suicidology, more than 5,000 young adults and teenagers in this age range die by suicide each year. Unfortunately, teen depression is not understood as well as it should be and treatment methods – including inpatient treatment – are not always effective at providing young people with the services and support that’s necessary.

When a teen receives inpatient or outpatient care and still takes his or her own life, it is important to determine if the mental health counselors or care providers lived up to their duties as required by law. A failure to provide appropriate care and to perform a proper suicide assessment can result in a claim against any care provider, while inpatient facilities can also be held accountable for failure to adequately  monitor patients to prevent death by suicide.

Inpatient and Outpatient Treatment Must Help Teens Fight Suicidal Ideation

Argus Leader recently took an in-depth look at the problem of teen suicide, sharing the story of a 17-year-old who took her own life after a lengthy battle with depression. The young woman was a volunteer and mentor to others who took dual credit classes and who planned to attend university in the fall. Unfortunately, her family had a history of mental illness and the young woman began to develop depression after a move and after her parent’s divorce when she was in the fifth grade. She was also a victim of bullying in school, and she began cutting which is a common coping measure for teens who struggle to deal with emotional pressure. She also attempted suicide in fifth grade, and was hospitalized in an inpatient treatment facility.

She ultimately would make several more suicide attempts and be hospitalized at the same inpatient facility several times before dying by suicide.  She received a variety of different treatments, including transcranial magnetic stimulation, which is a relatively new depression treatment aimed at stimulating nerve cells in the brain using magnets. Unfortunately, the treatment efforts were not successful and she died by suicide this year.

Her story is similar to the struggles endured by many other teens, who care providers often do not understand how to treat effectively. Efforts are underway to improve the care young people receive, and 20 states have now adopted the Jason Flatt Act to require public school personnel to complete required training on youth suicide prevention and awareness.

Awareness is important, but can only go so far if the teens who are identified as being at risk are not provided with treatments that make a difference in their depression. Unfortunately, if mental health care providers and inpatient treatment centers do not develop more effective ways of treating and preventing teen suicide, tragic deaths of young people will  continue to occur.

Identifying people at risk of suicide is an essential step to providing these patients with the care they require.  A new study shows care providers in the emergency room have an important role to play in identifying people at risk; this is yet another study stating the obvious.  Healthcare professions in an ER setting must do their part to ensure patients are identified so they can receive appropriate care. If not, an attempted suicide may occur within minutes to hours of an unthoughtful disposition.

ER Nurses Can Help Identify Patients at Risk of Death by Suicide

NewsWise reported on the recent study showing the important role emergency room caregivers can play in preventing a suicide. The research was conducted by UMass Medical School.  Researchers discovered when emergency room nurses conducted a universal suicide risk screening, almost double the number of at-risk patients were identified. At-risk patients included those who were positively identified as thinking about suicide or patients with attempted suicide.

The study spanned a five year period. During this time, there were 236,791 visits to emergency rooms included in the study. Suicide risks screenings performed on patients increased from 26 percent to 84 percent of patients undergoing screening over the study period. This increased the rate of detection of suicide risk from 2.9 percent to 5.7 percent.

The suicide screening performed in the emergency room was simple. Nurses in the ER departments were trained to administer a brief questionnaire to patients focused on three risk factors for suicide: depressive symptoms, lifetime attempts to die by suicide, and active suicidal ideation.

Patients were identified as having a positive screen if they had either confirmed they have active suicidal ideation or if they had attempted to die by suicide within six months of the time of the visit to the emergency department.  With this screening process, a subset of patients was identified whose risk of suicide was serious enough the patients needed inpatient psychiatric treatment. Other patients were identified who needed additional evaluation and intervention resources such as a self-help safety card and information about a suicide prevention lifeline.

The lead author of the study indicated: “Our study is the first to demonstrate that near-universal suicide risk screening can be done in a busy ED during routine care. The public health impact could be tremendous, because identification of risk is the first and necessary step for preventing suicide.”  The lead author is correct and we applaud the entire team performing the research.  We hope that the study is transformed into action in the emergency departments and the study is not just a group soliloquy among academics.

No further efforts to help identify risk of suicide in emergency departments are needed at this time.  This need has been answered by the Suicide Prevention Resource Center last year, 2015.  Skip Simpson highly recommends the outstanding work produced by the SPRC: “Caring for Adult Patients with Suicide Risk: A Consensus Guide for Emergency Departments.”  This important work (the ED Guide) is designed to assist emergency department (ED) providers with decisions about the care and discharge of patients with suicide risk.

When patients seek either inpatient care or outpatient treatment for mental illnesses including depression, the treatment they receive is often inadequate. Depression is one of the greatest risk factors for suicide, especially among severely depressed patients who are hospitalized due to suicidal ideation. Unfortunately, even in inpatient settings where patients are supposed to receive treatment from consummate professionals, mental healthcare providers are often left guessing, because of poor training, on what treatments will be effective with no actual scientific method of helping patients.

Scientific America calls the current approach to treating mental illnesses, including depression, the “shotgun approach,” and describes the shortcomings of this treatment method. The term refers to the fact psychiatrists often try many different types of medications in a very imprecise manner.

When patients receive inpatient treatment or outpatient treatment and the wrong medications are provided to treat depression, some of these medications can actually increase the risk of suicide- especially if patients end up having to stop taking the drugs and going through a withdrawal process. Mental health professionals may sometimes be held accountable for the harm their failed treatment efforts can cause, including when a patient attempts to die by suicide. This is especially true in an inpatient setting where care providers should quickly be able to identify when a medication is doing more harm than good.

Improving Mental Healthcare in Inpatient and Outpatient Settings To Prevent Death by Suicide

Centers for Disease Control and Prevention list a history of mental disorders, and particularly clinical depression, as among the top risk factors for suicide. Unfortunately, while there are many medications to treat mental disorders, a trial-and-error approach is usually taken to decide which of these different drugs to try.

Scientific America gives an example of one patient who had been in and out of intensive psychiatric care over close to two decades. She had been diagnosed with bipolar disorder and had experienced periods of suicidal depression.  She had been prescribed antipsychotics, antidepressants, anticonvulsants, mood stabilizers, and anticonvulsants. She had also undergone group and individual therapy, cognitive therapy, and behavioral therapy- but none of the treatments received had made any lasting impact.  The medication she’d been prescribed did lots of different things, from blocking dopamine to focusing on norepinephrine.

Her story was common, as mental illnesses are frequently treated based on guessing which medications will affect observable symptoms, rather than based on getting a correct diagnosis of an underlying cause and treating that specific condition. Genetics and brain imaging in the future could provide clearer answers regarding what is actually going wrong in the brain structure or brain function so more accurate treatments could be provided, and there has been extensive research in this area. Unfortunately, there are continued challenges in finding common markers within different diagnoses.

While treating with medication and experimenting with different drug therapies is challenging and imprecise, it is likely to be the most common method of providing care until research advances. When a patient is in an inpatient setting and different medications are being experimented with, it is imperative for care providers to ensure they are monitoring the effects of medication and are alert for any potential risk of suicidal ideation.  When nothing is working,  Electroconvulsive therapy (ECT) should quickly be considered and carefully explained to the patient and the patient’s family.

Study shows that the first week and first year after diagnosis have elevated risk

While it’s well-known that people suffering from cancer also face high levels of distress and psychiatric symptoms, some research indicates a specific link between the cancer diagnosis itself and death by suicide.

In one study, researchers reviewed medical records on 14,000 people, 786 of whom had been diagnosed with a type of cancer. The study found that among those with a cancer diagnosis, the overall suicide rate doubled compared to the cancer-free population – with significant increases beyond that in the time immediately following the diagnosis.

According to the study results, the risk of suicide increased by a factor of 12 within the first week after diagnosis. That risk tapered off over time, but remained high, as patients diagnosed with cancer were five times more likely to die by suicide within 12 weeks of the diagnosis and three times more at risk within the first year after diagnosis.

Significantly, the research also found a link between prognosis and suicide risk. Those patients who were diagnosed with more deadly cancers, as well as those who were also suffering from another medical condition, were more likely to die by suicide. That suggests that a feeling of hopelessness was partially to blame for their deaths.

Intervention after diagnosis can prevent suicide

One of the most persistent suicide myths says that when people want to attempt suicide, nothing can be done to stop them.  The reality is that a person’s urge to end his or her own life will pass with time. The study results bear this out, as the suicide risk was observed to be strongest right after diagnosis – when the situation seemed most dire – and tapered off substantially as people went on living after being diagnosed with cancer.

Suicide prevention attorney Skip Simpson knows that compassionate—don’t gloss over the word; it is important—intervention can make all the difference for a suicidal person, even someone suffering from a disease as grave as cancer. Most people who are prevented from dying by suicide recover from their impulses to take their own lives. Even someone who seems hopeless still has the capacity to face cancer with determination and a will to live.

Sadly, too many patients never have that chance. Doctors who specialize in treating cancer rarely have the mental health training or experience needed to recognize the warning signs that a patient may be at risk of dying by suicide. Too many patients die while their lives are in the hands of people who are supposed to protect them.

Friends and family members need to be aware of the heightened risk of death by suicide in the weeks and months following a cancer diagnosis. By proactively intervening and encouraging people to seek help, it’s possible to protect patients when they are at their most vulnerable.

Montana universities are taking steps to address suicide epidemic

At the first ever Montana Suicide Prevention Summit last month, advocates for suicide prevention called for mental health and emotional education for the general public, starting at the grade school level.

Marny Lombard, the mother of a Montana State University student who died by suicide in 2013, and Karl Rosston, the suicide prevention coordinator for Montana’s Department of Health and Human Services, were among the key speakers at the summit. Both emphasized the need to prepare ordinary people to recognize and appropriately address suicide risk factors rather than relying exclusively on mental health professionals.

Montana has the nation’s highest suicide rate, nearly double the national average. Every other state in the Rocky Mountain region is close to the top as well. And while some suicide risk factors, such as altitude, are geographically fairly unique to the Rockies, most hold significance nationwide.

Rosston cited several suicide risk factors common in Montana and the surrounding states, including social isolation, easy access to firearms, high rates of alcohol consumption and a social stigma against mental illness. Many people in the West, particularly men, are uncomfortable seeking professional help for depression or emotional health – and that’s true in other parts of the country as well.

That means friends and family must play a key role in encouraging, supporting and protecting people at risk of suicide. Lombard pointed out that at-risk college students are much more likely to turn to their friends than professors or mental health professionals.

Friends and family members can help to prevent inpatient suicide

Even in cases where at-risk persons are already receiving professional help, friends and family play a hugely important role in preventing suicide. The unfortunate reality is that many mental health professionals lack the training and experience to recognize and appropriately address the warning signs that a person is at risk of death by suicide.

Friends and family members who know a person’s interests, background and personality are especially well-equipped to recognize early signs that a person may be at risk. Even when mental health professionals have the necessary training – and, again, many do not – there is no substitute for actually knowing the person.

Relatives and close friends of people in inpatient care need to be their advocates and their support system. Frequent visits and phone calls not only reduce the feeling of isolation that leads to many suicides, but also provide opportunities for loved ones to recognize those warning signs and work with caregivers to appropriately intervene.

Unfortunately, many mental health professionals fail to take appropriate steps to help patients at risk of suicide, even when they are warned of the danger. When that happens, friends and family members with some training in mental health are well-equipped to hold negligent caregivers accountable.

Skip Simpson has a couple of recommendations to understand what a friend or loved one can do to better understand how to help.  First, obtain training from the QPR Institute. There are three steps anyone can learn to help prevent suicide: Question, Persuade, and Refer.  See https://www.qprinstitute.com

Also, there is a quick read called “The Suicide Lawyers: Exposing Lethal Secrets” wherein Skip Simpson and his then partner were interviewed about what Skip Simpson had learned in his years of litigating suicide cases. Skip heard many clients say after starting litigation “if I had only known.” Skip Simpson wanted everyone to know what to look for and what to do before tragedy hit a friend, loved one, business colleague or anyone.

Despite some improvements, service members remain at elevated risk of dying by suicide

A new study released February 18 shows that the U.S. military is struggling to provide adequate care for active-duty troops suffering from post-traumatic stress disorder and clinical depression.

Conducted by RAND Corp., this study surveyed 40,000 cases, making it the largest ever of its kind. The results are chilling: Only a third of soldiers with PTSD and less than one in four soldiers with clinical depression receive even the minimum number of therapy sessions after their diagnosis.

According to military officials, the culprit is a lack of personnel. Commenting on the study, Brad Carson, the acting principal deputy undersecretary of defense for personnel and readiness, said, “We just don’t have enough mental health professionals to meet the demand.”

In addition, many service members are unaware of the mental health services available to them – or unwilling to seek help because of the persistent stigma associated with mental health. While the Department of Defense is working to reduce this stigma, a separate study also conducted by RAND Corp. found that some of their efforts may not be as effective as they could be. In particular, some of those stigma-reducing programs do not target service members who are already seeking mental health treatment.

Military treatment in vulnerable periods above national average

The study did find that the military is taking positive steps to treat at-risk service members during one of their most vulnerable times: immediately after discharging from inpatient facilities. During the first year after being released from hospital care, soldiers die by suicide at a rate of 264 per 100,000, more than 20 times above the national average.

According to the study, 86 percent of those with PTSD or depression were seen by a mental health specialist within seven days after discharging from a hospital, and that figure increased to 95 percent within the first 30 days. In this particular area, the military medical system is well ahead of the civilian system.

In part, the military’s success in this field is owed to a 2014 internal Army medical command memorandum, cited by the RAND Corp. study, that stated soldiers need to be seen within 72 hours of discharging from a hospital. Commanders were instructed to require soldiers to attend a make-up session if one is missed. Moreover, the memorandum established a policy of not discharging soldiers during weekends and holidays to avoid issues with losing track of follow-up care.

Even with more mental health professionals, the standard of care remains low

Another seemingly positive element is that the military has increased its staff of mental health professionals by 42 percent over the last seven years – 9,295 today compared to 6,546 in 2009.

However, increasing the number of staff has not necessarily improved the level of care. Many of the new mental health professionals lack experience; meanwhile, many experienced professionals have been forced into early retirement.

Suicide prevention attorney Skip Simpson, a 20-year military veteran, knows that many mental health professionals lack the necessary training to help people at risk of dying by suicide. This influx of inexperienced professionals means that the military medical system is even less likely to be able to recognize the warning signs of suicide and effectively intervene, leaving military personnel at elevated risk.

The study results show that, while the military is taking fairly effective steps to help soldiers when they are most imminently vulnerable to suicide, it is still struggling to provide the sort of early intervention and care that can prevent deaths from suicide in the long run.

As the San Diego Tribune recently reported, suicide rates are high among veterans who have served in combat since the attacks on 9/11/01. Unfortunately, research into veteran suicides reveals that both the VA and civilian health institutions are not doing enough to help when veterans appear to be giving up on treatment or experiencing despair. In some cases, veterans in inpatient care are not even being provided with the minimum level of assistance they need.

When someone is in a VA hospital or other treatment facility and there is a risk of death by suicide, steps need to be taken to ensure the person is properly monitored and an effective treatment plan is in place. When this does not happen and inpatient suicide occurs, the family members of the victim need to hold the institution and mental health professionals working at the institution accountable for their failures. This is especially true in situations where professionals who work with veterans regularly should be aware of signs of suicidal ideation and should ensure the proper healthcare is provided for patients who are receiving inpatient psychiatric care.

Veterans at Risk of Inpatient Suicide

According to the San Diego Tribune, one case which has spurred the VA to try to make some changes involved a 37-year-old Air Force Veteran who died by suicide at a local hospital within days of being released from a lockdown psychiatric hold. He had been released from lockdown even though he clearly was not yet ready for release, as he was still experiencing suicidal ideation. He was admitted to a drug rehabilitation program at the same hospital with the belief he would get further help in the rehab program. Unfortunately, he hanged himself in his room.

Following this veteran’s death, the hospital decided to formalize the process of handoffs among inpatient units so staff members in different units would document that they had reviewed the patient’s case together and were aware of the risks. This is certainly a positive change: If veterans are to be released from one inpatient program to a different one when still at risk of suicide, extra precautions will need to be taken by new care providers to be watchful for continuing signs of suicidal ideation.

Unfortunately, changing the process of handoffs may not be enough to stop the epidemic of veteran suicides. Paul Rieckhoff, the executive director of Iraq and Afghanistan Veterans of America believes the government is downplaying the severity of the suicide crisis, which is a major public health issue more resources are needed to address. He compared the failures to provide appropriate care to suicidal veterans to the lack of response in the early days of the AIDS crisis.

The government has a responsibility to veterans, and the VA in particular has an obligation to make sure veterans are getting the care they need. Most importantly, facilities treating veterans must take seriously their duties to monitor and protect those who served, especially as suicide rates remain high.

Zero Suicide represents a commitment to identify, protect, and treat people who are at risk of suicide. Central to this commitment is the ability to record and properly share accurate information about a patient’s history and treatment. Without this information, each clinician that treats a patient must start from scratch — an inefficiency that will frustrate health care providers and patients, as well as affect the quality of care. Careful documentation also allows us to understand how health care systems can be improved and patient care made more effective.

The documentation essential to Zero Suicide has another benefit. It can protect clinicians and institutions from malpractice suits. Suicide is the most common cause of legal action against mental health care professionals. The central issues in most suicide malpractice cases are whether the clinician should have anticipated the risk of suicide and whether he or she provided care appropriate to this risk. Showing that a clinician met the standard of care appropriate for suicide risk can stop a malpractice suit in its tracks. Patient care should be documented in real time. Juries may suspect that medical records created after the fact rather than during treatment are inaccurate or self-serving.

Assessments of suicide risk should be carefully documented. It is a fundamental principle of good practice that risk assessment is more than simply using a screening instrument—clinical observation and judgment are also essential. These observations should be documented in the patient’s medical record. Patient responses to questions about suicide and self-harm should be recorded in their own words, and quotation marks used to clearly distinguish which statements represent clinical judgments and which are verbatim reports of what a patient said.

Embarrassment and anxiety can make patients reluctant to admit they are thinking about suicide. They may want to protect family secrets about substance abuse, mental health disorders, sexual abuse, or family violence. They may be in denial or afraid of being institutionalized or feel that no one can help. Involving family members can be crucial to accurately assessing a patient’s risk and making care decisions. Family members can provide information that the patient can’t—or won’t—and this information should be carefully recorded. It should also be noted if family members cannot be reached or are uncooperative. If a suicide results in a malpractice suit, it is the family that will sue. Accurate information about the family’s involvement—or lack of involvement—in patient care can be critical to the outcome.

The clinician should also document the decisions made while developing a patient care plan, how this care plan was implemented, and the criteria used to decide the steps needed to preserve the patient’s safety (such as whether the patient admitted to actively planning his or her suicide and whether the patient has access to firearms).

It is also important for the clinician to document his or her review of medical records and consultations with other service providers. If medical records or prior providers are not available, all attempts to obtain records and reach providers should be documented.

Focusing on the possibility of malpractice lawsuits turns the clinician’s attention away from the patient to him- or herself. Thoroughly and accurately documenting the assessment and care of patients who may be at risk of suicide will help deter malpractice lawsuits as well as contribute to quality care, patient safety, and the ability of clinicians and the health care system to work toward the goal of zero suicides.

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Virginia governor Terry McAuliffe’s plan to close Catawba Hospital, a 110-bed psychiatric facility located near Roanoke, is the latest blow to the state’s underfunded and uncoordinated mental health system.

Over the past four decades, Virginia has already lost nearly 80 percent of its psychiatric hospital beds, leaving fewer than 1,500 statewide. Compounding the problem is the lack of community-based services, such as counseling, housing and treatment, needed for people struggling with mental illness to get the care they need outside an inpatient facility.

Due to the state’s failure to invest in those services, hundreds of discharge-ready patients are crowded into a limited number of beds, stuck at a hospital level of care because there is no plan for them to step down. This leaves little room for those who are most at risk.

As a result, people suffering from mental illness and substance disorders are left in a place that is ill-equipped to care for them: the criminal justice system. Nearly 7,000 Virginians with mental illness are currently incarcerated, more than four times the number in psychiatric hospitals.

Lack of Services Leads to Tragedy

Without the dedicated care they need, inmates with mental illnesses are at increased risk of abuse, neglect and suicide. In one recent tragedy, Jamycheal Mitchell, a mentally ill 24-year-old man, was arrested after shoplifting $5 worth of snacks from a convenience store. He wasted away and died after four months of neglect in jail.

A judge repeatedly ordered that Mitchell be transferred to a psychiatric hospital, but no beds were available. Meanwhile, at Eastern State Hospital, the nearest state psychiatric facility, some two dozen patients had been designated ready for discharge but remained in their beds due to a lack of community-based services.

Even when beds are available, failures to effectively coordinate care can be deadly. In November 2013, Austin “Gus” Deeds, a 24-year-old college student with bipolar disorder, stabbed and slashed his father, R. Creigh Deeds, 13 times before dying by suicide.

That night, the Deeds family had gotten a court order that gave the state six hours to place Gus in an inpatient treatment facility. Mental health evaluator Michael Gentry claimed he called 10 facilities that could care for Gus, but phone records show that he only called seven. Tragically, two of the three facilities that were not called had space available.

The elder Deeds, a Virginia state senator, survived the attack and has been a vocal advocate for mental health reform since. He is also pursuing a $6 million wrongful death suit against the state.

A Nationwide Trend

Virginia’s issues with mental health are far from unique. Rather, the lack of psychiatric beds is a result of a nationwide initiative in the 1970s to downsize psychiatric hospitals in favor of community-based care. While well-intentioned, this initiative ultimately led to cuts across the mental health system, as funding did not follow the patients into the community.

As such, people suffering from mental illness and their loved ones are left to deal with confusing bureaucracy, long wait times for services, overcrowded facilities and overworked care providers. In such environments, patients are commonly neglected and even abused, leaving them at elevated risk for inpatient suicide.