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

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. The patient admits that he was, in fact, trying to get up the nerve to crash his car and kill himself.  He started to swerve on purpose but then straightened out when he thought of how his suicide would devastate his mother.  He explains, "When I am in a dark hole, it seems that nothing will ever get better for me; suicide seems like the only way out."  His psychiatrist confirms that the patient has had suicidal thoughts in the past, nearly always when he is drinking.  The patient agrees to hospitalization for further evaluation and treatment.  Which of the following is the most appropriate next step to reduce the risk of suicide in this patient?

A) Discontinue lithium and administer electroconvulsive therapy
B) Discontinue lithium and start an antidepressant
C) Discontinue lithium and start an antipsychotic
D) Discontinue lithium and start another mood stabilizer
E) Maintain lithium and address alcohol use