A 17-year-old girl is brought to the emergency department by her parents due to worsening depression. The patient was diagnosed with major depressive disorder and started on escitalopram 3 months ago. Her symptoms had improved on escitalopram but worsened 5 days ago after she was caught cheating on a test at school. Since then, the patient has felt worthless and has started having thoughts of killing herself. The parents share that her suicidal thoughts worsen at night and that she "works herself up," crying and repeatedly apologizing for "being a horrible daughter." The patient says, "I made one mistake, and now my life is ruined. No college is going to accept me." Family history is significant for bipolar disorder in her mother. The patient has been taking increasing amounts of the mother's clonazepam to help her fall asleep. Vital signs are within normal limits. Physical examination is unremarkable. On mental status examination, the patient's hair and clothes are unkempt. She is tearful and makes poor eye contact. Her thought process is linear and organized. Which of the following is the most important factor in assessing this patient's suicide risk?

Question

A 17-year-old girl is brought to the emergency department by her parents due to worsening depression.  The patient was diagnosed with major depressive disorder and started on escitalopram 3 months ago.  Her symptoms had improved on escitalopram but worsened 5 days ago after she was caught cheating on a test at school.  Since then, the patient has felt worthless and has started having thoughts of killing herself.  The parents share that her suicidal thoughts worsen at night and that she "works herself up," crying and repeatedly apologizing for "being a horrible daughter."  The patient says, "I made one mistake, and now my life is ruined.  No college is going to accept me."  Family history is significant for bipolar disorder in her mother.  The patient has been taking increasing amounts of the mother's clonazepam to help her fall asleep.  Vital signs are within normal limits.  Physical examination is unremarkable.  On mental status examination, the patient's hair and clothes are unkempt.  She is tearful and makes poor eye contact.  Her thought process is linear and organized.  Which of the following is the most important factor in assessing this patient's suicide risk?

Quizplus · Accepted Answer

11ec25c8_d7b6_a1c9_bc81_79547d66a524_MD0003_00 Active substance use, including alcohol and prescription and/or illicit drugs, is associated with increased suicide risk in both adolescents and adults. Although this patient's age, sex, and family history of psychiatric illness are static factors that contribute to her risk for suicide attempt, her benzodiazepine use (eg, taking her mother's clonazepam to help her sleep) has disinhibiting effects that most increase her acute suicide risk. Substance intoxication in adolescents especially heightens the impulsivity and poor judgment generally seen in this age group. In combination with a psychiatric disorder (eg, major depressive disorder) and a stressful life event (eg, caught cheating at a test), as seen in this patient, disinhibition from substance use can play a major role in suicidal behavior. In some studies, antidepressant medications have been associated with a slightly increased risk of suicidal thoughts and behaviors in adolescents compared with placebo (resulting in the FDA black box warning); however, the evidence is inconclusive, with the expert consensus favoring antidepressant use. This patient's depression had improved on escitalopram prior to the acute stressor of being caught cheating, making antidepressant initiation a less likely contributor to her suicide risk (Choice D). (Choice A) Although adolescence/young adulthood is associated with increased suicide risk, it is a static risk factor and not as critical in assessment and treatment planning as is this patient's recent and increasing benzodiazepine use. (Choices C and E) Suicide risk is increased in adolescents who have a family history of mood disorders and/or suicidal behavior. Suicide attempts are more common in adolescent females than in males. However, compared to active substance use, these static risk factors are less significant in the acute setting. Educational objective: Active substance use, including alcohol and prescription and/or illicit drugs, is associated with disinhibition and an increased risk of suicide. Substance intoxication in adolescents especially heightens the impulsivity and poor judgment generally seen in this age group. References: Psychiatric emergencies: assessing and managing suicidal ideation. (http://www.ncbi.nlm.nih.gov/pubmed/28372713)

A 17-Year-Old Girl Is Brought to the Emergency Department by Her