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. The physician reassesses the patient several hours later. She says, "I am so embarrassed. I never should have said that. I lose control of myself when I am drunk." The patient explains that she and her boyfriend are having relationship difficulties and she is afraid that he will leave her. She reaffirms that she has never received any psychiatric treatment, although she took an intentional overdose of sleeping pills when she was 18 and wanted to die after breaking up with her boyfriend. The patient has a family history of depression and thinks that her maternal uncle may have committed suicide, although "my family never talks about it." She has been feeling depressed and describes difficulties with sleep and concentration. Her appetite is decreased and she has lost 3.17 kg (7 lb) over the past month. The patient works at a coffee shop and is a part-time student at a local community college. She is thinking of dropping out of school as she has no interest in the classes and her grades are poor. Apart from her boyfriend, she has few friends and is estranged from her family. Which of the following is this patient's strongest risk factor for suicide?

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. The physician reassesses the patient several hours later.  She says, "I am so embarrassed.  I never should have said that.  I lose control of myself when I am drunk."  The patient explains that she and her boyfriend are having relationship difficulties and she is afraid that he will leave her.  She reaffirms that she has never received any psychiatric treatment, although she took an intentional overdose of sleeping pills when she was 18 and wanted to die after breaking up with her boyfriend.  The patient has a family history of depression and thinks that her maternal uncle may have committed suicide, although "my family never talks about it."  She has been feeling depressed and describes difficulties with sleep and concentration.  Her appetite is decreased and she has lost 3.17 kg (7 lb) over the past month.  The patient works at a coffee shop and is a part-time student at a local community college.  She is thinking of dropping out of school as she has no interest in the classes and her grades are poor.  Apart from her boyfriend, she has few friends and is estranged from her family.  Which of the following is this patient's strongest risk factor for suicide?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c067_2bb5_8f63_df2b38d60fa5_MD0005_00 This patient has multiple risk factors for suicide, but her history of trying to kill herself with a sleeping pill overdose is the most significant. History of attempted suicide is the strongest predictive risk factor for suicide. The greatest predictor of future behavior is past behavior; patients with a previous suicide attempt are 5-6 times more likely to make another attempt than those who have not made a previous attempt. (Choices A, B, and E) Additional risk factors for suicide in this patient include her current depressive symptoms, unstable relationship with her boyfriend, family history of suicide, and lack of family support. However, the single strongest predictive factor for suicide is a history of attempts. (Choice D) Impulsivity, especially in young adults, is also associated with increased suicide risk. The disinhibiting effect of alcohol and its potential to increase the risk of this patient acting on suicidal thoughts is concerning and should be addressed in counseling. Educational objective: History of suicide attempts is the strongest risk factor for suicide. Comprehensive suicide assessment requires a careful analysis of both risk and protective factors. References: Determinants and outcomes of serious attempted suicide: a nationwide study in Finland, 1996-2003. (http://www.ncbi.nlm.nih.gov/pubmed/18343881) Suicide risk assessment and formulation: an update. (http://www.ncbi.nlm.nih.gov/pubmed/24011694) Risk factors for suicide in individuals with depression: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/23411024)

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