This case involves a male veteran who was undergoing extensive psychological treatment at an in-patient mental hospital. During the course of his treatment, the man revealed to his doctors that he was struggling with suicidal thoughts, as well as symptoms of major depression, however no change to his treatment was made, even for minimally invasive transcranial magnetic stimulation, nor was he placed under closer observation. In addition to his mental issues, the man was also being treated for an addiction to opiate painkillers with Subuxone. However, his access to this medication was not closely monitored. Eventually, doctors found the man dead in his room from an intentional overdose of opitates. It was alleged that doctors should have placed the man under closer observation as soon as his suicidal ideations were revealed.
Question(s) For Expert Witness
- 1. Are you familiar with the proper steps and protocols to follow when patient presents with similar symptoms?
- 2. Should a patient exhibiting addiction/suicidal tenancies by referred to a substance abuse clinic, addictionologists or substance abuse professional?
Expert Witness Response E-006013
I have 25 years experience in dealing with psychiatric issues from childhood to the elderly patients. Most the my practice today is adult and the neuro general psychiatric patients. I am the medical director for a neurogeropsychiatric unit which includes adult the patient’s of and the neurogeropsychiatric patients. I supervise residents and fellows in management of complex cases and often we have dual diagnosis patients with substance and mood disorders. We often manage many of the substance issues ourselves and frequently will connect patient’s to outpatient management of substance disorders. So were quite experienced in managing of this type of the patient. Clearly patient like this does need comprehensive care and what is implied by this case report is that that was not applied. In particular, both the comorbid psychiatric disorders and substance disorders, which are a form of psychiatric disorders, both need to be comprehensively and concomitantly addressed to best address the interest of the patient. When this is not done of then the patient can decompensate and a bad outcome can occur such as in this case.
Expert Witness Response E-032201
I am familiar with procedures to follow for patients with symptoms described as above. A patient exhibiting high suicide risk should be stabilized inpatient and discharged with an aftercare plan that steps down in level of care with monitoring for risk. Given that opioid use in general and opioid use disorder is a proximal risk factor for overdose and suicide, a referral to a specialist beyond primary care is appropriate. In this particular case, it appears a pain management consult, ideally someone familiar managing co-occurring chronic pain and opioid use disorder would be ideal although this may not be available.