Day 138

‘Situational awareness’ (SA) is one of the major tenets of safety in high-risk situations such as aviation, policing and medicine. As the name suggests, it means having an accurate understanding of our surroundings or situation – where we are, what happened, what is happening, what is changing and what could happen. Good SA requires:

  1. Gathering relevant information
  2. Making sense of the collected data
  3. Thinking ahead about possible outcomes

Let’s look at the areas where SA could have been better in my son’s care.

Gathering information:

  1. He was under the care of his GP who saw him 2 days before Day 0. Neither did he talk to him about suicidal thoughts, nor did he get him to fill out a PHQ-9 that would tell him about his overall mental state.
  2. I told the GP that he was really depressed and I would like him to be referred to Psychiatry services but he decided to increase the dose of his antidepressants instead. We know that antidepressants may worsen depression and cause suicidal ideology.
  3. Nobody suggested that he maintain a ‘Mood Chart’ so that the trends in his mental state could be known better.
  4. The patient is a young male with recently diagnosed Bipolar illness who is not on Lithium which is the drug of choice and has proven anti-suicidal effects in such patients.

Ref: http://www.bmj.com/content/346/bmj.f3646

 Making sense of collected data

  1. Given that not much data was collected and my assessment of the situation was not given much attention, there was nothing much to work on.
  2. NICE guidelines suggest that if a patient is depressed for 6-8 weeks, they should be referred to specialist services and he fell in that category but this action was not taken despite being suggested.
  3. It was not picked up that this patient needed specialist care for various reasons that were known : young male patient with recently diagnosed Bipolar illness, severely depressed for 6 weeks, prematurely discharged by Psychiatric services due to extraneous factors without any expert follow-up or monitoring in place.
  4. He was on medications that might increase his risk of suicide.

Thinking ahead about possible outcomes

  1. Young males are at the highest risk of suicide. So, that was a very real possible outcome that was not anticipated.
  2. His illness had been diagnosed only 10 weeks prior so it was very early in its course and hence unstable.
  3. The depression had been preceded by a manic phase and that puts him in a high-risk bracket.
  4. He had shown some signs of improvement over the previous weekend that also put him at higher risk.
  5. No discussion took place with me as his sole carer about his care at home, signs of crisis and when I should think of taking him to Emergency services.

So, our Situational Awareness was poor. Not surprisingly, so was the outcome.

11 thoughts on “Day 138

  1. Even if the antidepressants were fine for him (I’m on 2 different sorts, have tried many more – one flipped me immediately into mania) — none of them take effect immediately, so there should have been more attention paid to what was going on right then, to tide him over while the meds kicked in and while they decided whether the meds were working or not.

    Suicidal ideations should cause the question (by the doctor/s) ‘do you have a method?’ If that’s a yes, it’s then ‘do you have a plan?’ At either of those 2 stages, my psychiatrist would offer hospitalisation.

    I told a GP in the UK that I was suicidal, which I later found out meant she was obliged to contact emergency services. She ignored it completely. One night I was off my head to the point where my mother took me to the ER – I got a tranquiliser and sent home.

    Lithium would have taken quite a while to reach its therapeutic dose (if it had worked for him, sadly it didn’t for me), so he’d still have needed interim care and attention.

    I honestly don’t understand why GPs tend not to refer to psychiatrists a lot of the time. Bipolar people really, really need them. A GP doesn’t have the right qualification or experience in psych meds and in the very, very tricky field of getting them right for each individual bipolar person. I pretty much had to jump up and down and insist on a referral – even with the fact that I pay all my medical bills in cash.

    And yup – a suicide rate 4 x that of the rest of the population and definitely more males than females, in a major way.

    10 weeks into a bipolar diagnosis is very early days. I’m 6 or 7 months into mine and still nowhere near having the right meds. And I see my psychiatrist once a month and have email contact in between.

    Bipolar has been called ‘the cancer of psychiatry’ – it’s a severe condition and needs to be taken very seriously.

    AND you had spoken to the GP and told him your concerns.

    I’d say that the medical field let your son down very badly indeed. It takes time for the patient and family etc to learn about the disorder – and usually by the time of diagnosis, we are in a pretty scared and miserable state.

    It probably isn’t a good idea for you to get into all of this post mortem – but I figured that if you need to, maybe I can offer a little info. And a massive virtual hug.

    Liked by 2 people

    • That is very helpful indeed. Thank you. I go over this again and again in my head but only write about it occasionally. When he was diagnosed, it was a very confusing and traumatic time for all of us. I did not have a clue about what to do for a few days!

      Like

      • When I was diagnosed, I sat in a sort of stunned silence for about 24hrs, then howled my eyes off for the next 24, and stayed bloody miserable about it for a long time. I imagine that if I had a kid who was diagnosed, I’d probably feel even worse, because good mothers care and often take the blame, at least initially. It’s a huge thing to face and there is no certainty of a positive outcome no matter what.

        Liked by 1 person

      • Writing it all out ruthlessly will probably help you get through it, as long as you can stop at the end (yes, there is one). If you don’t want to blog stuff, write it on paper (and/or write to him) and burn it outside so the smoke can get to the sky.

        Liked by 1 person

  2. Sometimes I wonder if Carers are thought to be competing with the GPs and all that crew? My mum got a similar treatment from them over and over until the eve of my brother’s demise. Even he who we thought was as gentle as a lamb, attempted suicide by over medicating during a very bad depressive episode which lasted at least 3 months. Thanks for sharing and hope you feel better as the days go by

    Liked by 1 person

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