A 52-year-old man is brought to the emergency department by his roommate after threatening to commit suicide. He is angry about being taken to the hospital and says, "I just want to go home and sleep." His roommate says, "I can't take it anymore; I thought he was going to jump out of the car on the way to the hospital." The patient has a history of recurrent major depression, post-traumatic stress disorder, and alcohol abuse. He describes increasing depression since his divorce 5 years ago. He feels hopeless, has difficulty getting out of bed, and eats only one meal a day. The patient ruminates about his failed marriage and blames himself for his heavy drinking and losing contact with his 2 grown children. He has always owned a gun, which he usually keeps in a locked drawer in a bedside table. However, in the last week he has taken the gun out and held it before going to sleep "because it feels like a security blanket, it's reassuring." The patient has suicidal thoughts but does not think he will act on them. He says, "I just need to know I have a way out." His medical record indicates that he tried to overdose 3 months ago by taking a handful of sleeping pills and drinking 2 liters of vodka. Last year, he tried to hang himself in his garage but was discovered by his roommate. The patient has been followed by a psychiatrist in an outpatient clinic. He felt better when taking duloxetine but has not taken the medication for the past few months as he can no longer afford it. He insists that he is not feeling suicidal now and demands to leave.
Which of the following is the most appropriate next step in management of this patient?

Question

A 52-year-old man is brought to the emergency department by his roommate after threatening to commit suicide.  He is angry about being taken to the hospital and says, "I just want to go home and sleep."  His roommate says, "I can't take it anymore; I thought he was going to jump out of the car on the way to the hospital."  The patient has a history of recurrent major depression, post-traumatic stress disorder, and alcohol abuse.  He describes increasing depression since his divorce 5 years ago.  He feels hopeless, has difficulty getting out of bed, and eats only one meal a day.  The patient ruminates about his failed marriage and blames himself for his heavy drinking and losing contact with his 2 grown children.  He has always owned a gun, which he usually keeps in a locked drawer in a bedside table.  However, in the last week he has taken the gun out and held it before going to sleep "because it feels like a security blanket, it's reassuring."  The patient has suicidal thoughts but does not think he will act on them.  He says, "I just need to know I have a way out."  His medical record indicates that he tried to overdose 3 months ago by taking a handful of sleeping pills and drinking 2 liters of vodka.  Last year, he tried to hang himself in his garage but was discovered by his roommate.  The patient has been followed by a psychiatrist in an outpatient clinic.  He felt better when taking duloxetine but has not taken the medication for the past few months as he can no longer afford it.  He insists that he is not feeling suicidal now and demands to leave. 
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1b5_2fa6_8f63_19bb4a02efce_MD0005_00 This patient is at high, imminent risk for suicide. He has severe depression, suicidal ideation with a plan, and access to lethal means. He recently attempted suicide by overdose, has a history of attempted hanging, and daily contemplates shooting himself. He is angry and wants to be discharged, placing him at risk for running away from the emergency department if given the opportunity. The highest priority in this situation is to ensure his safety by placing him on 1:1 observation and arranging for involuntary hospitalization. The patient's immediate surroundings and belongings should be searched for objects that he could use to harm himself, and he should not be left unattended. (Choice A) Contacting the outpatient psychiatrist is important but not an immediate priority. Although the outpatient psychiatrist could provide useful information about the patient's diagnosis and treatment, this is unlikely to change his immediate management. The assessment of imminent risk and assurance of safety are the responsibility of the physician currently assessing the patient. (Choice B) There is already sufficient justification to hospitalize this patient based on his history and recent behavior. Reassessing him for suicidal ideation an hour later would not change the decision to admit him to the hospital. (Choice D) The patient will likely refuse voluntary hospitalization. Discharging this actively suicidal patient against medical advice would be unsafe. (Choice E) This patient needs aggressive treatment of his depression, but antidepressants do not work right away and are generally not started in the emergency department. When the patient is stabilized and ready for discharge, it will be important to reduce any barriers to care, including affordability of his medication. The immediate priority, however, is his safety. Educational objective: Patients who are actively suicidal and refusing treatment should be placed on 1:1 observation and hospitalized under involuntary status. References: The depressed patient and suicidal patient in the emergency department: evidence-based management and treatment strategies. (http://www.ncbi.nlm.nih.gov/pubmed/22164363)

A 52-Year-Old Man Is Brought to the Emergency Department by His