Q:  When Should I Go to the Hospital?

just a quick question.. i have read about so many people that have gone to the hospital. I am not sure for what reason.  when do you say let's go?  i guess i am tring ask at what stage do you think it would be good to go to the hospital..  now i wound up in the hospital because of suicide attempts in the past, but i walked out of the hospital within hours of being in the er. no one has said anything to me. even with seeing the scars on  my arms and wondering why would sombody take all those pills..  i did not go to the hospital on my own.. i had no idea i was going..  so when would you say is a best time..           

Dear M' -- 
Well, that's a practical question, although one we might hope doesn't need answering very often in any given person's life. In fact, how often this question needs answering is kind of related to the answer! Let's think of this two ways: first, for a person who has never before been in a psychiatric hospital and is now extremely depressed, for the first time in his life, and thinking about suicide (Robert); and then, for a person who's been hospitalized 10 times before, and is having suicidal thoughts again (Susan).

Robert: the purpose of hospitalization for Robert might be (at least) twofold -- first, to prevent suicide; and secondly, to get more aggressive treatment going for his depression. He might be under the care of a primary care doctor, for example, who referred him for psychotherapy (but Robert didn't go) and started him on an antidepressant.  (We should wonder if the antidepressant might be part of why Robert is now thinking about suicide; that's what the FDA was recently trying to get people to be thinking about, with their new warnings. But let's say Robert was having vague thoughts about suicide before the antidepressant, and now those have just gradually intensified, as his depression has gradually worsened without any new features.  All this would suggest that the antidepressant is not the problem, as far as the suicidal thinking goes). 

In this case, as long as Robert is okay with the idea, we might want to think about hospitalizing Robert pretty early on, not waiting. Perhaps he can see a psychiatrist this way much more quickly than if the primary care doc' tries to refer him. Perhaps Robert's suicidal thinking is just now beginning to involve thinking in a more concrete way about how he might take his life. Perhaps the depression has reached the point where Robert can't really accomplish anything at work, even though he's still going there every day, and he might be at risk of losing his job now. For any of these reasons, we might think to put Robert in the hospital; indeed, we perhaps should have thought to do so before these points were reached. 

By contrast, consider Susan. She might have been hospitalized the first time for reasons such as Robert's. But now, she's been around that loop 10 times. Each time, her depression comes back and her suicidal thinking returns.  Now the situation is getting tricky. We might say that "hospitalization is of no lasting benefit" and not put her in. That's how we used to do it in New Mexico where I trained. But in Oregon, we don't do that. Oregon is a richer state, all told. So a different attitude is affordable, apparently (this is an extremely complex issue, mind you; one could write a book about all the factors that are involved in determining how a medical care system approaches this issue). In Oregon, we keep putting Susan in the hospital every time she says she's suicidal -- for a variety of reasons, but one of the biggest is that medical professional who is told that could easily be sued if they don't help get Susan into the hospital and then Susan later kills herself. 

But one group of authors, at least, has wondered whether hospitalizing Susan might actually be bad for her. After all, the process teaches her "when life is overwhelming, say "suicide" and you'll find all your immediate stresses removed and be placed in a warm, supportive environment" (a very odd environment, granted, but most people figure out within 24 hours that while it's weird, it's a good place to be, at least in my local hospital's psych' unit). So maybe, say these authors (e.g. Kurt Strosahl, though I haven't kept up with what has happened to this thinking recently), hospitalization is actually reinforcing suicidal thinking, and therefore we should avoid hospitalizing people like Susan because we may actually be harming them thereby.

A program designed by a very good research psychologist (Marsha Linehan, Ph.D.) was developed around this idea that hospitalizing could basically be teaching the wrong message; and that instead a different message could be taught that would be much more useful in the long run. It's called Dialectic Behavioral Therapy, or DBT. Given the cuts on your arms, this might be a program worth learning about. Here's one good summary; and the website on which it appears has a section on self-harm behaviors generally. Unfortunately, good DBT can be hard to find, so be careful there, don't get your hopes up all of a sudden. 

You can imagine all the variations between Robert and Susan. So there are many answers to your question, as you can see; it depends on the person and her/his situation and history. I hope this little essay may give you some structure for seeing how those decisions are made. I do not intend here to tell you anything about how to make yours.  Good luck with that, though. 

Dr. Phelps 

Published April, 2006