A 28-year-old man with a history of bipolar I disorder is brought to the emergency department after being pulled over by police for driving erratically. The police report indicates that the patient appeared alcohol-intoxicated and refused to cooperate with questions, stating, "I have the skills of a race car driver and a need for speed." He has been on lithium for years and says he has been adherent. The patient has a history of bilateral knee injuries sustained in an accident when he jumped from a high ledge. He has no other medical history. The emergency physician contacts the outpatient psychiatrist, who reports that the patient has been treated with lithium for the past 3 years. He had a therapeutic lithium level and appeared stable at his last visit 2 weeks ago. The patient is re-interviewed when he is sober. He felt upset after his girlfriend left him and was turned down for a job, and so decided to "get drunk." He is apologetic for driving recklessly and says he intends to follow up with his outpatient psychiatrist. Although the patient admits to a history of crack cocaine use, he currently uses no illicit substances other than marijuana on weekends. Temperature is 37.2 C (99 F), blood pressure is 140/80 mm Hg, and pulse is 88/min. Physical examination is normal. The patient is alert, and his speech is nonpressured. Urine toxicology screen is negative for illicit substances.
Which of the following is the most appropriate next step in management?

Question

A 28-year-old man with a history of bipolar I disorder is brought to the emergency department after being pulled over by police for driving erratically.  The police report indicates that the patient appeared alcohol-intoxicated and refused to cooperate with questions, stating, "I have the skills of a race car driver and a need for speed."  He has been on lithium for years and says he has been adherent.  The patient has a history of bilateral knee injuries sustained in an accident when he jumped from a high ledge.  He has no other medical history.  The emergency physician contacts the outpatient psychiatrist, who reports that the patient has been treated with lithium for the past 3 years.  He had a therapeutic lithium level and appeared stable at his last visit 2 weeks ago.  The patient is re-interviewed when he is sober.  He felt upset after his girlfriend left him and was turned down for a job, and so decided to "get drunk."  He is apologetic for driving recklessly and says he intends to follow up with his outpatient psychiatrist.  Although the patient admits to a history of crack cocaine use, he currently uses no illicit substances other than marijuana on weekends.  Temperature is 37.2 C (99 F), blood pressure is 140/80 mm Hg, and pulse is 88/min.  Physical examination is normal.  The patient is alert, and his speech is nonpressured.  Urine toxicology screen is negative for illicit substances. 
Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c067_a0e6_8f63_417737003a06_MD0005_00 This patient has a number of risk factors for suicide, including major psychiatric illness, recent losses (job and relationship), impulsivity, and substance use. The possibility that his erratic driving and previous jump from a ledge were motivated by suicidal intent should be considered. Alcohol use is strongly associated with increased suicide risk as the disinhibiting effects of intoxication frequently contribute to suicide attempts. A suicide risk assessment is the most important intervention at this time and should be performed prior to discharge. Targeted questions regarding any suicidal thoughts, intent, means, or plan should be asked. Aside from static risk factors (eg, age, gender, race, marital status, past attempts, family history), the assessment should also focus on acute, modifiable risk factors such as impulsivity, hopelessness, and recent psychosocial stressors. (Choice A) Although checking this patient's lithium level would be important for management, performing a suicide risk assessment takes precedence as it would determine whether he can be discharged safely or needs to be admitted. If the patient displayed signs of lithium toxicity (eg, slurred speech, unsteady gait), a lithium level would be more urgent. (Choices B and C) Discharging this patient without performing a comprehensive suicide risk assessment would be unsafe. The outpatient psychiatrist's report that the patient was "stable" 2 weeks earlier is no assurance that he is not currently at risk. A referral for substance abuse counseling would be appropriate once he is determined to be psychiatrically stable. (Choice E) This patient has no signs suggestive of early alcohol withdrawal. Prophylactic treatment for alcohol withdrawal is indicated for patients with a history of chronic heavy alcohol use, seizures, or delirium tremens. Educational objective: A suicide risk assessment that focuses on acute risk factors should be performed in all patients who come to the emergency department with psychiatric symptoms or erratic behavior. The mixture of hopelessness, impulsivity, and disinhibition due to substance use is a particularly lethal combination. References: Literature-based recommendations for suicide assessment in the emergency department: a review. (http://www.ncbi.nlm.nih.gov/pubmed/23040403) Screening for suicidal ideation and attempts among emergency department medical patients: instrument and results from the Psychiatric Emergency Research Collaboration. (http://www.ncbi.nlm.nih.gov/pubmed/23413776)

A 28-Year-Old Man with a History of Bipolar I Disorder