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GPs' views: Wife begs you to help suicidal husband who refuses to see doctor

Three GPs share their approach to a practice problem

Three GPs share their approach to a practice problem

Case history

You are duty doctor for the afternoon; Mrs Smith is on the phone and wishes to speak to you urgently about her husband. You have never seen Mr Smith, but he did see a locum two months ago asking for sleeping tablets. The record notes that he was quite depressed, but without any suicidal ideation. He did not want any antidepressants, so was advised to come back for review in two weeks. He has not attended since.

Mrs Smith is very worried. He has become much more depressed, has stopped going to work, and after a lifetime of moderate drinking, has taken to the bottle. Over the last few days he has started talking about ending it all; she is very frightened, but he absolutely refuses to consult a doctor. She asks you not to tell him she has called.

Dr Patricia Cahill 'Mrs Smith might not be aware he saw the locum so confidentiality must be protected'

If I know this woman, it will be easier to assess the situation. I have to decide from my conversation with her how urgent this matter is. The request for hypnotics and the history of alcohol could point to an addictive problem. Whether it is alcoholism or depression, Mr Smith may be getting angry and irritable with his wife. Mrs Smith could well be under strain, she herself could be depressed and could be the priority patient.

I wouldn't want to feel manipulated in any way or get involved in marital strife. While I am on the phone, I would look at Mr Smith's notes. I would be careful of what I said, ensuring I maintained patient confidentiality. Mrs Smith may not be aware her spouse has been seen.

Ideally I would want to speak with him on the phone. If I feel this man may be at risk of suicide, I would visit him, probably straight after surgery, unless it was clear that it could wait.

I would ask Mrs Smith to mention to her husband that she had called me. If she was fearful of this, I could be tactful when I had contact with Mr Smith, but couldn't promise that he would never find out.

If he does need to be admitted to hospital, and this is against his will, family relations can be very damaged, especially if he sees a compulsory admission as his wife's fault. Unless there are exceptional circumstances, I would not want to consult with a patient when in collusion with another.

I hope, when I talk with Mr Smith, that I would be able to engage with him in a meaningful way, which will be difficult if he is drunk. If he appears to be a significant risk to himself or his wife because of his mental state, I would arrange admission to hospital, preferably with his consent. If he doesn't need immediate treatment, I would aim to build some rapport and arrange follow-up.

Patricia Cahill has been a GP for 10 years ­ she practises in Ipswich, Suffolk

Dr Kieran Walsh 'Mr Smith has all the risk factors and his wife is right to be worried'

About 4,000 people in the UK kill themselves every year. Could this man be one of them? Certainly he has many risk factors for suicide. He is male and depressed and has a problem with alcohol. Most importantly, he has started talking about ending it all. So Mrs Smith is right to be worried and her worries must be taken seriously and dealt with as soon as possible.

First of all Mr Smith must be seen and assessed. The assessment must weigh up his risk of suicide: is he preoccupied with suicidal thoughts? Has he made a plan to kill himself? Has he taken steps to start carrying out that plan? Is he hearing voices telling him to end it all? If the answer to some or all of these questions is Yes he needs urgent referral to a psychiatric unit.

But how do you make the assessment if he refuses to see a doctor? You could take a non-confrontational approach.

You could try to convince his wife that you are going to have to make a visit and she should tell her husband and try to convince him this is necessary. He may relent and see sense. During your visit he may agree to talk to you and subsequently agree to admission to hospital if you feel this is necessary.

But what if he doesn't see sense? The alternative is a compulsory admission for assessment. This must be by an approved social worker and a psychiatrist and a doctor who knows the patient ­ typically his own GP. The practice may have a mechanism for contacting the patient's own GP in emergencies such as this.

Kieran Walsh worked as a clinician before moving into medical education ­ he currently works on a medical education website, teaches MRCGP candidates and helps set exams for MRCGP Ireland

Dr Nigel De Kare-Silver 'I've often found when you actually visit they are grateful, not hostile'

You are told this man is depressed with suicidal ideation. On its own it is difficult enough to see a patient who by all accounts is seriously ill, but refusing to come to see his GP. When the patient is seriously depressed it is even more so. The apparent alcoholism compounds the problem.

No easy clinical intervention exists to make anyone stop drinking and, certainly in our local experience, psychiatrists frequently do all they can, regardless of the severity of self-neglect or suicide intent, to back away and hand over to alcohol services, themselves weak at engaging people. He will need to be visited and will need a long time.

Ahead of this you will need to negotiate with his wife, telling her that, despite her anxieties, it is important you do visit, even though this will mean revealing her as the source of those concerns. In such circumstances I have often found when I actually knocked on the door I didn't get the hostility I was anticipating. Many people recognise they are ill and, though they are verbally antagonistic to their family, are very grateful when they see the doctor has come out of his way to find them.

The priorities must be to unpick how much he is drinking, and how close to suicide he is. Treatment is difficult. For all the support your arrival holds out to the patient and his family he will learn you are limited in what you can offer. Alcohol services will support him but only if he genuinely wants to stop drinking and not on an immediate basis.

Psychiatric services will see him but you may need to battle with them to get an appointment. If he is seriously suicidal he will need an assessment by the mental health team with a view to sectioning, itself a humiliating and time-consuming experience and often pejoratively handled by the team once they are aware of any alcoholism.

Were it to come to hospitalisation, he may be off your workload for a number of weeks and may emerge less depressed than earlier but with underlying precipitating issues barely touched.

Nigel De Kare-Silver is a GP in north-west London and a trainer and course organiser

What does this incident teach us?

Responding to requests for visits

  • Requests for advice, prescriptions and even conversations outside the chip shop should all be considered potential visit requests.
  • A good telephone consultation can allow you to accurately assess the need for a visit and its urgency. It can also make your visit easier by preparing you, the patient and relatives.
  • In this case, you can make sure of the phone numbers for the community mental health team and approved social worker, check both the patient's and carer's records for previous history, and perhaps warn the carer of possible outcomes.
  • Do not promise to keep the caller's identity secret. Doctors rarely make social calls to patients they don't know!
  • Should you have a policy of telephoning all patients prior to visiting?

Assessing suicide risk

  • Do you have a clear idea of how to assess suicide risk?
  • Always try to ask about suicidal ideation but prepare the ground first with questions like 'Do you find life is not worth living sometimes?'.
  • As well as looking for isolation, severe depression, psychotic symptoms and evidence of alcoholism as risk factors, check for specific plans and consider access to the means to commit suicide and opportunity.
  • Failure to inquire about suicidal ideas is a common reason to fail in the video component of summative assessment.

Continuity of care

  • Both these patients are likely to continue to consult you after this crisis and building up a trusting relationship with both is important.
  • His wife needs support as a carer and her needs may influence your decision about admission.
  • A good consultation: patient-centred, with active listening, aiming for a shared understanding of the problem, will improve the chances of concordance, including voluntary admission.
  • Although compulsory admission may strain the doctor-patient relationship, this sort of consultation and honesty at this stage is likely to reduce any damage.

Alcohol problems

  • The patient's level of dependence on alcohol requires assessment.
  • Compulsory admission is not appropriate if this is the primary problem
  • Expect the third degree about this from the psychiatrist if seeking admission, especially if the patient has been drinking today.

Richard Stokell is a GP in Birkenhead, Merseyside

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