Psychiatry · Year 3 · from Psychiatry

Case 1: Acute Suicidal Crisis

Patient Demographics

  • Age: 19 years old
  • Sex: Male
  • Occupation: College freshman

Chief Complaint

Per roommate: "He texted me that he's thinking about ending it all. I'm bringing him in."

History of Present Illness

The patient is a 19-year-old male brought to the emergency department by his roommate after sending a text message stating "I can't do this anymore. I've been thinking about jumping off the parking garage. Everyone would be better off without me." The roommate found him in his dorm room, tearful, holding a bottle of acetaminophen.

The patient admits to the text and states he has been having suicidal thoughts for the past 2 weeks that have intensified over the past 3 days. He describes a specific plan to jump from the campus parking structure. He has scouted the location twice. He states he feels hopeless about his future after failing two midterms and being placed on academic probation. His girlfriend of 2 years broke up with him last week, saying he was "too depressing to be around."

He has been isolating himself, skipping classes, not eating, and sleeping 14-16 hours daily. He wrote a note to his parents but has not sent it yet. He denied taking any pills; he says the roommate arrived before he could.

He has no prior psychiatric history. He denies prior suicide attempts. He drinks alcohol heavily on weekends (8-10 drinks) but denies current intoxication. He denies drug use. No family history of suicide.

Mental Status Examination

Appearance: Disheveled, unshaven, tearful young man in wrinkled clothing

Behavior: Cooperative but withdrawn; poor eye contact; psychomotor retardation

Speech: Slow rate, soft volume, increased latency

Mood: "Worthless... hopeless"

Affect: Depressed, constricted, hopeless quality

Thought Process: Linear, impoverished, ruminative

Thought Content:

  • Active suicidal ideation with specific plan (jumping)
  • Has scouted location (preparatory behavior)
  • Intent: "I was going to do it tonight"
  • Access to lethal means: High location accessible
  • Wrote note (preparing affairs)
  • Hopelessness: "Nothing will ever get better"
  • Worthlessness: "Everyone is better without me"
  • No homicidal ideation

Perceptions: No hallucinations

Cognition: Alert, oriented x3; concentration impaired

Insight: Limited - believes suicide is the only solution

Judgment: Severely impaired

Risk Assessment

Risk Factors:

  • Active suicidal ideation with specific plan
  • Preparatory behaviors (scouting location, writing note, acquiring pills)
  • Expressed intent
  • Male sex
  • Access to lethal means
  • Recent losses (relationship, academic standing)
  • Hopelessness
  • Social isolation
  • Heavy alcohol use
  • Age (college students at elevated risk)
  • No current treatment

Protective Factors:

  • No prior attempts
  • Roommate involvement (help-seeking by proxy)
  • No psychotic symptoms
  • No family history of suicide
  • Expressed some ambivalence ("I was going to do it" suggests did not)

Risk Stratification: HIGH/IMMINENT

  • Active ideation with plan, intent, means access
  • Preparatory behaviors
  • Recent acute stressors
  • Multiple risk factors with limited protective factors

Immediate Management

1. Ensure Safety:

  • Constant 1:1 observation (cannot be left alone)
  • Secure environment: Remove all potential ligature points, sharps, medications
  • Search belongings for means
  • Patient in hospital gown

2. Medical Stabilization:

  • Serum acetaminophen level: Negative (did not ingest)
  • Alcohol level: Negative
  • Urine drug screen: Negative
  • Basic metabolic panel: Normal

3. Collateral Information:

  • Roommate: Confirms 2-week decline, increasing isolation
  • Parents (contacted with patient consent): Unaware of any problems, supportive
  • No prior psychiatric treatment

4. Document Risk Assessment:

  • All risk factors identified
  • All protective factors identified
  • Interventions taken
  • Rationale for disposition

Disposition

Criteria for Psychiatric Hospitalization - MET:

  • Imminent danger to self
  • Unable to contract for safety
  • Requires supervised setting for stabilization
  • Does not have adequate outpatient support structure

Admission Type:

  • Voluntary admission preferred if patient agrees
  • Patient initially ambivalent but agreed to voluntary admission after discussion
  • If refused, would meet criteria for involuntary hold (danger to self)

Inpatient Treatment Plan

Safety:

  • 1:1 observation initially
  • Unit precautions (sharps, ligature)
  • Daily reassessment of suicide risk
  • Transition to 15-minute checks when clinically appropriate

Diagnostic Assessment:

  • Provisional diagnosis: Major Depressive Disorder, Single Episode, Severe
  • Rule out Alcohol Use Disorder

Pharmacotherapy:

  • Start sertraline 50 mg daily for depression
  • Monitor for activation/worsening suicidal ideation (Black Box Warning)
  • PRN hydroxyzine 25 mg for anxiety

Psychotherapy:

  • Daily supportive therapy
  • Safety planning (to complete before discharge)
  • Cognitive interventions for hopelessness

Discharge Planning (to begin early):

  • Contact university counseling center
  • Outpatient psychiatry appointment
  • Family involvement
  • Means restriction (campus parking structure access)
  • Medical withdrawal from semester if needed

All cases for this lecture as Markdown