A 25-year-old woman is brought to the emergency department after her boyfriend called police and reported that she was threatening to kill herself. They had been arguing when the woman suddenly grabbed a kitchen knife, waved it in the air, and threatened to stab herself. The patient says to the emergency physician, "I didn't mean what I said. This is all a big misunderstanding. I don't know why my boyfriend overreacted. We both had a little too much to drink tonight. I'm sure you know how that can get! I got upset when we were arguing and I just said something stupid. I have no intention of killing myself." The patient has no psychiatric history. She drinks socially and smokes marijuana. She does not use any other drugs or prescription medications. Vital signs are within normal limits. Examination shows no abnormalities. On mental status examination, the patient is alert with loud, slightly slurred speech. She says her mood is "fine" and denies any suicidal ideation, intent, or plan.
Which of the following is the most appropriate next step in management of this patient?

Question

A 25-year-old woman is brought to the emergency department after her boyfriend called police and reported that she was threatening to kill herself.  They had been arguing when the woman suddenly grabbed a kitchen knife, waved it in the air, and threatened to stab herself.  The patient says to the emergency physician, "I didn't mean what I said.  This is all a big misunderstanding.  I don't know why my boyfriend overreacted.  We both had a little too much to drink tonight.  I'm sure you know how that can get!  I got upset when we were arguing and I just said something stupid.  I have no intention of killing myself."  The patient has no psychiatric history.  She drinks socially and smokes marijuana.  She does not use any other drugs or prescription medications.  Vital signs are within normal limits.  Examination shows no abnormalities.  On mental status examination, the patient is alert with loud, slightly slurred speech.  She says her mood is "fine" and denies any suicidal ideation, intent, or plan. 
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient denies suicidal intent and dismisses her suicidal threat as a mistake made under the influence of alcohol. However, she still exhibits signs of possible alcohol intoxication (loud, slightly slurred speech; social disinhibition), and her assurance that she is not suicidal cannot be accepted. In general, physicians should not clear patients for discharge from the emergency department when they are still intoxicated. Intoxication with alcohol or other substances is a known risk factor for completed suicide due to increased impulsivity and impaired judgment. When there is concern that the patient may be suicidal, the physician must observe the patient and perform a suicide assessment when the patient is completely sober. Speaking with the boyfriend and contacting family members for collateral information would also be advisable. (Choices A and B) It would be inappropriate to discharge this patient as her denial of suicidality while still intoxicated is unreliable. If the patient is considered appropriate for discharge when reevaluated in a sober state, then referrals for psychiatric follow-up could be made. (Choice C) This patient should be reevaluated when sober and it is premature to hospitalize her at this point. Hospitalization would be necessary if further evaluation indicated that she had active suicidal ideation with intent or plan. (Choice E) Although there is a rough correlation between blood alcohol levels and alcohol effects in a typical social drinker, the level should not be used as the sole criterion for discharge. It is more important to perform a suicide assessment when the patient is clinically sober. Educational objective: Decisions regarding discharge from the emergency department should not be based on an intoxicated patient's statements. Patients with suicidal threats or behavior must be reassessed when they are clinically sober. References: Alcohol: the lubricant to suicidality. (http://www.ncbi.nlm.nih.gov/pubmed/23440995) Alcohol and suicidal behavior: what is known and what can be done. (http://www.ncbi.nlm.nih.gov/pubmed/25145740)

A 25-Year-Old Woman Is Brought to the Emergency Department After