Ever Wondered?

There are plenty of uncertainties in this world. You never know when you will die, you never know when your car is going to break down, you never know whether or not the flight will be delayed, etc...

The same applies to psychiatry. Being a "new wee trainee" in this job, or rather the most junior member of staff, I really find it difficult to judge whether or not a patient is telling me truth, or whether he/she is simply manipulating me. It all boils down to experience, I suppose. But being on call by myself, is pretty scary.

The other day, I was asked to review a young lad, who has a 18 month history of depression. He wanted to kill himself, by hanging himself with a rope in the woods. He also drinks too much alcohol and abuses illicit drugs. Now, he said he couldn't find a rope, and hence, ended up drinking pints of beer. When asked whether or not he still thought about commiting suicide, he said "no." He seemed very alert and lucid. Although he did have the alcohol stench, he was not intoxicated or withdrawing from it. So I thought that he was speaking from his heart. Unfortunately, I wasn't really sure if I was going to send him home.

I spoke to the consultant who advised to send him home, and we will review him in the community. He explained that as he doesn't have any ongoing suicidal ideation, he will be grand. However, deep inside of me was thinking, "what if he was just telling me what I wanted to hear? What if he goes home, wakes up in the middle of the night, get a rope to hang himself, or jump off a bridge?" Lots of thoughts went through. But, then again, I have no experience in this field, and the consultant certainly has seen plenty suicidal cases. So I informed patient of the plan and he left. His partner wasn't happy, as she was concerned that once he goes home, he would start to be angry or start to drink more, and would probably throw things around the house or argue with her..etc... hmm....right, so despite being depressed, he could be rather agitated too. So I explained to her that, there wasn't any indications for him to be admitted. Yes, agree that he could be throwing a tantrum at home, but that is certainly not an indication to stay in the hospital.....at least that was what I thought anyway. hmm...I thought again, "what if he decides to abuse his wife? he has done it before, but not for the past 3 yrs. Will I be held responsible for that?" sigh...I do not know. But, I soon rationalized that, he has a lucid mind, and if he said he is not going to do anything nasty or kill himself, I should trust him. *note I'm "trying" to use my ant-sized clinical judgement. So home the patient went. At the same time, I felt sorry for his partner, as I can understand her fear.

Overnight, I wondered....*shit, I really hope that he doesn't commit suicide. otherwise, I would take my own life away! I also hoped that he doesn't harm anyone. But then again, if he really wanted to kill himself earlier on, he would have persisted to find the rope, instead of buying cans of beer.....that's me trying to convince myself that it was the correct decision to let him home.

I discussed my uncertainties with my consultant. He said that 1-2 % of people who attempted suicide, but failed, will proceed to kill themselves in 1-2 years. Right.

He added that we could never predict when that person will do it. So there is never a clear line about when you should send a patient home. However, obviously, if the patient continues to say "yes, I am going to drink 10 bottles of bleach when I go home," then that is probably an indication that the patient should stay and be assessed further. It all boils down to experience. Right.

There are some many uncertainties.