Was Suicide Attempt Foreseeable?

In 2009, a 14-year-old Michigan boy entered a home-based, nonhospital treatment program for at-risk teens. His family was concerned about his mental health, as he had been caught smoking marijuana. He was also being treated for depression by a psychiatrist from the program’s administrating facility.

While enrolled in the program, the patient tried to hang himself but was discovered by his mother before death occurred. He was taken to a hospital, where marijuana and lysergic acid amide (LSA) were found in his system. Since the teen kept a morning glory plant in his bedroom, it was surmised that he had sucked on its seeds to achieve an LSD-like high. It was believed that the depressant effect experienced as he came down off the drug triggered suicidal feelings.

As a result of oxygen deprivation, the patient was rendered quadriplegic. He was unable to walk, talk, or feed himself. He died in 2012, at age 17.

The plaintiffs claimed that the defendants failed to properly diagnose, monitor, and treat their son and that he had been placed in the program in order to prevent what ultimately happened. The defendants denied any negligence.

Outcome

A $5.5 million verdict was returned.

Comment

Suicide can be difficult to predict, yet we are often called upon to do just that. For clinicians working in the emergency department or urgent care settings, the likelihood of encountering at-risk patients is higher.

Liability in this case turns on whether the suicide attempt was reasonably foreseeable. We have a 14-year-old boy smoking marijuana and being treated as an outpatient for depression. There was no history of prior hospitalization, personality or thought disorder, suicidal ideation, or prior suicide attempt. Apart from the marijuana, there was no history of substance abuse (since the morning glory seed use was not discovered until after the suicide attempt). 

Based on this information, would a reasonably prudent clinician detect the imminent suicide risk that ended this patient’s life? Those inclined to answer “Yes” should be prepared to state precisely what evidence was used to arrive at this conclusion. Hindsight bias may allow us to see trouble brewing in this case but will do little to form a workable standard for every depressed teenager who uses marijuana.

That being said, suicide must be taken seriously: It is the third leading cause of death among persons ages 15 to 24 and the second leading cause of death among those ages 25 to 34. Among 15- to 24-year-olds, suicide accounts for 20% of all deaths annually.¹ Suicide also carries high malpractice risk, and failure to prevent suicide is the most common claim against mental health professionals.² Non–mental health clinicians also face liability exposure, but are often less equipped to recognize and deal with imminent psychiatric events.

Psychiatry is not an exact science. For clinicians accustomed to acting on hard evidence, psychiatry can be frustratingly “squishy.” The terminology can be misused, and the diagnosis subject to interobserver differences. There are no binary tests to “rule out” conditions and no therapeutic ranges within which we can feel safe. So what can we do?

First, we can double down on the structure that is there. Be familiar with the operative Diagnostic and Statistical Manual of Mental Disorders (DSM, now in its fifth revision), or have a reference handy. Use all diagnostic terms according to the framework in the DSM; a plaintiff’s attorney will pick apart careless diagnoses, and jurors will expect clinicians to be precise. 

Second, have an approach for addressing suicidality (and homocidality) forthrightly. Consider using a suicide screening tool in cases where there is a coexisting concern (eg, substance use, scholastic difficulty, traumatic life event). A screening tool may protect the patient and be helpful from a legal standpoint for the clinician. For example, the Columbia-Suicide Severity Rating Scale (C-SSRS) has been demonstrated to provide improved assessment of suicide risk.³

Use of a generally accepted screening tool may have several advantages. It demonstrates concern for the patient and a willingness to take suicidality seriously. It also prompts the uncertain clinician on how to proceed in unfamiliar waters. Furthermore, a properly executed tool will likely be respected by jurors when used in conjunction with the clinician’s demonstrated concern and judgment. Obviously, such a tool should be used as a floor, not a ceiling; where the answers on a rating scale look “good” but clinical concern remains, good clinical judgment should prevail.

In this case, there were no facts disclosed that suggested imminent suicide risk, so it seems hard to fault the psychiatrist and the treatment program for the tragic results. However, the jury expected them to do more.

Use of a screening tool in this case may have shown that the program had an organized plan to address suicide risk in these “at-risk” kids. It would have provided tangible documentation that suicide risk was considered and may have yielded an extra layer of defense against the claim that this patient’s suicide attempt was foreseeable. Most importantly, the tool may have actually saved the patient’s life by revealing his pain and suicidal thinking.

We have yet to discuss the most unusual aspect of this case: the use of morning glory flower seeds as a drug of abuse. Morning glory seeds contain LSA, which produces an effect similar to LSD. Generally, the user crushes or chews the seeds or extracts the LSA by soaking them in cold water. On consumption, the user experiences LSD-type hallucinations and may experience agitation, anxiety, and mood disturbances, including depression. Apparently, the jury was not persuaded that the morning glory seed abuse caused the patient’s suicide attempt.

In conclusion, take suicide seriously. Have a plan to manage at-risk patients. Document your concern, evaluation, and findings. Consider implementing a suicide screening tool in your practice to ensure the proper questions are asked, answered, and docu­mented. —DML

REFERENCES

1. CDC. Suicide: facts at a glance (2012). www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf. Accessed November 6, 2013.

2. Simpson S, Stacy M. Avoiding the malpractice snare: documenting suicide risk assessment.  J Psychiatr Pract. 2004;10(3):185-189. www.reidpsychiatry.com/columns/Stacy%2005-04.pdf. Accessed November 15, 2013.

3. Posner K, Brown GK, Stanley B, et al. The Columbia–Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011;168:1266-1277.  

In 2009, a 14-year-old Michigan boy entered a home-based, nonhospital treatment program for at-risk teens. His family was concerned about his mental health, as he had been caught smoking marijuana. He was also being treated for depression by a psychiatrist from the program’s administrating facility.

While enrolled in the program, the patient tried to hang himself but was discovered by his mother before death occurred. He was taken to a hospital, where marijuana and lysergic acid amide (LSA) were found in his system. Since the teen kept a morning glory plant in his bedroom, it was surmised that he had sucked on its seeds to achieve an LSD-like high. It was believed that the depressant effect experienced as he came down off the drug triggered suicidal feelings.

As a result of oxygen deprivation, the patient was rendered quadriplegic. He was unable to walk, talk, or feed himself. He died in 2012, at age 17.

The plaintiffs claimed that the defendants failed to properly diagnose, monitor, and treat their son and that he had been placed in the program in order to prevent what ultimately happened. The defendants denied any negligence.

Outcome

A $5.5 million verdict was returned.

Comment

Suicide can be difficult to predict, yet we are often called upon to do just that. For clinicians working in the emergency department or urgent care settings, the likelihood of encountering at-risk patients is higher.

Liability in this case turns on whether the suicide attempt was reasonably foreseeable. We have a 14-year-old boy smoking marijuana and being treated as an outpatient for depression. There was no history of prior hospitalization, personality or thought disorder, suicidal ideation, or prior suicide attempt. Apart from the marijuana, there was no history of substance abuse (since the morning glory seed use was not discovered until after the suicide attempt). 

Based on this information, would a reasonably prudent clinician detect the imminent suicide risk that ended this patient’s life? Those inclined to answer “Yes” should be prepared to state precisely what evidence was used to arrive at this conclusion. Hindsight bias may allow us to see trouble brewing in this case but will do little to form a workable standard for every depressed teenager who uses marijuana.

That being said, suicide must be taken seriously: It is the third leading cause of death among persons ages 15 to 24 and the second leading cause of death among those ages 25 to 34. Among 15- to 24-year-olds, suicide accounts for 20% of all deaths annually.¹ Suicide also carries high malpractice risk, and failure to prevent suicide is the most common claim against mental health professionals.² Non–mental health clinicians also face liability exposure, but are often less equipped to recognize and deal with imminent psychiatric events.

Psychiatry is not an exact science. For clinicians accustomed to acting on hard evidence, psychiatry can be frustratingly “squishy.” The terminology can be misused, and the diagnosis subject to interobserver differences. There are no binary tests to “rule out” conditions and no therapeutic ranges within which we can feel safe. So what can we do?

First, we can double down on the structure that is there. Be familiar with the operative Diagnostic and Statistical Manual of Mental Disorders (DSM, now in its fifth revision), or have a reference handy. Use all diagnostic terms according to the framework in the DSM; a plaintiff’s attorney will pick apart careless diagnoses, and jurors will expect clinicians to be precise. 

Second, have an approach for addressing suicidality (and homocidality) forthrightly. Consider using a suicide screening tool in cases where there is a coexisting concern (eg, substance use, scholastic difficulty, traumatic life event). A screening tool may protect the patient and be helpful from a legal standpoint for the clinician. For example, the Columbia-Suicide Severity Rating Scale (C-SSRS) has been demonstrated to provide improved assessment of suicide risk.³

Use of a generally accepted screening tool may have several advantages. It demonstrates concern for the patient and a willingness to take suicidality seriously. It also prompts the uncertain clinician on how to proceed in unfamiliar waters. Furthermore, a properly executed tool will likely be respected by jurors when used in conjunction with the clinician’s demonstrated concern and judgment. Obviously, such a tool should be used as a floor, not a ceiling; where the answers on a rating scale look “good” but clinical concern remains, good clinical judgment should prevail.

In this case, there were no facts disclosed that suggested imminent suicide risk, so it seems hard to fault the psychiatrist and the treatment program for the tragic results. However, the jury expected them to do more.

Use of a screening tool in this case may have shown that the program had an organized plan to address suicide risk in these “at-risk” kids. It would have provided tangible documentation that suicide risk was considered and may have yielded an extra layer of defense against the claim that this patient’s suicide attempt was foreseeable. Most importantly, the tool may have actually saved the patient’s life by revealing his pain and suicidal thinking.

We have yet to discuss the most unusual aspect of this case: the use of morning glory flower seeds as a drug of abuse. Morning glory seeds contain LSA, which produces an effect similar to LSD. Generally, the user crushes or chews the seeds or extracts the LSA by soaking them in cold water. On consumption, the user experiences LSD-type hallucinations and may experience agitation, anxiety, and mood disturbances, including depression. Apparently, the jury was not persuaded that the morning glory seed abuse caused the patient’s suicide attempt.

In conclusion, take suicide seriously. Have a plan to manage at-risk patients. Document your concern, evaluation, and findings. Consider implementing a suicide screening tool in your practice to ensure the proper questions are asked, answered, and docu­mented. —DML

REFERENCES

1. CDC. Suicide: facts at a glance (2012). www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf. Accessed November 6, 2013.

2. Simpson S, Stacy M. Avoiding the malpractice snare: documenting suicide risk assessment.  J Psychiatr Pract. 2004;10(3):185-189. www.reidpsychiatry.com/columns/Stacy%2005-04.pdf. Accessed November 15, 2013.

3. Posner K, Brown GK, Stanley B, et al. The Columbia–Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011;168:1266-1277.  

In 2009, a 14-year-old Michigan boy entered a home-based, nonhospital treatment program for at-risk teens. His family was concerned about his mental health, as he had been caught smoking marijuana. He was also being treated for depression by a psychiatrist from the program’s administrating facility.

While enrolled in the program, the patient tried to hang himself but was discovered by his mother before death occurred. He was taken to a hospital, where marijuana and lysergic acid amide (LSA) were found in his system. Since the teen kept a morning glory plant in his bedroom, it was surmised that he had sucked on its seeds to achieve an LSD-like high. It was believed that the depressant effect experienced as he came down off the drug triggered suicidal feelings.

As a result of oxygen deprivation, the patient was rendered quadriplegic. He was unable to walk, talk, or feed himself. He died in 2012, at age 17.

The plaintiffs claimed that the defendants failed to properly diagnose, monitor, and treat their son and that he had been placed in the program in order to prevent what ultimately happened. The defendants denied any negligence.

Outcome

A $5.5 million verdict was returned.

Comment

Suicide can be difficult to predict, yet we are often called upon to do just that. For clinicians working in the emergency department or urgent care settings, the likelihood of encountering at-risk patients is higher.

Liability in this case turns on whether the suicide attempt was reasonably foreseeable. We have a 14-year-old boy smoking marijuana and being treated as an outpatient for depression. There was no history of prior hospitalization, personality or thought disorder, suicidal ideation, or prior suicide attempt. Apart from the marijuana, there was no history of substance abuse (since the morning glory seed use was not discovered until after the suicide attempt). 

Based on this information, would a reasonably prudent clinician detect the imminent suicide risk that ended this patient’s life? Those inclined to answer “Yes” should be prepared to state precisely what evidence was used to arrive at this conclusion. Hindsight bias may allow us to see trouble brewing in this case but will do little to form a workable standard for every depressed teenager who uses marijuana.

That being said, suicide must be taken seriously: It is the third leading cause of death among persons ages 15 to 24 and the second leading cause of death among those ages 25 to 34. Among 15- to 24-year-olds, suicide accounts for 20% of all deaths annually.¹ Suicide also carries high malpractice risk, and failure to prevent suicide is the most common claim against mental health professionals.² Non–mental health clinicians also face liability exposure, but are often less equipped to recognize and deal with imminent psychiatric events.

Psychiatry is not an exact science. For clinicians accustomed to acting on hard evidence, psychiatry can be frustratingly “squishy.” The terminology can be misused, and the diagnosis subject to interobserver differences. There are no binary tests to “rule out” conditions and no therapeutic ranges within which we can feel safe. So what can we do?

First, we can double down on the structure that is there. Be familiar with the operative Diagnostic and Statistical Manual of Mental Disorders (DSM, now in its fifth revision), or have a reference handy. Use all diagnostic terms according to the framework in the DSM; a plaintiff’s attorney will pick apart careless diagnoses, and jurors will expect clinicians to be precise. 

Second, have an approach for addressing suicidality (and homocidality) forthrightly. Consider using a suicide screening tool in cases where there is a coexisting concern (eg, substance use, scholastic difficulty, traumatic life event). A screening tool may protect the patient and be helpful from a legal standpoint for the clinician. For example, the Columbia-Suicide Severity Rating Scale (C-SSRS) has been demonstrated to provide improved assessment of suicide risk.³

Use of a generally accepted screening tool may have several advantages. It demonstrates concern for the patient and a willingness to take suicidality seriously. It also prompts the uncertain clinician on how to proceed in unfamiliar waters. Furthermore, a properly executed tool will likely be respected by jurors when used in conjunction with the clinician’s demonstrated concern and judgment. Obviously, such a tool should be used as a floor, not a ceiling; where the answers on a rating scale look “good” but clinical concern remains, good clinical judgment should prevail.

In this case, there were no facts disclosed that suggested imminent suicide risk, so it seems hard to fault the psychiatrist and the treatment program for the tragic results. However, the jury expected them to do more.

Use of a screening tool in this case may have shown that the program had an organized plan to address suicide risk in these “at-risk” kids. It would have provided tangible documentation that suicide risk was considered and may have yielded an extra layer of defense against the claim that this patient’s suicide attempt was foreseeable. Most importantly, the tool may have actually saved the patient’s life by revealing his pain and suicidal thinking.

We have yet to discuss the most unusual aspect of this case: the use of morning glory flower seeds as a drug of abuse. Morning glory seeds contain LSA, which produces an effect similar to LSD. Generally, the user crushes or chews the seeds or extracts the LSA by soaking them in cold water. On consumption, the user experiences LSD-type hallucinations and may experience agitation, anxiety, and mood disturbances, including depression. Apparently, the jury was not persuaded that the morning glory seed abuse caused the patient’s suicide attempt.

In conclusion, take suicide seriously. Have a plan to manage at-risk patients. Document your concern, evaluation, and findings. Consider implementing a suicide screening tool in your practice to ensure the proper questions are asked, answered, and docu­mented. —DML

REFERENCES

1. CDC. Suicide: facts at a glance (2012). www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf. Accessed November 6, 2013.

2. Simpson S, Stacy M. Avoiding the malpractice snare: documenting suicide risk assessment.  J Psychiatr Pract. 2004;10(3):185-189. www.reidpsychiatry.com/columns/Stacy%2005-04.pdf. Accessed November 15, 2013.

3. Posner K, Brown GK, Stanley B, et al. The Columbia–Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011;168:1266-1277.