A 17-year-old boy comes to the office at his father's insistence due to a change in behavior. Ever since his girlfriend ended their relationship last month, the patient has been unable to complete his schoolwork and is uninterested in playing the sports he previously enjoyed. He spends most of his time in his room and refuses to come out for meals. The patient says, "It's too much effort to even get out of bed. I thought everything was going well, and suddenly she just ended it. I don't want to go to school and see her ever again." On further questioning, the patient reports that he has trouble falling asleep and keeps checking his ex-girlfriend's social media posts to see what she is doing in the evenings. He has thought about hanging himself with rope his father keeps in the garage. He has not spoken to anyone else about his suicidal thoughts and does not know if he will act on them. The patient says, "I tried to tell my best friend how I feel, but he just told me to 'get over her.' He doesn't understand and neither will my parents. Please don't tell my parents what I am going through." Which of the following is the most appropriate course of action for this patient?

Question

A 17-year-old boy comes to the office at his father's insistence due to a change in behavior.  Ever since his girlfriend ended their relationship last month, the patient has been unable to complete his schoolwork and is uninterested in playing the sports he previously enjoyed.  He spends most of his time in his room and refuses to come out for meals.  The patient says, "It's too much effort to even get out of bed.  I thought everything was going well, and suddenly she just ended it.  I don't want to go to school and see her ever again."  On further questioning, the patient reports that he has trouble falling asleep and keeps checking his ex-girlfriend's social media posts to see what she is doing in the evenings.  He has thought about hanging himself with rope his father keeps in the garage.  He has not spoken to anyone else about his suicidal thoughts and does not know if he will act on them.  The patient says, "I tried to tell my best friend how I feel, but he just told me to 'get over her.'  He doesn't understand and neither will my parents.  Please don't tell my parents what I am going through."  Which of the following is the most appropriate course of action for this patient?

Quizplus · Accepted Answer

This patient is severely depressed, has suicidal ideation with thoughts about hanging himself, and may have intent to act on these thoughts. Although confidentiality should be maintained whenever possible to facilitate rapport and encourage trust, if an adolescent patient is at risk of harm to self or others, safety becomes more important and confidentiality must be broken in order to facilitate treatment. Due to his high risk of self-harm, the parents should be informed and the patient should be hospitalized immediately so that he can be closely monitored and placed on suicide precautions. This should preferably be done with parental consent and support, but if necessary it can be done on an involuntarily basis. (Choice A) Although the patient should be encouraged to tell his parents what is going on, family therapy can take time and his risk of suicide is high. He must be hospitalized immediately for safety. (Choice B) Although it is best to treat adolescents with the family's support of the treatment, parental consent is not required for emergency hospitalization. (Choice D) Asking the parents to remove the rope is important, and this needs to be done before the patient is discharged from the hospital. However, sending the patient home with supervision is unsafe and places an unfair burden on the family. (Choice E) In cases where there is risk of harm, confidentiality should not be maintained. The parents should be informed. (Choice F) This patient is expressing suicidal ideation with a plan and possible intent and needs emergency hospitalization for his safety. Scheduling an urgent psychiatric evaluation would be appropriate if he were not actively suicidal. Educational objective: A teenager with active suicidal ideation must be hospitalized for safety and the parents must be informed. Parental consent is ideal but not required for hospitalization. References: Suicidality in adolescence: review and legal considerations. (http://www.ncbi.nlm.nih.gov/pubmed/15378595)

A 17-Year-Old Boy Comes to the Office at His Father's