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Lack of assessment and management of suicidal patient (00HDC13101)

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(00HDC13101, 15 March 2004)

Psychiatrist ~ Mental health service ~ Diagnosis ~ Pharmacological management ~ Risk management ~ Co-ordination of services ~ Education of patient and caregivers ~ Treatment options ~ Professional standards ~ Rights 4(1), 4(2), 4(4), 4(5)

The family of a mentally ill man who committed suicide complained that the man's condition was not appropriately diagnosed, his suicide risk not identified, his medication and treatment not managed appropriately, and the family not kept adequately informed.

The 31-year-old man had a 12-year history of mental illness, which had begun with episodes of depression while he was at university. There was uncertainty regarding his diagnosis, as he presented with both schizophrenic and affective symptoms in equal measure. An initial diagnosis of schizophrenia was changed to schizoaffective disorder, as a depressive syndrome and manic symptoms surfaced. Episodes of psychosis and depression led to several admissions to hospital.

Following two suicide attempts, a six-month period of compulsory treatment allowed successful pharmacological intervention. The man was stabilised with a combination of carbamazepine (a mood stabiliser) and haloperidol (an antipsychotic agent), and he made steady progress for a period of 4½ years. The antipsychotic drug was injected at the clinic, and the mood stabiliser was self-administered.

Eight months prior to the deterioration of his mental health, the man had been assigned a new psychiatrist, but his case manager had not arranged an appointment for him. By the time the psychiatrist saw the man, the case manager had detected a deterioration in the patient's mental state. A break-in and assault at the man's house by his new partner's former husband had unsettled the man and made him feel unsafe. His new partner was not supportive of psychiatric intervention or medication.

The man was stressed and wanted to reduce his medication, a move opposed by the case manager but supported by the psychiatrist. The psychiatrist reduced the man's medication but did not communicate this to the case manager, which led to conflict between the case manager and the patient at the time of the next injection, and a request by the man for a new case manager. The relationship between the psychiatrist and the case manager also deteriorated because of communication issues and the decision to alter the man's medication. A new case manager was assigned.

The psychiatrist formed the opinion that the man was suffering from bipolar disorder rather than from schizophrenia, and that the depression the man was feeling was a side effect of the antipsychotic agent. Hence, he agreed to reduce the medication. At the same time, unbeknown to the psychiatrist, the man stopped taking the mood-stabilising medication. When clear signs of a depressive episode emerged, the patient was restarted on the anti-depressants. However, the man became increasingly depressed and committed suicide.

The Commissioner's expert advisor stated that, although the psychiatrist's diagnosis of bipolar disorder was appropriate, the conclusion that the haloperidol was the predominant cause of the depression was untenable. The fact that the man had remained well on the combination of mood stabiliser and haloperidol for six years made it unlikely that he would suddenly become sensitive to the depressant effects of haloperidol. The psychiatrist had not given enough weight to the traumatic impact of the break-in and attack, and their aftermath. The removal of the mood stabiliser was likely to have contributed to the man's depression. Moreover, the psychiatrist's conviction that haloperidol was the root problem blinded him to other factors and prevented him from eliciting significant information, such as psychotic phenonema, and from giving appropriate weight to the man's history.

Once evidence of evolving depressive/psychotic features began to emerge, the psychiatrist did not record them in the man's risk-management plan, and did not amend the plan accordingly. By not conducting a formal risk analysis as part of the risk-management plan, he failed to identify the seriousness of the suicide risk, and to adequately consider, and discuss with the man and his family, alternative treatments and hospital admission. In addition, the psychiatrist did not ensure that the man was prescribed the correct medication, and that he understood the risks of failing to take it.

The psychiatrist did not keep other team members adequately informed of his actions, and the reasons behind them, and did not educate and communicate with the man's partner and family, despite their role as caregivers. The psychiatrist's lack of adequate records reduced their value to others involved in the man's care.


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