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. On further questioning, the patient acknowledges that he has been feeling very depressed since losing his job and breaking up with his girlfriend. He has struggled with suicidal thoughts on and off and admits that his previous jump from a ledge was a suicide attempt that occurred during a period of severe depression. He has had no suicidal thoughts for over a year until tonight, when he started drinking. Which of the following questions is the most important to ask the patient at this time?

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. On further questioning, the patient acknowledges that he has been feeling very depressed since losing his job and breaking up with his girlfriend.  He has struggled with suicidal thoughts on and off and admits that his previous jump from a ledge was a suicide attempt that occurred during a period of severe depression.  He has had no suicidal thoughts for over a year until tonight, when he started drinking.  Which of the following questions is the most important to ask the patient at this time?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c068_3d27_8f63_9340a67da433_MD0005_00 The patient now admits to having suicidal thoughts, and the physician should carefully assess him for safety. This involves a systematic assessment of suicidal ideation, intent (desire to act on a suicide plan), and plan (details of method, place, time, and access to means). The physician should also ask the patient how close he has come to acting on his plan, including rehearsals or aborted attempts (initiates act but then stops). In this case, it is imperative to determine if the patient's erratic driving indicated suicidal behavior. If there is reason to believe this is the case, the patient is at high risk for harm to himself and others and hospitalization is indicated. (Choice A) Although all suicidal patients should be assessed for access to guns, it is more important to determine whether the patient's erratic driving was actually suicidal behavior that would warrant immediate hospitalization. (Choices B and C) A history of suicide attempts is the strongest predictor of future suicide attempts. For this reason, the physician should obtain a detailed history of all previous attempts. A family history of suicide attempt is another risk factor. However, clarifying the seriousness of the patient's recent dangerous behavior is more important for immediate management. (Choice D) Patients who say that they would be "better off dead" have passive suicidal ideation (thoughts of death or a wish to die but no thoughts of killing self). However, this patient has expressed active suicidal thoughts that should be assessed first due to their severity. Educational objective: Patients brought to the emergency department for behavior indicating a high likelihood of self-harm should be systematically assessed for suicidal ideation, intent, and plan. Obtaining specific details of the incident is essential for evaluating the seriousness of suicidal risk. Patients who have attempted suicide or who endorse active suicidal ideation with a specific plan and intent require hospitalization. References: Reducing suicide risk: challenges and opportunities in the emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/27451339) Managing suicidal patients in the emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/26443554)

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