Is suicidal ideation always an emergency?

[Zyprexa_Ho]

Is suicidal ideation always an emergency aka always a reason for inpatient treatment, or is *planning* suicide the actual emergency? Would someone be committed for suicidal ideation or would there need to be evidence of a plan?

[Davey Do]

Good question, jsfarri.

"Threat of self harm" meets criteria for a voluntary or involuntary admission.

Patients have been admitted for the threat of self harm being a passive death wish or vague suicidal thoughts without a plan to actual life-threatening attempts.

[elkpark]

You have to consider the larger picture. Some individuals have chronic PDW or SI and the presence of PDW or SI doesn't necessarily mean they are in acute danger.

Also, the criteria for involuntary commitment vary from state to state. For instance, in my state, the state commitment laws specify that there must be an "act of furtherance" in order to petition an involuntary commitment -- just saying that you want to kill yourself isn't enough by itself; you have to have also done something to indicate that you are dangerous (although that "something" can be something as small as picking up a bottle of pills -- the person doesn't actually have to have hurt her/himself (yet)).

Obviously, the criteria for voluntary admission are looser than criteria for involuntary admission.

[nurse lala, BSN, RN]

Suicidal ideation is not always an emergency.

Some people report having daily suicidal thoughts, for years and years, without ever acting on it. Does chronic suicidal ideation merit inpatient treatment? Usually only in the context of other factors that indicate increased risk. Risk factors include a recent loss, a new diagnosis...

Planning out and/or taking steps towards a suicide is called preparatory behavior. Preparatory behavior merits a mental health assessment to determine optimal treatment. An admission is almost always indicated when a person is actively preparing to suicide. There are exceptions, such as the individual who is incapable of implementing a plan. Years ago, I was consulted on a gent who was a paraplegic who would talk about suicide, really stressing the caregivers.

Where I live, there are two means for involuntary mental health treatment. One is a temporary hold. In my state the initial hold is for 72hours, then we can apply for an added 14 day hold. In extreme cases a third, 30 day hold will follow. The time is needed for the legal process of commitment. Criteria for a commitment varies from state to state. In Ca, a person who is chronically and acutely suicdal can be committed. Commitment is an expensive process for the facility, because the wheels of justice move slowly and the patient may stay for a year and more before a bed at a locked long term facility can be found.

Not every clinician needs proof of a plan. In my experience, when the patient denies allegations, then proof is needed. It is collateral data which supports your concern the person is at risk. Without any proof, Abuses will occur as they did in the past.

Can you imagine being forcefully hospitalized just on the strength of your ex-wife's words?

Please share are your concerns with the charge nurse.

[Chaoticdreams33, MSN, RN]

I work in an ED and we do all of the psychiatric consults to determine level of care, and like others have mentioned, the presence of suicidal ideation does not always require an inpatient hospitalization. There are a lot of factors that go into this decision, and then also commiting a person if need be. But basically if the person is having suicidal ideation with a plan and intent then they are at imminent risk and can be involuntarily hospitalized.

[elkpark]

But basically if the person is having suicidal ideation with a plan and intent then they are at imminent risk and can be involuntarily hospitalized.

Again, this varies from state to state. It's important to be familiar with the specific requirements of the involuntary commitment laws in the state in which one is practicing.

[WinterLilac]

This is a good question because I've dealt with a complicated case for the past 6 months.

I work in a recovery facility, completely voluntary and the people are not as unwell as those in the inpatient unit. Still unwell but not that unwell.

We have a client who ebbs and flows between suicidal ideation and suicidal intent. Last night she was wandering the streets (unknown to staff) and returned saying she was 'jumping in front of cars but they just went around me'.

This morning she said she wants to die, hates herself but would never do anything to kill herself because she 'doesn't like pain and doesn't like blood'.

So what do we do, as a non-clinical organisation (except during business hours), with someone like this? We can have as many crisis management plans as we want but should she carry through with suicidal intent, where do we stand?

[Chaoticdreams33, MSN, RN]

Again, this varies from state to state. It's important to be familiar with the specific requirements of the involuntary commitment laws in the state in which one is practicing.

very true and very important. I should have been more clear that I was referring to my specific experience and in my state of CT. However I Am not aware of any state in the US where an imminent risk to self or others is not grounds for some type of involuntary commitment or hold. In my state a person can be held for up to 72 hours for a psychiatric evaluation on a police examination request or a LCSW paper. A physician emergency certificate is signed by a licensed physician after the psychiatric evaluation is complete and if the person meets criteria for an involuntary psychiatric hospitalization, and this paper is good for up to 15 days. (Of course patients can request a probate court hearing if they disagree with this decision, or they can sign In voluntarily if they change their mind).

I am not sure how up to date this is, but I did find it interesting as a side by side quick comparison.

http://www.treatmentadvocacycenter.org/storage/documents/State_Standards_Charts_for_Assisted_Treatment_-_Civil_Commitment_Criteria_and_Initiation_Procedures.pdf

[elkpark]

However I Am not aware of any state in the US where an imminent risk to self or others is not grounds for some type of involuntary commitment or hold.

That is true in my experience, also. My point, though, was that the definition of "imminent risk" varies from state to state. In my state, as I mentioned, there has to be "an act of furtherance" in addition to suicidal ideation, even suicidal ideation with a plan. Some states consider inability to care for self (e.g., wandering barefoot in the snow; putting oneself at risk through carelessness or negligence but not actively trying to hurt oneself) to be grounds for an involuntary commitment; some don't. Some states permit involuntary commitment for EtOH/drug abuse/dependence; some don't. There is a lot of variation around the country.

[pigginsrn]

If involuntary commitment only requires carelessness then we could make a case for anyone.

[nurse lala, BSN, RN]

So what do we do, as a non-clinical organisation (except during business hours), with someone like this? We can have as many crisis management plans as we want but should she carry through with suicidal intent, where do we stand?

You are afraid the client is not stable because she reports self destructive thoughts and possible behavior. She has been there 6 months now. You are worried about consequences.

Questions that come to my mind:

Is this her baseline or has her risky behavior escalated?

Are you talking to her about her continued self destructive behavior despite being sober?

Is there a psychiatrist involved?

Is she treatment compliant?

As a licensed psych nurse, you need to adhere to LPN practice guidelines, facility policy, and the treatment plan.

Get clarification on the standard level of functioning for a client to remain in your facility.

Report your and document your concerns about her appropriateness to continue living there.