Cases That Test Your Skills

The nurse who worked the system

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Ms. Y has been hospitalized for suicidality 49 times in 6 years. Until now, her providers have condoned her sense of entitlement. How would you intervene?



CASE: A ‘high utilizer’

Ms. Y, a 49-year-old intensive care registered nurse, is admitted to the psychiatric hospital for suicidal ideation for the eighth time in 1 year. Ms. Y has chronic suicidal ideation with multiple attempts and has been on disability for 3 years for treatment of severe depression. She has been hospitalized for depression with suicide ideation 49 times since her divorce 6 years ago. She is prescribed fluoxetine, 60 mg/d, quetiapine, 400 mg/d, and clonazepam, 2 mg/d.

Ms. Y reports the same series of events that preceded her previous hospitalizations: severe insomnia led to a worsening of her other depressive symptoms, including intense suicidal ideation. In an attempt to sleep, she took “a couple” of extra clonazepam. She called her therapist, who was alarmed by her slurred speech and pleas for help. A friend drove Ms. Y to the hospital, where she was directly admitted without being evaluated in the emergency room (ER).

The authors’ observations

Ms. Y possesses 7 of the 11 characteristics of a high utilizer of psychiatric services (Table 1),1,2 defined as a patient who is:

  • 2 standard deviations above the mean number of visits to an urban psychiatric emergency service in 6 months or
  • has 4 inpatient admissions in a quarter or 6 inpatient admissions in 1 year.
Ms. Y always is directly admitted because she refuses to go through the ER for evaluation. She seems to know just how much medication to take to remain medically stable. She receives special treatment—she can call her therapist, ask for admission, and have her request granted. Until now, Ms. Y’s care providers have condoned her entitlement.

Table 1

Common characteristics of high utilizers* of psychiatric services

Developmental delays
Enrolled in a mental health plan
History of voluntary and involuntary hospitalization
Personality disorders
Likely to be uncooperative
Substance abuse or dependence (or history)
History of incarceration
Unreliable social support
Young Caucasian women
* Defined as having either 2 standard deviations above the mean number of visits to an urban psychiatric emergency service in 6 months or 4 inpatient admissions in a quarter or 6 inpatient admissions in 1 year
Source: References 1,2

The author’s observations

Because previous hospitalizations and courses of ECT have provided Ms. Y with only minimal, short-lived improvement, the treatment team decides to reconsider her diagnosis and treatment plan. Ms. Y’s first psychiatrist diagnosed her with major depressive disorder. After thoroughly interviewing Ms. Y and reviewing her history, the hospital psychiatrist determines that she meets criteria for borderline personality disorder (BPD) in addition to major depression. The psychiatrist explains this diagnosis to Ms. Y, provides her with education and support, and recommends dialectical behavioral therapy (DBT) and case management. She rejects the new diagnosis and treatment plan and pleads for help establishing treatment with a new psychiatrist.

The team at the psychiatric hospital feels Ms. Y needs to receive ongoing treatment from a psychiatrist. In the hope that she will be able to establish a therapeutic alliance with a new psychiatrist and therapist, they decide to continue working with Ms. Y if she accepts the BPD diagnosis and agrees to undergo DBT.

EVALUATION: A troubling pattern

Before Ms. Y’s husband divorced her, she had not received psychiatric care and had no psychiatric diagnosis. During the contentious divorce, she experienced depressive symptoms that later intensified, and she was unable to return to her previous high level of functioning.

Ms. Y became suicidal and was hospitalized for the first time shortly after the divorce was finalized and her ex-husband remarried. She began treatment with a psychiatrist, whom she idealized and saw for 5 years.

When this psychiatrist—who had been one of the few stable relationships in Ms. Y’s life—moved to another state, Ms. Y experienced a rapid recurrence of depression. She began treatment with 3 other psychiatrists but fired them because they “never understand me” like her first psychiatrist did, and she never felt she received the consistent, supportive care she deserved. She become suicidal and again required psychiatric hospitalization. This pattern continued up to her current admission.

The authors’ observations

Ms. Y briefly returns to work between hospitalizations but is not able to tolerate the stress. At one point she was admitted to an out-of-state facility; after this 2-month stay, she remained out of the local psychiatric hospital for 6 months but then became unable to function and was readmitted to the local psychiatric hospital.


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