Case Study: Treating Mental Illness — Best Practices Win the Day

Repurposed from The Scope, First Quarter, 2025

The 25-year-old female patient in this case had a tumultuous family life, alternating between residing with her family and with other relatives. She suffered a mental breakdown at age 16, requiring admission to a psychiatric hospital, which was attributed to her social history. Thereafter, she was treated by a psychiatrist for bipolar disease.

While attending a university, the patient continued weekly treatments with counselors on campus. In her junior year, she was admitted to the hospital as she had not been taking her prescribed medications for several weeks. She was discharged and returned to campus but left school before the end of the semester due to severe stress. She continued to seek counseling and inpatient treatment at various hospitals and facilities and attended outpatient counseling sessions.

Hospital Admission

The patient was subsequently admitted to the emergency department (ED) of a MLMIC-insured hospital with suicidal ideation, having attempted to set papers on fire outside the counseling facility prior to a session. Police were called, and she informed them that she was suicidal, wanted to kill herself, and had a plan in place to do so. She was initially seen by a nurse practitioner, who noted that the patient presented with suicidal ideation. The patient denied drug and alcohol abuse and raised no medical concerns.

The patient was then seen by a social worker. The patient was noted to have a history of borderline personality disorder and reported that her case manager was not available that day, thus triggering her to act out and try to start a fire. She denied suicidal/homicidal ideation or intent to harm herself at that time and demonstrated no sign of psychosis. She was future oriented, with plans to see her therapist, attend a medical appointment, and keep an appointment with her psychiatrist the following week.

The patient was next evaluated by a psychiatrist, who noted her borderline personality disorder, anxiety, schizophrenia, depression, and multiple prior ED visits. She appeared to have a history of seeking shelter in the hospital when she was experiencing life challenges. The patient admitted that she wished to be hospitalized but denied being suicidal. She stated she had become upset when her case worker left on vacation.

The patient was noted to be on medications, including several trials. Her physical exam was within normal limits, and she was diagnosed with borderline and dependent personality disorder. The patient was pleasant during her interview, and there were no signs of psychosis. The plan was to discharge her with follow-up at an outpatient clinic. Care was coordinated between the hospital and psychiatric counseling services for her to attend a counseling session upon discharge.

After discharge from the ED, the patient attempted to arrange for transportation without success. She contacted a family member, who advised that the patient was no longer welcome in their home. In addition, she attempted to contact some agencies for housing but could not get in contact with anyone to assist her. At that point, the patient went to a wooded area, where she threw herself down an embankment. As a result, she suffered two broken legs, a spinal fracture, and a fractured pelvis.

The patient was brought via ambulance back to our insured hospital but was later transferred to another hospital, where she underwent multiple surgeries and remained during her rehabilitation. After four months, the patient was discharged to a psychiatric facility and later discharged to live independently.

Lawsuit Filed…and Verdict Reached

The patient brought a lawsuit against the MLMIC-insured hospital and psychiatrist, along with the nurse practitioner and social worker. She claimed negligence in the failure of the hospital and their employees to admit her due to suicidal ideation. In addition, it was claimed that her discharge plan was deficient as the hospital failed to contact her family and ensure that she would be returned to a safe environment. The plaintiff’s counsel made a demand of $5 million.

MLMIC’s psychiatric expert opined that the standard of care was met as the patient was not suicidal during her admission to the ED and concluded that the patient had a borderline personality disorder with heightened reactivity and impulsiveness. He felt that the post-discharge events where the patient felt rejected triggered the suicide attempt.

During her examination in the ED, the patient was found to be rational and future oriented, with intention to continue with future treatment, thus demonstrating that she was not suicidal. The standard of care for borderline personality disorder would have been to avoid inpatient hospitalization as these patients do not fare well in an institutional environment.

Prior to trial, the hospital, nurse practitioner, and social worker moved for summary judgment and were successfully dismissed from the lawsuit. When the case proceeded to trial against the psychiatrist, the plaintiff did not present as overly sympathetic but had significant, documented injuries.

The plaintiff’s expert testified to departures by the psychiatrist in his evaluation and assessment of the patient and his decision to discharge her. MLMIC’s psychiatry expert testified that the standard of care was met in that our insured properly evaluated the patient, determined that the patient was not suicidal, and made an appropriate plan for discharge. The patient’s attempt at suicide was sudden and unpredictable and emerged from a series of events that developed after her discharge. At the conclusion of testimony, a decision was made to enter into a high/low agreement. The jury received the case and, after deliberations, returned a verdict in favor of the defense. However, as MLMIC had entered into a high/low agreement, we were required to pay the “low” of $350,000.

Risk Management and Legal Analysis

Bipolar disorders are very difficult for physicians to treat. The patient in this case had all the symptoms of this condition, including emotional instability, a history of unstable relationships, and difficulty trying to maintain relationships. She also felt a lack of worth and was unable to regulate her emotions and maintain relationships due to her lack of emotional control. This was exemplified by her negative relationship with her family. The patient also exhibited a lack of impulse control, as her suicide attempts revealed. Her view of life was altered, as she felt that “everything in her life was bad.” Unfortunately, due to this often-expressed belief, attempted suicide can be construed as an attention-seeking mechanism. However, interestingly, the patient was able to maintain herself for some time in college before her condition seemed to exacerbate.

People diagnosed with bipolar disorder tend to be unable to control their emotions and have mood swings. They often feel anxious and empty and without self-worth. The National Institute of Mental Health, part of the National Institutes of Health, confirms this by describing a person with this disorder as having an inability to control emotions, feelings of anxiety, and no feelings of self-worth. Relationships with other individuals are often perceived as all good or all bad. Therefore, since this patient had a distorted image of herself, she would be likely to engage in impulsive behavior, such as attempting suicide.

This patient visited the ED frequently and attempted suicide several times. Her inability to sustain any type of relationship with her family eliminated the potential for obtaining key support. Therefore, to the professionals in the ED, her frequent mood swings and other behaviors fit the pattern of a typical bipolar patient. Although these patients can and do participate in some behavioral therapy, bipolar patients present treatment difficulties to providers as medications are not typically used unless the disorder is associated with depression, as with this patient.

From a legal perspective, the psychiatrist’s choice of treatment, proper examination of the patient, and documentation in the ED record were able to overcome the arguments of the plaintiff’s attorney, whose main allegation was that the patient was not properly evaluated. In addition, there was an allegation that this patient did not have the cognitive ability to care for herself and that the psychiatrist, as part of his examination, did not evaluate her for suicidal risk.

Documentation of his findings was key in successfully defending against the plaintiff’s claims, resulting in a verdict that was favorable to the defendant. The plaintiff’s argument was not supported by the documentation, which clearly indicated that the patient was told to return to the ED if she had a recurrence of suicidal ideation.

 The patient, appropriately, was also given an appointment to be seen by a therapist and was cognitively evaluated as to whether she was able to care for herself.

Documentation of risk is always necessary when dealing with a psychiatric patient. Finally, the patient was placed on Effexor, an antidepressant medication. This was also reasonable treatment given the symptoms the patient was experiencing. Despite all the appropriate handling of the patient’s condition, she attempted suicide after leaving the ED.

When a psychiatrist chooses a course of treatment within the range of medically acceptable choices, based upon a proper examination and evaluation, the doctrine of professional medical judgment insulates the psychiatrist from liability.¹

Thorough documentation is always beneficial to defend against allegations in a medical malpractice lawsuit. As exemplified in this case, progress notes clearly reflected that the patient was both properly evaluated and treated for suicide risk. The patient denied suicidal ideation, planning, or intent. The fact that she later attempted suicide does not necessarily change the defensibility of this case, since suicide attempts are often unpredictable. It is very likely that the outcome of this litigation would not have been favorable to the defense if the documentation had not been thorough, reasonable, and appropriate. Psychiatric cases are difficult to evaluate in a busy ED, but in this case, because of good documentation of an appropriate examination, the defense was able to prevail.

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Sources:

1 Dumas v. Adirondack Med. Ctr., 89 A.D.3d 1184 (3d Dept. 2011). Durney v. Turk, 42 A.D.3d 335, 336 (1st Dept. 2007).

This document is for general purposes only and should not be construed as medical, dental or legal advice. This document is not comprehensive and does not cover all possible factual circumstances. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors for any questions related to legal, medical, dental or professional obligations, the applicable state or federal laws or other professional questions.