Transporting the high-risk psychiatric patient: Clinical and legal challenges


“I’ve given up, doctor. We gave it our best, but I am at the point where I want to end my life.” You receive this call at 2 a.m., and you’re flooded with a series of emotions and are bewildered – until your training kicks in.

Dr. Lorenzo Norris, editor-in-chief of MDedge Psychiatry, and assistant professor of psychiatry and behavioral sciences at George Washington University, Washington

Dr. Lorenzo Norris

Countless hours of working with patients in emergency department settings while on call as a resident inform your ability to triage the situation. Years of supervision guide your supportive statements as you work collaboratively with your patient to address the emotional and existential distress. As the call proceeds and you realize that your patient will require hospitalization, you are struck by a sobering question: “How am I going to arrange for my patient to go to the nearest hospital in the middle of the night?”

The options for transporting patients with serious mental illness (SMI) typically vary from bad to worse and usually filter down to three possibilities:

1. Get a friend or family member to transport them to the nearest ED.

2. Call emergency medical services (EMS) for transport to the nearest ED.

3. Call the police and request transport to the nearest ED.

Several factors would determine which of those options you would use alone or in combination. Current training paradigms for mental health professionals offer a limited body of literature on evidenced-based strategies for patients with SMI. Transporting high-risk psychiatric patients requires great care and respect, and in-depth knowledge about patients’ vulnerabilities. At best – if not handled properly – these experiences can aggravate patients’ mental health conditions. At worst, they can lead to the loss of our patients. Together, we have more than 40 years’ experience working in complex mental health care systems that run the gamut, from providing direct clinical care to directing mental health care divisions.

Sobering statistics prevail

In 2017, suicide was the 10th leading cause of death in the United States, accounting for more than 47,000 deaths. Suicide was the second-leading cause of death among individuals aged 10-34 and the fourth leading cause of death for individuals aged 35- 54.1 In 2017, more than 70,200 Americans died from a drug overdose, including illicit drugs and prescription opioids.2 Drug overdose deaths nearly quadrupled between 1999 and 2017, from 16,849 deaths to 70,237, respectively.2

Shana Palmieri, JD, a managing partner of Healthcare Legal Education & Consulting Network, and chief clinical officer and cofounder of XFERALL

Shana Palmieri

The life expectancy of an American with SMI is 14-32 years less than that of the average population.3 Those numbers are on par with many sub-Saharan countries, including Sudan and Ethiopia, and surpass the health disparities for most racial and ethnic groups.

The decrease in life expectancy for people with SMI is rarely the result of suicide but rather the effect of medical comorbidities, including heart disease, stroke, pulmonary disease, diabetes, and cancer.3 Individuals with SMI are much more likely to suffer from chronic illnesses that are associated with co-occurring addictions, side effects of psychotropic medications, and social determinants of mental health, such as poverty.

Major depressive disorder among people with SMI presents acute and chronic medical risks. For example, people with major depressive disorder are at a higher risk for stroke and cardiovascular disease.4 There is a threefold increase in cardiac-related deaths for individuals who experience depression after a heart attack.5 In addition, depression increases the risk of cardiac-related death after a heart attack more than any other risk factor, except for congestive heart failure.6

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