A 43-year-old woman presents to the emergency department complaining of feeling "horrible." She has not been sleeping through the night, has been losing weight, and has crying fits throughout the day. These symptoms began about 3 months ago when she discovered that her husband was having an affair. She feels betrayed and foolish for having failed to recognize it sooner. She states that she has been doubting her abilities as a wife and mother. She has also stopped participating in her weekly book club and has not returned phone calls from friends and family recently, preferring to keep to herself instead. She says she "just can't take the embarrassment" and has been having frequent thoughts of suicide. The patient has been drinking 2-3 glasses of wine to help her fall asleep at night and using marijuana several times a month. She has no psychiatric history. Physical examination is unremarkable. Which of the following is the most appropriate next step in management of this patient?
Suicide assessment: ideation, intent & plan |
Evaluate ideation
Evaluate intent
Evaluate plan
|
All patients presenting with depression should be carefully screened for suicidal risk, as this screen is critical in determining the appropriate treatment setting and frequency of follow-up care (Table). This patient is having suicidal thoughts, but their content and intensity are unclear and there is no indication of whether she has a plan or intent to act on a plan. Before a treatment plan and setting is decided, it is essential to assess whether she is considering acting on a specific suicide plan.
Hospitalization to maintain safety is indicated for patients with active suicidal ideation that includes a plan and intent to act (Choice A). Patients with suicidal ideation but no specific plan or intent need intensive outpatient treatment, but not necessarily hospitalization (eg, treat the underlying disorder with medication and/or psychotherapy, increase the frequency of clinical contact, mobilize supports).
(Choice B) Ruling out medical conditions (eg, hypothyroidism, vitamin deficiencies) is common practice in patients with a new episode of depression. However, this patient's clear history of a stressor, lack of medical symptoms, and normal physical examination make a medical cause unlikely. Furthermore, suicidality is a psychiatric emergency, and a risk assessment is the most immediate concern at this point. Laboratory tests would not change immediate management.
(Choice C) Assessing for drug use is important as many substances can cause or make depression worse. This woman is likely using alcohol and marijuana to manage her depressive symptoms and should be counseled against this. However, obtaining a urine drug screen would not affect immediate management.
(Choices E, F, and G) These treatment recommendations may be appropriate, but suicide assessment and determination of the appropriate treatment setting take precedence. The selective serotonin reuptake inhibitor sertraline is a first-line antidepressant. Individual psychotherapy is useful in the treatment of mild to moderate depression with or without medications. Couples counseling may be considered after the patient is stabilized.
Educational objective:
All depressed patients should be screened for suicidal ideation, intent, and plan. Actively suicidal patients with intent and plan will often need to be hospitalized for stabilization and to maintain their safety.