A 72-year-old man with a history of chronic pain and unknown psychiatric history comes for an initial visit due to diminished energy and anxiety for the past 3 months. He appears very sad and moves slowly. He has felt terrible since his wife died unexpectedly from a brain aneurysm 4 months ago and is filled with guilt because he did not get her to the hospital sooner. Since her death, the patient has suffered from disturbed sleep and is unable to focus on his favorite activities, including coin collecting and fishing. He drinks a bottle of wine nightly to fall asleep and isolates himself from others because he does not feel like socializing anymore. The patient feels hopeless and wants to end his life, saying, "I cannot carry on without her." He has contemplated hanging himself and recently drove by a hardware store with thoughts of buying a rope, but ultimately did not. The patient is advised to enter a psychiatric hospital. However, he refuses and says, "I promise to try any help you could offer me as an outpatient." Which of the following is the most appropriate next step in management of this patient?

Question

A 72-year-old man with a history of chronic pain and unknown psychiatric history comes for an initial visit due to diminished energy and anxiety for the past 3 months.  He appears very sad and moves slowly.  He has felt terrible since his wife died unexpectedly from a brain aneurysm 4 months ago and is filled with guilt because he did not get her to the hospital sooner.  Since her death, the patient has suffered from disturbed sleep and is unable to focus on his favorite activities, including coin collecting and fishing.  He drinks a bottle of wine nightly to fall asleep and isolates himself from others because he does not feel like socializing anymore.  The patient feels hopeless and wants to end his life, saying, "I cannot carry on without her."  He has contemplated hanging himself and recently drove by a hardware store with thoughts of buying a rope, but ultimately did not.  The patient is advised to enter a psychiatric hospital.  However, he refuses and says, "I promise to try any help you could offer me as an outpatient."  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d80d_4d99_bc81_0540949ac612_MD0003_00 This patient has symptoms consistent with major depression and reports suicidal ideation with a specific method. His aborted trip to the hardware store to buy a rope indicates that the patient recently had some intent and an organized plan for self-harm (rehearsing a plan is not uncommon prior to suicide attempts). His depressive symptoms appear to be worsening, and he has several other major risk factors for suicide that can be remembered by using the mnemonic SAD PERSONS (Table): old age, male gender, alcohol abuse, chronic pain, and lack of support/significant other. His anxiety, hopelessness, and disturbed sleep patterns are additional clinical risk factors. Given this high level of suicide risk, it is necessary to admit the patient to a psychiatric unit (involuntarily if necessary) to ensure his safety as the first step in care. Significant concern about the patient's immediate safety overrides any "promises" that he may make about agreeing to outpatient treatment, especially when there is no established therapeutic alliance or relationship between patient and physician. (Choices B and G) Outpatient psychotherapy, with or without antidepressant treatment, would not adequately address the imminent safety concerns in this patient. His depressive symptoms (ie, suicidality and marked functional impairment) are more severe than those seen in normal bereavement. (Choice C) There is little evidence that a "no-harm" contract (a patient promise not to harm self when feeling suicidal) is effective in reducing suicide. (Choice D) Hypothyroidism, which can also present with sad mood, diminished energy, slow movement, and poor concentration, can be assessed with serum TSH testing. However, this patient's high suicide risk precludes outpatient management. (Choice E) Antidepressants can take weeks to become fully effective and alone would not adequately address the patient's suicide risk. It is also inappropriate to give family members responsibility for monitoring the patient's safety. (Choice F) Day programs are outpatient programs. This patient would remain at risk, particularly in the evenings when alcohol intoxication and loneliness could predispose him to a higher risk of suicide. His level of suicide risk requires treatment in an inpatient (ie, locked unit) setting. Educational objective: Active suicidality is associated with intent and plan for self-harm. The first step in the care of patients with active suicidality is to ensure their safety by admitting them to a psychiatric unit (involuntarily, if necessary). References: Understanding suicide across the lifespan: a United States perspective of suicide risk factors, assessment & management. (http://www.ncbi.nlm.nih.gov/pubmed/28639299) Suicide risk assessment and suicide risk formulation: essential components of the therapeutic risk management model. (http://www.ncbi.nlm.nih.gov/pubmed/25226200)

A 72-Year-Old Man with a History of Chronic Pain and Unknown