By Robert Lamberts, M.D.
I had a tough situation in the office yesterday.
One of my patients is a 17-year old who went to the ER on Sunday for shortness of breath. They said she had a panic attack and should follow-up with me as soon as possible.
When I saw her, she was clearly distressed, but not to the point of needing to be hospitalized. I asked her what was up and she told me that she had been kicked out of school recently because she stabbed someone with a knife – apparently only after that person grabbed her forcibly. She lives with her mother and her father is a homeless alcoholic. Her mother tells her not to talk to him, but he calls regularly and tells her that she is all he has. He also says that he might kill himself. She knows that he shouldn’t say this kind of thing to her, but it puts her in a hard situation. On one hand, she knows that it tears her apart to talk with him. On the other hand, she fears that if she does not talk to him, he will kill himself.
I asked her if she ever thought of killing herself, and she said she had – especially after talking to her father – but was not at this time suicidal. She had a real good friend with her who was very supportive.
So I am stuck in a dilemma. On one hand, she is clearly depressed and needs both medication and psychological counseling. On the other hand, since there is a black-box warning for using SSRI’s in teens, putting her on one would put me at huge risk for a lawsuit should she follow-through and kill herself. I think she is at very high risk of doing that in the long-run, and don’t really have a longstanding relationship with her as her doctor. I did what I could to tell her to talk with either her friend or me if she should feel she is close to killing herself, but I don’t really know her that well. I am trying to reach one of the local child psychiatrists, but most of them are several months out for new patient visits.
Now I am not trying to solicit advice on the specifics of this case – I really want to give an example of the difficult decisions we face on a regular basis. The lack of good psychiatric care is at the root of a lot of these problems (see my previous post). It is one thing for me to play “amateur psychiatrist” in the adult patient, but when the medical-legal risk is higher, I am faced with a big dilemma. What would you do?