Suicidal patients exist both as in-patients and out-patients. The treater has a duty to exercise adequate skill in the diagnosis and care of such patients and an additional duty to take adequate precautions when suicidal (or other self-injurious) risk is identified. A medical malpractice may occur when there is either a failure to diagnose the risk or a failure to treat it.

Suicide and suicide attempts are rare events and may be difficult to predict. Nevertheless, certain risk factors increase the likelihood a suicide attempt may occur. I believe the central clinical failure occurs when the treater fails to exercise the required degree of care, that is to say, the care is sub-standard.

To begin, suicidality must be a clinical consideration in certain groups of patients: those who have had a recent suicide attempts, a past history of suicide attempts, recent suicide threat(s), a diagnosis of Major Depressive Disorder, Bi-Polar Disorder, Schizophrenia, Chronic Substance Abuse, recent discharge from a psychiatric hospital, or mental incompetence. Certain clinical factors heighten the risk of suicidality. Panic attacks, recent onset of hallucinations or delusions*, anhedonia (loss of interest in pleasurable activities), severe insomnia, recent diagnosis of a severe potentially life threatening medical condition, or a recent personal loss, e.g. marital separation, death of a parent or child, financial crisis, discovery/belief of spousal infidelity. Some medications, including antidepressants, are known to cause increased suicidality as are corticosteroids (cortisone, prednisone).

In a legal context, for a plaintiff to demonstrate medical negligence, he must demonstrate with a preponderance of the evidence that the suicidality was clearly identifiable on the basis of recognized criteria used by most clinicians in their specialty. Certain mental health care providers may have little or no training with high risk patients such as a marriage and family therapists (MFTs) or inexperienced or inadequately trained psychologists. Newly minted specialists generally don’t have a lot of experience with high risk patients unless they have had a good psychiatric hospital exposure, including psychiatric emergency training.

Even when the treater exercises sufficient diligence, a bad outcome may occur, i.e. suicide or a suicide attempt. Ultimately malpractice cases are brought because of a bad outcome. However, treaters don’t and can’t guarantee an outcome, only conscientious diligence in adequately diagnosing and treating the patient, i.e. providing the standard of care.

Contemporaneous treatment notes are the best way for the clinician to document reasonable care and skill. Doctor-patient interactions, discussing pros and cons of various treatment approaches, a patient’s acknowledgment that taking certain medications includes certain risks including increased risk of suicide, the content of relevant therapy topics discussed including suicide, ongoing assessments of suicidality in at-risk patients, documentation of denial of suicidality upon inquiry, all bolster clinical demonstration of the therapist’s attention to reasonable care and skill. Peer consultation about the case is another, as is documented literature review.

In conclusion, when the clinician has implemented and documented adequate care and skill to diagnose suicide risk and to treat it, he has achieved the expected standard of care for the treatment of the potentially suicidal patient.

* A “hallucination” (as opposed to a delusion) is an abnormal sensory experience such as hearing voices or seeing people or things which aren’t there.

A “delusion” (as opposed to a hallucination) is an irrational belief.  It may be, for example, persecutory, a sexual fixation or belief, grandiose or relating to one’s health.