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. The patient is started on duloxetine in the inpatient psychiatric unit. He is willing to take the medication but remains angry about being hospitalized. He is initially withdrawn and uncommunicative but after several days is more conversant. The patient still wishes he were dead but expresses no desire to hurt himself. After 1:1 observation is discontinued, he is monitored with 15-minute checks. After 2 weeks, the patient is noticeably less depressed and has no suicidal thoughts. His appetite has improved, and he is eating 3 meals a day. Discharge planning is begun and a follow-up appointment is scheduled with his outpatient psychiatrist. Which of the following is most important prior to discharge?

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. The patient is started on duloxetine in the inpatient psychiatric unit.  He is willing to take the medication but remains angry about being hospitalized.  He is initially withdrawn and uncommunicative but after several days is more conversant.  The patient still wishes he were dead but expresses no desire to hurt himself.  After 1:1 observation is discontinued, he is monitored with 15-minute checks.  After 2 weeks, the patient is noticeably less depressed and has no suicidal thoughts.  His appetite has improved, and he is eating 3 meals a day.  Discharge planning is begun and a follow-up appointment is scheduled with his outpatient psychiatrist.  Which of the following is most important prior to discharge?

Quizplus · Accepted Answer

Explanation: This patient currently denies active suicidal ideation, intent, or plan, but remains at high risk. Although the patient is ready for discharge, the physician should be aware that any psychosocial stressor has the potential to worsen his depression and/or precipitate a bout of drinking, both of which could lead to acting on suicidal impulses. The immediate post-discharge period is particularly high-risk. Guns in the home are associated with significantly increased suicide risk. In addition to close follow-up and ongoing suicide risk assessment, removal of the gun from the patient's home could be life-saving. Friends and family members can often assist with removal of guns. A collaborative plan involving the clinician, patient, and an individual or law enforcement officer designated to remove the gun should be followed up with a planned phone call confirming its removal. (Choice A) Self-assessment suicide rating scales depend on the subject's truthfulness and are not always reliable. They should not substitute for clinical suicide risk assessment. (Choices B and C) Although counseling the patient about medication adherence and discussion with the outpatient psychiatrist are important, addressing this patient's ready access to guns (a highly lethal suicide method) takes precedence. (Choice E) A no-suicide contract is a signed agreement between the patient and clinician in which the patient notifies the clinician of suicidal thoughts and agrees not to act on them. Although such contracts are still used in clinical practice, there is no evidence that they actually reduce the incidence of suicide. They may give the clinician a false sense of security and are not a substitute for careful and ongoing suicide risk assessment. Educational objective: Guns in the home are associated with significantly increased suicide risk, and physicians should address their removal from all patients at risk for suicide. No-suicide contracts have not been shown to prevent suicide. References: Gun safety management with patients at risk for suicide. (http://www.ncbi.nlm.nih.gov/pubmed/17967118) The accessibility of firearms and risk for suicide and homicide victimization among household members: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/24592495)

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