Friday, April 29, 2005

Murder-suicide leads to suicidal response

A distraught and depressed lady in Colorado Springs shot her two sons and then turned the gun on herself a few days ago. There were many factors involved, to be sure, including job loss, husband having to work out of state, bipolar disorder, etc. The details can be seen in this Rocky Mountain News article.

So, what does this have to do with a medical blog? Well, it turns out that this unfortunate lady had been taken to a Colorado Springs hospital the previous day for threatening suicide; she was seen, evaluated, and released. Subsequently, the now typical vicious finger-pointing has started, with blame for this tragedy being assigned to the hospital and its staff. What irks me, however, is the irresponsible nature of the remarks made by the pastor of the church that this lady and her family attended. Without a good understanding of how psychiatric patients are evaluated in emergency rooms, he publicly launched into a tirade against the treating facility:

"What were they thinking?" Haggard said. "She's bipolar, she's under pressure. She's ADD, she's on medication and she's distraught, and they send her home? They might as well have sent her to Kmart. She would have gotten better care there."
That's not they type of compassionate, introspective thought I would have expected from the leader of a 12,000 member church. Mental health problems abound in this country, and their treatment is a very inexact science. It is also profoundly underfunded. With incidents such as this, there is always a (natural) response of regret --- often, the signs of depression are there, but it is hard to grasp how serious the situation is until it is too late. This post is not designed to criticize Rev. Haggard's theology and approach to religion. However, a pastor, of all people, regardless of denomination, must be sensitive to the difficulties associated with dealing with depression.

Indeed, the signs of depression were there, and their import was missed. A neighbor remarked:
"I knew she was depressed. Everyone in the neighborhood knew she was depressed, but not to that point."
Even the pastor had noted changes. Their children had gone to the same school until recently, and the family had attended his church, but:

Haggard said he hadn't seen Julie Rifkin for nine months.

"Most of the years I knew her, her husband was gainfully employed and she was around with her boys," Haggard said.

"The past year or year and a half of pressure has been incredible on them."

Perhaps, rather than publicly chastising the hospital, a more appropriate response would have been to privately express concerns to the hospital, hold a meeting with the administration, and help work towards a system that might prevent incidents like this in the future. Perhaps as the leader of such a large congregation Rev. Haggard could seize this opportunity to educate his flock to the signs and symptoms of depression; establish an early intervention program; work with the local hospitals to start a volunteer system that checks on patients seen and discharged from the emergency department; do something other than try to assign blame. Finger-pointing and back-biting are not going to bring this lady and her two sons back to life. If the people that knew this lady the best (church members that had not seen her in 9 months, neighbors, etc.) were unable to prevent this tragedy, it is hard to point fingers at an overtaxed emergency room that sees more patients than any other in the state (I don't work there; the statistics are published yearly). I am not blaming Rev. Haggard for his feelings; this is a very difficult and emotional issue to tackle. I just wish he would find a more constructive outlet for them.

As a physician, this issue hits close to home. I have missed diagnoses. I have sometimes made the wrong decision in the course of a patient's care. There is no worse feeling in the world, but fortunately in my field these are rarely irreparable mistakes. But, I guess that in the mind of
Rev. Haggard, that makes me equivalent to a K-Mart stock boy when it comes to my ability to care for patients.

As a physician, this issue cuts deep. I care for trauma patients, and often see patients who have attempted, or are successful with, suicide. Many, like this lady, have no good option for mental health care, as they are uninsured or have Medicaid --- and there simply is no funding for these patients to be seen or hospitalized. It is frustrating to have a patient attempt suicide, be treated for their injuries, spend a paltry few nights on an inpatient ward, and be discharged........and come back a few weeks later with another, sometimes successful, attempt.

As a person, this issue hits close to the heart. I have missed the signs of overwhelming depression. I have missed the subtle (and not so subtle) clues that someone is contemplating taking their own life. It is part of the reason that I started writing this blog, trying to find a way to express my own thoughts and emotions about whatever crosses my mind. You see, my brother was successful in his attempt a few years ago. And I have to live with that every day.