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‘Suicide watches’ often destined to fail

The New York City medical examiner's office made a statement on Sunday, after completing the autopsy on the accused sex trafficker.

Every mental hospital, jail and prison receives patients and inmates who are suicidal. In psychiatric hospitals these days, suicidal actions and thoughts are a chief reason for admission. In prisons, suicides are the main cause of death. In jails, the rate of suicide is up to three times higher than prisons because jails are smaller, and there is often no screening and little watchfulness. For acutely suicidal persons, watchfulness is the only mechanism for ensuring safety; there are no drugs available to reduce acute suicidality; ketamine is currently being championed for the purpose, but the drug is still largely experimental.

In hospitals, there are various levels of suicide watch. The highest is one-on-one, whereby a staff member must constantly be in the presence of the patient, often at arm’s length. Next comes 15-minute checks, and then 30-minute checks. But even 15-minute checks are fraught with danger, as a patient can hang himself and strangulate in a few minutes. Thirty-minute checks are rather useless for a seriously suicidal patient. Most suicidal patients have already figured out where to hang themselves and with what appliance — shoe laces, a bedsheet, a belt. Hence these items are regularly confiscated for a suicide watch. But a determined patient can still find ways using wiring or pieces of string, or another person may furnish him contraband. Those who truly wish to die eventually succeed, despite all the precautions available.

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In mental hospitals, there are enough staff to attend to the various levels of watchfulness and therapy can occur. In jails and prisons, the situation is very different. Guards have many duties; one-on-one watch is not possible. Thus, suicidal patients often are put into a bare room and dressed in paper gowns that cannot be torn apart. The watchfulness is tantamount to social isolation and sensory deprivation, and the prisoner is utterly alone, without any therapeutic intervention. Television monitoring may occur, or the inmate may be housed with another prisoner who, presumably, will sound an alarm if any kind of suicide is attempted.

In hospitals, seclusion often takes place after a patient has been violent, but staff may be assigned to watch the patient, or television monitoring may occur. Being intrinsically therapeutic, a hospital goal is to remove the patient from seclusion as soon as possible. In prisons, removal for treatment occurs far less because, in fact, there exists no therapeutic milieu.

Outside forces sometimes operate. Parents or spouses or attorneys may advocate for more humane conditions and demand that the inmate be integrated within the general population, but, in effect, this moves him to a place where he cannot be watched. Superimposed on the problem of watchfulness is the insidious issue of morale and attitude. Guards may feel that an inmate who has committed a heinous crime, such as child molestation, deserves the worst outcome. Suicide is viewed as a naturally occurring event, not as a dire illness that needs intervention.

Forensic institutions for the criminally insane have physicians on staff, and guards have more training in mental illness. I visited one in Denmark in which staff were highly educated; indeed, the culture of the institution was so relatively benign that a fish tank was in the main lounge. Contrast this with other inhospitable and dangerous places I have been where guards are sullen and little attention is payed to the plight of mankind.

Screening for suicide is not simple. Many patients and inmates hide their suicidal impulses. Others become acutely suicidal only after realizing the hopelessness of their lives, but they do not necessarily tell anyone.

Even in hospitals, suicidality is denied. Indeed, in today’s world of insurance coverage, a nurse might pop into patient’s room to ask if he is still suicidal today. If the patient happens to say “no,” this could lead the insurer to halt further inpatient coverage. It is as if suicide comes and goes like the wind, when in fact suicidality is a chronic illness often configured in the mind of man at an early age. It is not easy to cure, much less prevent in a place where few care about what happens.

Dr. John R. Lion (newtlion@aol.com) is a psychiatrist in Baltimore, a clinical professor at the University of Maryland School of Medicine and on the courtesy staff of Sheppard Pratt Hospital.

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