Emergency Medicine · Year 3 · from Emergency Medicine

Case 2: Acute Suicidal Crisis with High-Risk Features

Patient Demographics

  • Age: 42 years
  • Sex: Female
  • Occupation: Recently unemployed accountant

Chief Complaint

"I wrote a note to my kids and was going to take all my pills tonight."

History of Present Illness

The patient is brought to the emergency department by police after her 16-year-old daughter found a suicide note in her bedroom and called 911. The patient admits she had planned to take an overdose of her amitriptyline and alprazolam tonight after her children went to sleep. She had written goodbye letters to each of her three children. She reports feeling hopeless for the past 3 months since losing her job and her husband leaving her. She has been unable to pay bills and received an eviction notice last week. She states she "can't see any way out" and believes her children would be "better off without me." She denies any previous suicide attempts but endorses passive suicidal ideation over the past several weeks that has intensified to active planning over the past 3 days. She has collected approximately 90 tablets of amitriptyline 50 mg and 60 tablets of alprazolam 1 mg. She denies current alcohol or drug use.

Psychiatric History

  • Major depressive disorder, diagnosed 15 years ago
  • Two prior psychiatric hospitalizations for depression (ages 28 and 35), neither involving suicide attempts
  • Current medications: Amitriptyline 100 mg at bedtime, alprazolam 1 mg three times daily
  • No history of psychosis or mania
  • No history of substance use disorder

Vital Signs

  • Temperature: 98.2 degrees F (36.8 degrees C)
  • Blood pressure: 142/88 mmHg
  • Heart rate: 92 bpm
  • Respiratory rate: 16/min
  • Oxygen saturation: 99% on room air

Mental Status Examination

Appearance: Disheveled, appears older than stated age, wearing pajamas, tearful Behavior: Cooperative but withdrawn, minimal eye contact, psychomotor retardation Speech: Soft, slow, low volume, decreased spontaneity Mood: "I just want it to end" Affect: Constricted, tearful, congruent with stated mood Thought process: Linear, goal-directed, but ruminative Thought content:

  • Active suicidal ideation with specific plan (overdose)
  • Lethal means available (90+ TCA tablets, 60+ benzodiazepine tablets)
  • Preparatory behaviors (suicide note written, affairs being put in order)
  • Hopelessness prominent
  • No homicidal ideation
  • No delusions or hallucinations

Cognition: Alert, oriented x4, attention and concentration impaired Insight: Poor - believes death is the only solution Judgment: Severely impaired

Suicide Risk Assessment (Columbia-Suicide Severity Rating Scale)

  • Lifetime history: No prior attempts (lower risk factor)
  • Current ideation: Active suicidal ideation with specific plan and intent
  • Risk factors: Major depression, recent major losses (job, marriage, housing), hopelessness, access to lethal means, social isolation
  • Protective factors: Children (though currently perceived as burden), no prior attempts, no substance use, cooperative with evaluation
  • Overall risk: HIGH - requires inpatient psychiatric admission

Management

Immediate Safety:

  1. 1:1 continuous observation implemented
  2. All personal belongings searched and secured
  3. Patient placed in safe room (ligature-resistant)
  4. Security notified

Medical Clearance:

  1. ECG: QTc 460 ms (borderline prolonged on TCA)
  2. Basic metabolic panel: Within normal limits
  3. Urine drug screen: Positive for benzodiazepines (prescribed)
  4. Blood alcohol level: Negative
  5. Acetaminophen and salicylate levels: Negative
  6. Pregnancy test: Negative

Psychiatric Intervention:

  1. Psychiatric consultation obtained
  2. Patient initially refused voluntary admission
  3. Involuntary commitment initiated based on:
  • Mental illness (major depressive disorder)
  • Imminent danger to self (active plan, available means, intent)
  • Unable to make informed decisions about care due to severity of depression
  1. Emergency commitment petition completed

Collateral Information:

  1. Daughter interviewed (with patient's consent)
  2. Medications secured by police from the home
  3. Primary care physician contacted

Disposition:

  • Admitted to inpatient psychiatric unit on involuntary status
  • Medications held pending psychiatric evaluation
  • Safety plan to be developed prior to eventual discharge
  • Lethal means counseling provided to family (secure all medications, no firearms in home)

Clinical Pearl

This case demonstrates multiple high-risk features for completed suicide: active ideation with a specific, lethal plan (TCA overdose is highly lethal); available means (stockpiled medications); preparatory behaviors (suicide note, putting affairs in order); hopelessness; recent major losses; and social isolation. The combination of a tricyclic antidepressant and benzodiazepines represents a highly lethal combination. The presence of children, while a protective factor in many cases, is not protective here as the patient perceives herself as a burden. Involuntary commitment is appropriate when a patient with mental illness poses imminent danger to herself and is unable to make informed decisions about psychiatric care.

Clinical Image

Image Description: Diagram illustrating the Columbia-Suicide Severity Rating Scale (C-SSRS) progression from passive suicidal ideation through active ideation without plan, active ideation with plan, to active ideation with plan and intent.

Attribution: Image adapted from Columbia Lighthouse Project materials. Public domain educational resource. Source: https://cssrs.columbia.edu/

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