Psychiatry · Year 2 · from Psychiatry
Case 1: Suicidal Ideation with Plan and Intent
Patient Presentation
Demographics: 45-year-old male
Chief Complaint: "I just want the pain to stop. I've figured out how to do it."
History of Present Illness: A 45-year-old man is brought to the emergency department by police after his ex-wife called 911. She received a text message from him saying "I'm sorry for everything. Take care of the kids. It's better this way." When police arrived, they found him in his car in his garage with the engine running. The patient had been sitting there for approximately 10 minutes before police arrived and turned off the engine. He did not resist and came willingly to the ED. On interview, he reports feeling hopeless for the past 2 months following his divorce, which was finalized 3 months ago. His wife left him for another man after 18 years of marriage. He lost his job as a construction foreman 6 weeks ago after calling in sick repeatedly due to depression. He has been drinking heavily (1 pint of vodka daily) to "numb the pain." He has not been eating or sleeping well. He reports losing 15 pounds in 2 months. One week ago, he began researching suicide methods online and decided carbon monoxide was "the easiest." He purchased a new hose to connect from the exhaust pipe. He wrote a note to his children (ages 14 and 12). Tonight, he executed his plan but was interrupted. When asked if he wishes he had died, he says "Yes. Nothing is going to change. I can't face my kids as a failure."
Past Psychiatric History:
- Depression diagnosed 10 years ago during a prior marital separation
- Treated briefly with sertraline, stopped after 3 months when he "felt better"
- No prior suicide attempts
- No psychiatric hospitalizations
Substance Use:
- Alcohol: Escalated from social drinking to daily heavy use over past 3 months
- No illicit drugs
- Smokes 1 pack/day
Medical History: Hypertension, hyperlipidemia
Family History: Father completed suicide by gunshot at age 50; brother with alcohol use disorder
Social History: Divorced, 2 children (limited contact since divorce), lives alone, unemployed, owns multiple firearms (kept at his brother's house since divorce)
Physical Examination:
- Vital signs: BP 148/92, HR 88, RR 16, T 37.0C
- General: Middle-aged man appearing older than stated age, disheveled
- HEENT: Mild scleral icterus
- Cardiac: Regular rhythm
- Pulmonary: Clear
- Neurological: Grossly intact
Mental Status Examination:
- Appearance: Unkempt, poor hygiene, appears fatigued
- Behavior: Cooperative but psychomotor slowing evident, poor eye contact
- Speech: Low volume, slow rate, monotone
- Mood: "Hopeless"
- Affect: Flat, constricted, tearful at times
- Thought process: Linear, goal-directed
- Thought content: Active suicidal ideation with plan (carbon monoxide) and intent (wishes he had died), no homicidal ideation, no psychotic symptoms
- Perception: No hallucinations
- Cognition: Alert, oriented x4
- Insight: Poor - "There's no point in treatment"
- Judgment: Severely impaired
Risk Assessment:
- Risk Factors:
- Male sex
- Age 45 (peak risk age for men)
- Divorced/single
- Unemployed
- Access to lethal means (firearms at brother's, but had method available tonight)
- Family history of completed suicide (father)
- Alcohol use disorder (active, heavy use)
- Current major depressive episode
- Hopelessness (strongest predictor of completed suicide)
- Lethal plan and intent
- Near-lethal attempt interrupted only by external intervention
- Research into methods, preparatory behaviors (wrote note, purchased supplies)
- Protective Factors:
- Children (but currently feels like a burden to them)
- Came willingly to ED
- No prior attempts
- Risk Stratification: IMMINENT RISK
Workup:
- Labs: Ethanol level 180 mg/dL, AST 95, ALT 62, carboxyhemoglobin 5% (mild elevation, no symptoms)
- Urine toxicology: Negative except alcohol
- PHQ-9: 24 (severe depression)
- Columbia Suicide Severity Rating Scale: Positive for ideation with plan, intent, and behavior
Diagnosis:
- Suicide attempt by carbon monoxide asphyxiation, interrupted
- Major Depressive Disorder, severe, with current suicidal ideation
- Alcohol Use Disorder, severe
Treatment:
- One-to-one observation initiated immediately
- Voluntary admission offered - patient declined ("no point")
- Involuntary psychiatric hold (danger to self) initiated per state law
- Medical clearance obtained (carboxyhemoglobin level not requiring hyperbaric treatment)
- CIWA protocol for alcohol withdrawal monitoring
- Safety planning attempted but patient unable to engage meaningfully
- Ex-wife contacted to confirm firearms secured (at brother's house, brother informed of situation)
- Admitted to locked inpatient psychiatric unit
- Treatment plan:
- Alcohol withdrawal management with symptom-triggered benzodiazepines
- Initiated mirtazapine 15 mg at bedtime (addresses depression, insomnia, appetite)
- Supportive therapy, motivational interviewing for alcohol use
- Family meeting scheduled with children (with patient's consent after stabilization)
- Discharge planning to include intensive outpatient program for dual diagnosis
- Hospital course:
- Mild alcohol withdrawal (peak CIWA 12), managed with lorazepam
- Mood improved over 10-day hospitalization
- Expressed regret about attempt by day 5
- Engaged in safety planning by day 7
- Converted to voluntary status on day 8
- Discharged to dual-diagnosis IOP with follow-up with psychiatrist in 3 days
Clinical Pearl: This case illustrates multiple high-risk features for completed suicide: male sex, middle age, divorced, unemployed, family history of suicide, active substance use, hopelessness, lethal plan with intent, and interrupted near-lethal attempt. The patient's wish that he had died is particularly concerning. Hopelessness is a stronger predictor of suicide than depression severity. Means restriction is critical - this patient had removed firearms but found another method, highlighting the importance of comprehensive lethal means counseling. Involuntary commitment was appropriate given imminent risk and inability to contract for safety. Always assess for alcohol withdrawal in patients with heavy use.