Paul is a 28 yo man with schizophrenia who has been psychiatrically stable and taking aripiprazole 15mg daily for five years. He lives by himself down the street from his parents and works full-time as a security guard. Two months ago, his aripiprazole refill was delayed for 2 weeks. Paul noticed that he had significantly more energy without the aripiprazole. Since he hadn’t heard voices in 4 years, he decided not to restart the medication.
Unfortunately, Paul began to hear voices again – first one, then multiple voices – telling him what he should do, then what he must do or else something bad was going to happen to his parents. Paul became very paranoid, stopped going to work, and stopped leaving his apartment. He continued to talk with his parents daily by phone but would not see them in person because he felt that his presence would endanger them.
Paul’s parents urged him to restart the aripiprazole, but Paul thought that the medication might kill him. Paul’s parents reach out to you for help. They’ve tried to convince Paul to go to the emergency room, but he won’t leave the house. Is there anything they can do? Paul has no history of suicidality or violence. You call and message Paul on the patient portal but he doesn’t respond.
How do you find crisis mental health resources?
In July 2022, the 988 Suicide and Crisis Lifeline launched. 988 is a national hotline available 24/7, 365 days a year. It is operated by 200 local, independently owned and operated crisis centers in the US. While there had been a national suicide hotline for years, 988 was developed as an alternative to 911 for mental health emergencies; it is both a number patients can call at 3am if they are feeling suicidal, and a resource to learn about local mental health crisis resources anywhere in the country.
988 calls are routed to the nearest crisis center for immediate counseling and information on local mental health services. One can also call 988 and request to be routed to a crisis center in another part of the country. If a local center is unable to answer, the call is routed to a national backup network.
Services through 988 are available in English, Spanish, and American Sign Language, and there are also subnetworks that connect with specialized services for Veterans and LGBTQI+ youth and young adults. To access this resource, patients, families, friends, and clinicians can call or text 988 or chat at 988lifeline.org.
988 is anonymous and confidential – if the caller does not provide their specific location, the counselor at 988 will not know where they are. If a caller identifies their location, is suicidal, cannot or will not work with the counselor on a safety plan, and the counselor thinks the caller will harm themselves imminently, emergency services will be called. This may be a mobile crisis team but could also be the police, particularly in rural areas. While most 911 calls result in the dispatch of emergency services, only a minority (<5%) of 988 calls result in the dispatch of emergency services.
Back to Paul
You call 988. You explain the situation to the counselor who answers your call, and she redirects the call to the crisis center near where Paul lives. You learn from that counselor that there is a local mobile crisis team near Paul and are connected by phone to that team. You speak with a social worker on the mobile crisis team about your concerns for Paul, and the team arrives at his door an hour later. Unfortunately, Paul will not talk with the mobile crisis team or open the door.
Paul’s parents talk with the mobile crisis team outside his apartment. Because there is no current concern for violence or suicidality, and thanks to food delivery services, Paul is taking care of his basic needs, there are no grounds for involuntary hospitalization in California. The mobile crisis team provides Paul’s parents with information about nearby psychiatry clinics with drop-in availability, in case Paul becomes open to psychiatric care.
You also review the criteria for involuntary admission in California with Paul’s parents. Someone can be involuntarily hospitalized only if they are an imminent risk to themselves or to someone else or are gravely disabled due to a mental illness. If Paul were brought to the emergency room in the future, he is more likely to be admitted if his parents emphasize the parts of his behavior that demonstrate imminent risk to himself or others or a lack of self-care due to psychosis. For example, it is more important to tell the emergency room doctor that Paul hasn’t eaten in a week because he thinks his food is poisoned than that he talks to himself all day because he is hearing voices.
At the end of the day, you are disappointed and exhausted. This case took up most of your afternoon, and Paul is still not in psychiatric care. You debrief the case with a colleague and realize that some things were accomplished: Paul’s parents now have local resources for accessible outpatient psychiatric care, and the local mobile crisis team is aware of the situation and available to consult. You acknowledge that this is a scary situation and that you have limited control.
What other support is available for Paul’s parents?
My worries about a patient generally pale in comparison to what a family experiences. NAMI, the National Alliance on Mental Illness, is a non-profit organization that supports families affected by serious mental illness through advocacy, education, and support. NAMI continues to play a major role in advocating for government support for the 988 Crisis Line.
NAMI operates a helpline on weekdays (10am-10pm EST, 800-950-NAMI (6264), text 62640, chat nami.org/help) that provides information, resources, and support from trained staff and volunteers with lived experience with mental health. NAMI also offers support groups and free classes for caregivers in English and Spanish, facilitated by trained family members of people with mental illness. Groups are available in-person and online, with some groups focused specifically on the families of children and young adults with mental health problems.
Key Points
- 988 is a national hotline available 24/7 and a resource to learn about local mental health crisis resources anywhere in the country.
- NAMI is a non-profit organization that supports families affected by mental illness through advocacy, education, and support. Their helpline, support groups, and family-to-family education programs may be helpful to your patients and their families.
Related PsychSnaps:
“How do you make a safety plan with a patient who has suicidal thoughts?” Emma Samelson-Jones, May 2024.
“Can suicide risk assessments prevent your patients from dying by suicide?‘ Emma Samelson-Jones, March 2024.
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