A 49-year-old woman comes to the office due to low mood. The patient has a 3-month history of worsening sadness, increased appetite with weight gain, and difficulty falling and staying asleep. She was dismissed from her part-time sales job 2 months ago due to poor performance and has been "too tired" to look for a new job. The patient's husband is threatening to leave her, and she has little contact with family or friends. She says, "My life is a mess, and I'm not sure that my marriage can be saved. I've had thoughts of taking all of my medications at once." The patient admits to drinking increased amounts of alcohol "to cope." She has hypothyroidism treated with levothyroxine; last year she had an episode of major depression for which she is currently on a maintenance dose of sertraline. Physical examination, including neurologic examination, shows no abnormalities. The patient is anxious, sad, and physically restless. She weeps softly throughout the interview, especially when discussing her marriage. Which of the following is the most appropriate next step in management?

Question

A 49-year-old woman comes to the office due to low mood.  The patient has a 3-month history of worsening sadness, increased appetite with weight gain, and difficulty falling and staying asleep.  She was dismissed from her part-time sales job 2 months ago due to poor performance and has been "too tired" to look for a new job.  The patient's husband is threatening to leave her, and she has little contact with family or friends.  She says, "My life is a mess, and I'm not sure that my marriage can be saved.  I've had thoughts of taking all of my medications at once."  The patient admits to drinking increased amounts of alcohol "to cope."  She has hypothyroidism treated with levothyroxine; last year she had an episode of major depression for which she is currently on a maintenance dose of sertraline.  Physical examination, including neurologic examination, shows no abnormalities.  The patient is anxious, sad, and physically restless.  She weeps softly throughout the interview, especially when discussing her marriage.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

This patient is at high risk for suicide. She has suicidal ideation with a specific plan in mind and access to means (eg, taking all her medications). She is under severe stress (eg, job loss, husband) and has little social support. In addition, she is drinking increasing amounts of alcohol, whose disinhibiting effects put her at risk of impulsively acting on her suicidal thoughts. Due to safety concerns, the most appropriate intervention is to hospitalize the patient to provide close monitoring and support while appropriate treatment is initiated. Performing a suicide risk assessment is critical in determining the appropriate level of care (ie, outpatient vs. inpatient). Patients with active suicidal ideation (eg, thoughts of taking action to harm oneself) are at greater risk than patients with passive suicidal ideation (eg, wish to be dead or go to sleep and not wake up). Patients should be asked if they have thought of a specific method and the lethality of the method, whether any preparations (eg, hoarding pills) have been made, and if they have access to the means to commit suicide. Recent stressors and the adequacy of social supports should also be considered. (Choices A and C) Cognitive-behavioral therapy and couples therapy are appropriate treatment considerations but would not be the next step in management given the need for hospitalization. (Choice B) The efficacy of a "contract for safety," in which the patient agrees not to act on suicidal thoughts and seek help instead, has not been demonstrated. It may provide a false sense of security to the clinician and place the patient at risk in an unsupervised setting. (Choice E) Inadequately treated hypothyroidism may be contributing to the patient's depression. However, thyroid function tests should be obtained prior to adjusting the levothyroxine dose, and hospitalizing the patient takes precedence. (Choices F and G) Increasing the dose of sertraline or changing the patient's antidepressant are treatment options but would not precede choosing inpatient level of care. Educational objective: Patients with depression should be carefully assessed for suicidal thoughts and behavior to determine the appropriate treatment setting. Patients with active suicidal ideation and both a plan and access to means are at increased risk and should be hospitalized. References: Psychiatric emergencies. (http://www.ncbi.nlm.nih.gov/pubmed/27262012) The role of general practitioners in prevention of depression-related suicides. (http://www.ncbi.nlm.nih.gov/pubmed/23269211) Suicide, suicide attempts, and suicidal ideation. (http://www.ncbi.nlm.nih.gov/pubmed/26772209)

A 49-Year-Old Woman Comes to the Office Due to Low