Clinical Cases and Medicolegal Implications

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CAUTIONARY TALES: MISUNDERSTANDING AND MISAPPLICATIONS OF RESILIENCE

Five clinical cases, all observed by the author or reported by colleagues, are presented in this (the third) and the following article in a 5-part series. They involve patients who were misperceived by their family, outpatient psychiatrist, and/or inpatient psychiatric team to manifest psychiatric health, recovery, or resilience, leading to tragic results with potential medicolegal consequences.

Case 1: A Bridge Too Close

Just prior to a meeting of a local chapter of the American Psychiatric Association, one psychiatrist uncharacteristically began to circulate among his colleagues with some urgency, asking that they sign a petition requesting the construction of fencing that could prevent a person from jumping off the Golden Gate Bridge.

When asked why he was doing this, he shared that he had recently lost his son, who had completed such a jump. He stated that his son had shown impressive resilience in overcoming academic difficulties to achieve excellent grades in his classes in high school. Having become popular enough to be elected to the student council, he had returned home from a farewell party given by his classmates prior to departing the next day to attend a prestigious university on the East Coast.

Achieving all this without any psychiatric treatment, the psychiatrist’s son had exhibited at most some mild intermittent anxiety about leaving his family and long-term friends. He did not appear to his family, friends, or teachers to need any serious discussion of his feelings or expectations about going off to college.

On the night before he was to leave, his father congratulated him and wished him success. There was no discussion of the son’s possible fear of failing and the loss of support from family, teachers, and close friends in his hometown. The son did not appear to his father to be dysphoric or unhappy. Later that night, while the family slept, this young man drove to the Golden Gate Bridge, where he jumped to his death.

The psychiatrist repeatedly stated that his son had never expressed any thoughts or feelings to the family or anyone else that indicated depression or suicidal ideation. His suicide, unexpected and shocking to all who knew him, must have been an impulsive act that could have been prevented by a barrier on the bridge that would give him a chance to stop and rethink instead of acting on this impulse.

Understandably, many of the psychiatrists present expressed their condolences and signed their colleague’s petition, while the citizens who had organized the petition drive were considering a lawsuit against unresponsive city officials. (Incidentally, in 2024, a suicide net was put in place under the bridge.)

Case 2: Pictures of Depression

A talented and accomplished young amateur photographer was found unresponsive in his apartment due to an overdose of medications, possibly taken in combination with at least 1 street drug. (The coroner’s report noted significant amounts of marijuana in the patient’s system at the time of death. However, the standard toxic screens did not include what are commonly referred to as “designer drugs,” which may have contributed to the patient’s death.)

At a memorial in a local gallery that featured a showing of the young man’s photographs, the man’s father angrily asserted that his son had been discharged prematurely from a psychiatric hospital. He believed the clinicians had been taken in by their patient’s apparent rapid recovery from a severe, debilitating depression. With antidepressants administered, the young man had manifested positive affect, appropriate social interactions, involvement in individual and group therapy, and, most notably, reinvolvement in his photography. He had reported that he did not feel depressed or suicidal.

The young man’s father argued that the clinicians had ignored his son’s history of repeated psychiatric admissions involving depression, suicidal statements, low self-esteem, and unresolved gender identity concerns. Although his son was once again reviewing his photographs, a photograph he had created not long before his hospitalization showed a severely damaged and decaying automobile, a potential indicator of the depth of his underlying depression. However, the treatment team apparently regarded this photograph as a sign of his return to creativity, with an interesting utilization of structure and color (somber colors, which his father reported were not usual for his son).

In his eagerness to be discharged from a locked unit, return to his apartment, enjoy the company of his peers, and restart marijuana and possibly other drug use, the son had denied experiencing any psychiatric symptoms. Against his father’s protests, he was discharged from the unit with a prescription for medications and an outpatient appointment two weeks later. Tragically, he overdosed and died prior to his outpatient appointment.

At the son’s memorial, the father explained that this pattern of premature discharge without proper exploration of his son’s chronic issues, including his fragile self-esteem, gender identity issues, and drug use, had occurred more than once before. Despite the history taken on admission, his son’s ability to present in less than 2 weeks as much improved once again succeeded in convincing the treatment team, already experiencing pressures from utilization reviews, that he “no longer met criteria for inpatient level of care” and was appropriate for discharge.

The father had been in contact with other parents who had suffered similar tragedies after what they felt was inadequate psychiatric care of their children. Surprised to learn how common this experience was, he discussed with the other parents the possibility of legal action in response to these potentially preventable deaths.

Case 3: An Internship Unfinished

A female intern working in a prestigious medical center on the West Coast was presented to a psychiatrist who had recently completed his residency and begun his private practice. She was referred to him by a senior colleague who stated that his practice was already full. The young psychiatrist felt complimented to receive such a referral from a more experienced colleague.

The intern reportedly was experiencing increasing depression, with symptoms including difficulty sleeping, decreased energy, overall anhedonia, and difficulty focusing on the tasks required to perform adequately in a very pressured environment. After interviewing the patient, who adamantly denied any suicidal ideation, the psychiatrist decided that she should be placed on an antidepressant and should take a medical leave of absence. He scheduled outpatient appointments, which continued for 7 weeks.

At that point, the patient began to self-report that she was sleeping well, felt that her energy and interest in her work had returned, and wanted to discontinue her medical leave and return to her medical duties while continuing the medication and her weekly appointments with the psychiatrist.

The psychiatrist likewise observed the patient’s apparent improvement in energy, affect, and enthusiasm for resuming patient care. He was impressed by her report that she was eating and sleeping well. When he reviewed with the patient the symptoms of depression she had initially reported, as well as the possibility (denied at the time) of suicidal ideation, she adamantly denied that any of these symptoms were present, insisting that she felt stable and capable of returning to work.

Although he believed that her medical leave should continue somewhat longer, the psychiatrist did not find sufficient cause to oppose her return to her internship, especially in view of her promise to continue the medications and her weekly appointments with him. He did not explore her self-reports for indications that she might have been manifesting stoicism in the guise of resilience.

He did take note of subtle messages from the medical school administration expressing concern about the increased workload placed on her peers by her absence. However, she denied feeling any concern regarding possible pressure from her colleagues and some of her advisors not only to continue to cover daily medical admissions and treatment, but also to be included in the on-call schedule (which would interfere with her ability to obtain adequate sleep during on-call coverage every other night). She also denied any potential guilt she might have felt about not “carrying her load,” as is expected of a fully functioning intern.

After continuing her weekly appointments for 4 weeks, the intern failed to keep her next appointment. The psychiatrist repeatedly attempted to contact her by page and phone calls to her apartment, but there was no response. Within a few days, he learned that she had been found unresponsive in her apartment, with empty medication bottles near her body. A toxic screen confirmed that she had died from an overdose of the antidepressant.

Her psychiatrist was left to question his overreliance on the self-reports of a patient whose external presentation, when treated with antidepressants, showed increased energy and positive affect in the context of external pressures and potentially guilt motivating her to return prematurely to a full workload.

Her parents, meanwhile, proud to have their daughter accepted to an internship at a prestigious medical center, with a bright future and no history of psychiatric illness or treatment, were shocked that she had committed suicide. They expressed a firm intention to sue the psychiatrist and the medical center for what they regarded as her preventable death.

Dr Baker, who is board-certified in both child/adolescent and adult psychiatry, has practiced and taught child, adolescent, and adult psychiatry on inpatient and outpatient units; also providing ER and unit overnight coverage as well as consult-liaison and crisis stabilization coverage at various Massachusetts hospitals including Harvard Medical Center teaching hospitals. She served as chief psychiatrist for the Residential Treatment Program at the Italian Home for Children in Boston from 2004 to 2021. She has published an earlier article with Thomas Gutheil, MD, in the Journal of Psychiatry and the Law (Volume 39 Fall 2011) dealing with treatment issues resulting from funding changes on a Massachusetts forensic unit and is a contributing member of the Program in Psychiatry and the Law at Harvard Medical School.