A 16-year-old girl is brought to the emergency department after her parents found her attempting to cut her wrists. The parents say that she is often "moody" but has never done anything like this before. The patient has been very upset since her boyfriend broke up with her last week. Examination shows numerous superficial cuts on her forearms in various stages of healing and a fresh deep laceration that requires 5 sutures. The patient admits to attempting suicide by cutting her wrists. When asked why she did it, she says, "I don't know. I felt so alone and angry. I just didn't want to be here anymore." The patient avoids eye contact and looks at the ground during the entire interview. She refuses to answer many questions but admits to feeling depressed over the past few months. When asked if she would do something like this again, the patient looks down and does not answer. Her parents want to take the girl to her pediatrician, whom they trust and feel knows the patient very well. They refuse psychiatric hospitalization, and insist that they will watch their daughter at all times. The patient wants to go home as well. Which of the following is the most appropriate course of action?

Question

A 16-year-old girl is brought to the emergency department after her parents found her attempting to cut her wrists.  The parents say that she is often "moody" but has never done anything like this before.  The patient has been very upset since her boyfriend broke up with her last week.  Examination shows numerous superficial cuts on her forearms in various stages of healing and a fresh deep laceration that requires 5 sutures.  The patient admits to attempting suicide by cutting her wrists.  When asked why she did it, she says, "I don't know.  I felt so alone and angry.  I just didn't want to be here anymore."  The patient avoids eye contact and looks at the ground during the entire interview.  She refuses to answer many questions but admits to feeling depressed over the past few months.  When asked if she would do something like this again, the patient looks down and does not answer.  Her parents want to take the girl to her pediatrician, whom they trust and feel knows the patient very well.  They refuse psychiatric hospitalization, and insist that they will watch their daughter at all times.  The patient wants to go home as well.  Which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

In recent years, suicide has alternated with homicide as the second or third leading cause of death in adolescents; between 5%-10% of adolescents make at least one suicide attempt in a given year. This patient has recently made a serious suicide attempt and is guarded and evasive when answering questions regarding whether she would attempt it again. She remains at high risk for another attempt and should be hospitalized (involuntarily, if necessary) for safety. Although efforts should be made to obtain parental consent, a minor can be involuntarily hospitalized for psychiatric causes without it. The exact procedures for involuntary psychiatric hospitalization vary from state to state. Although this patient's healed superficial cuts may represent nonsuicidal self-injury (NSSI), her recent deep laceration was associated with suicidal intent. In contrast to a suicide attempt (ie, act performed with some intent to die), NSSI may be used to cope with distressing negative affective states; it is seen in a wide range of disorders, including borderline personality, eating, and dissociative disorders. Some patients engage in both NSSI and suicidal behavior. (Choices B and C) Follow-up with the pediatrician and referral to outpatient psychiatric care would be indicated once the patient has been stabilized on the inpatient psychiatric service. Currently, this patient remains at high risk for suicide, and it would be unsafe to discharge her to outpatient care. (Choice D) Waiting 12 hours is unlikely to provide any information that will change the treatment plan for this patient, who is an acute threat to herself. Holding patients overnight is reasonable in other situations in which they will likely be better able to communicate the next day (eg, no longer intoxicated with alcohol or drugs). (Choice E) Safety is the priority at this point, and it would be inappropriate to discharge the patient to her parents, who cannot realistically monitor her at all times. Documentation of the parents' release of liability does not relieve the physician of the duty to protect the patient. Educational objective: Patients who are an acute threat to themselves should be hospitalized (involuntarily, if necessary) for treatment and stabilization. This principle also applies to minors, even without parental or guardian consent. References: Suicide and suicide attempts in adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/27354459) Non-suicidal self-injury. (http://www.ncbi.nlm.nih.gov/pubmed/23202887)

A 16-Year-Old Girl Is Brought to the Emergency Department After