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The Suicidal Patient
Pam Fry, MD
May, 11, 2016
Objectives:
To review the assessment and management strategies
associated with suicidal patients
To be able to successfully complete the online
psychiatric course on the American Psychiatric
Association:
http://education.psychiatry.org/Users/ProductDetails.a
spx?ActivityID=466
Definitions:
Suicide – self-inflicted death with evidence that the person
intended to die
Suicide attempt – self-injurious behavior with a nonfatal
outcome accompanied by evidence that the person intended
to die
Suicidal ideation – thoughts of serving as the agent of one’s
own death.
Suicidal intent – subjective expectation and desire for a selfdestructive act to end in death
Lethality of suicidal behavior – objective danger to life
associated with a suicide method or action
Deliberate self-harm – willful self-inflicting of painful,
destructive, or injurious acts without intent to die
Epidemiology
Suicide is rare!
Suicidal ideation occurs in 5.6% of the general US
population per year
Suicide attempts occur in 0.7% of the general US
population per year
Annual incidence of suicide is 10.7 suicides per
100,000 persons or 0.0107% of the total population
per year
The Psychiatric Evaluation
Signs and Symptoms that
increase suicide risk
Having a psychiatric disorder*
Aggression, violence toward others, impulsiveness,
hopelessness, agitation
Psychic anxiety = subjective feelings of anxiety,
fearfulness, or apprehension
Anhedonia, global insomnia, panic attacks
Psychosis and depression
Past Suicidal Behavior
Risk of suicide increases with more serious, more frequent,
and more recent attempts
Ask about aborted suicide attempts
Precipitants, timing, intent, consequences of past attempts
Medical severity of past attempts (lethality)
Intoxicant use
Interpersonal relationships
How do they feel about their prior attempts now?
Past medical/psychiatric
history
Identify prior psychiatric hospitalization, prior suicide
attempts
Identify medical diagnoses that could contribute to
suicide risk
Contact current psychiatric caregivers to assess
patient’s
Stability
Strength of therapeutic relationship
Family history of suicides or attempts, mental illness,
substance abuse, DV, abuse
Identify strengths,
vulnerabilities , and stressors
Identify social, financial, legal, interpersonal, and sexual stressors
Assess coping skills, personality traits
Factors that increase suicide risk:
Hopelessness
Aggression
Impulsivity
Narrow-minded thinking
Perfectionism
Polarized thinking
GAF (Global Assessment of Functioning) score
Suicidal ideation questions:
What led up to your thoughts?
Have you ever started to harm or kill yourself, but stopped before
doing something?
What do you envision happening if you kill yourself?
Plan and access to weapons?
Preparations made for your death?
Had you planned to be discovered, or were you found
accidentally?
Did you tell anyone? Did you seek help yourself?
Has your view of things changed?
Homicidal ideation questions:
Are there others who you think may be responsible for
what you’re experiencing? Are you having thoughts of
harming them?
Are there other people you would want to die with
you?
Are there others who you think would be unable to go
on without you?
Factors That Increase Suicide Risk
Suicidal ideation (plans, attempts, lethality, intent)
Psychiatric illness (depression, bipolar, schizophrenia, eating disorders, cluster
B personality disorders, axis I and II disorders)*
Substance and alcohol abuse
Physical disease and/or functional impairments
Psychosocial features – no social support, DV, drop in socioeconomic status,
unemployment
Childhood Trauma
Family History
Psychological and cognitive features
Demographic features – male, widow/divorced/single, elderly,
adolescent/young adults, white race, LGBT
Access to firearms, intoxication, poor therapeutic relationship.
Factors That Decrease Suicide Risk:
Children at home – unless postpartum
Pregnancy
Religion
Life Satisfaction
Sense of responsibility to family
Coping and problem-solving skills
Social support
Strong therapeutic relationship
Reality Testing ability
Psychiatric Treatment
Psychiatric Admissions
Psychosis present
Violent, near-lethal, or premeditated attempt
Precautions taken to avoid rescue or discovery
Persistent plan/intent present
Regrets surviving or more distress due to survival
Male, age >45, especially new onset SI or psychiatric illness
No or limited social support, unstable living situation
Impulsive behavior, severe agitation, poor judgment, or refusal of help
Altered mental status
Specific plan with high lethality or high suicidal intent
D/C from ER with follow-up
Suicidality is a reaction to a precipitating event
Especially if patient’s view of situation has changed
Plan/method and intent have low lethality
Patient has stable and supportive living situation
Patient is able to cooperate with follow-up
Chronic suicidal ideation and/or self-injury without
prior medically serious attempts with supportive/safe
living situation and outpatient care is ongoing*
Somatic Treatments
Major depression symptoms: SSRI’s
No conclusive evidence they prevent suicide
Agitation/anxiety symptoms: long-acting benzodiazepines
Bipolar or recurrent major depression: lithium
Strong evidence that long-term maintenance lowers suicide
and attempts
Schizophrenia and schizoaffective disorder: Clozapine
Significantly decreases rates of suicide attempts
Refractory or severe diseases: ECT
Pregnancy
Somatic Therapy
Anti-depressants
No documented decrease in suicide or attempts
Counsel about delay in clinically obvious improvements
Lithium
Majorly reduces suicides and attempts in patients with recurring bipolar disorder and major depression
Mood-Stabilizing Anticonvulsants
No evidence they reduce suicidal behavior
Antipsychotics
Clozapine has been shown to reduce suicide and attempts
Antianxiety Agents
Long acting >short acting, but no change in suicide/attempts
Can have worsening anxiety when short course is finished
Can increase impulsivity, which increases suicidal risk
ECT
Consider in patients who a delay in treatment response is life-threatening
Reduces short-term SI only
Psychotherapy:
Cognitive Behavior Therapy
Focuses on thoughts and beliefs and how they influence the patient’s
mood and actions and how the patient’s actions can be change
unhealthy behavior patterns
Dialectical Behavior Therapy
Form of CBT to treat suicidal thoughts and actions to balance/blend 2
extremes to find a middle ground
Helpful in personality disorders, chronic SI, and “self-harming women”
Interpersonal Therapy
Improves communication patterns and they ways people relate to others
Depression or dysthymia
Psychodynamic Therapy
Psychoanalytic theory that a patient’s behavior is affected by their
unconscious mind/past experiences
Documentation
Suicide risk assessment tools or scales have no predictive
value of actual suicide
Suicide risk assessments should be documented at
admission, discharge, and with significant changes in
patient’s condition
No-harm or suicide prevention contracts do not decrease
suicides
Should only be used in strong therapeutic alliances
Not for emergency settings
May discuss PHI with others if you feel patient is a danger to
self or others and gaining information will be helpful
The Quiz
1.
A 33-year-old man in the midst of financial struggles with
his carpentry business is brought into the emergency room
by his wife. Earlier that day, she went to his workshop and
surprised him halfway up a ladder positioned under a
noose tied to the rafters. He was holding a utility knife.
When she asked what he was doing, her husband broke
into tears and admitted he had been thinking she would
be better off if he died because she could collect on an
insurance policy. However, after preparing the noose to
hang himself, he thought about how he would miss their
children. When she discovered him, he was just about to
use the knife to cut down the noose. This suicidal behavior
is best described as:
A. Aborted suicide attempt
B. Persistent suicidal ideation
C. Suicide attempt
D. Suicide plan
1.
A 33-year-old man in the midst of financial struggles with
his carpentry business is brought into the emergency room
by his wife. Earlier that day, she went to his workshop and
surprised him halfway up a ladder positioned under a
noose tied to the rafters. He was holding a utility knife.
When she asked what he was doing, her husband broke
into tears and admitted he had been thinking she would
be better off if he died because she could collect on an
insurance policy. However, after preparing the noose to
hang himself, he thought about how he would miss their
children. When she discovered him, he was just about to
use the knife to cut down the noose. This suicidal behavior
is best described as:
A. Aborted suicide attempt
B. Persistent suicidal ideation
C. Suicide attempt
D. Suicide plan
2. Of the following statements about suicide risk factors, prediction, and
intervention, which is most accurate?
A. Although suicide is a rare event, it is possible to predict its occurrence if
multiple risk factors are considered.
B. Because it is impossible to predict suicide using risk factors, some risk
factors can be ignored.
C. Knowing that a risk factor is present and increases the patients relative
risk for suicide allows the psychiatrist to adapt the treatment plan
accordingly.
D. Since risk factors for suicide cannot be modified, the psychiatrist should
focus primarily on strengthening protective factors to decrease the patients
risk of suicide.
2. Of the following statements about suicide risk factors, prediction, and
intervention, which is most accurate?
A. Although suicide is a rare event, it is possible to predict its occurrence if
multiple risk factors are considered.
B. Because it is impossible to predict suicide using risk factors, some risk
factors can be ignored.
C. Knowing that a risk factor is present and increases the patients
relative risk for suicide allows the psychiatrist to adapt the
treatment plan accordingly.
D. Since risk factors for suicide cannot be modified, the psychiatrist should
focus primarily on strengthening protective factors to decrease the patients
risk of suicide.
3. As part of a patient safety initiative, a hospital administrator specializing in
risk management wants to develop a suicide assessment scale that must be
used on admission or discharge of any patient. The administrator asks for
your opinion. Which of the following general statements would be most
appropriate to make to the administrator?
A. Good clinical utility has been shown for a number of suicide assessment
scales developed for use in research, such as Beck's Scale for Suicide Ideation
and the Suicide Intent Scale.
B. Although they may help in opening communication with patients or
developing a thorough line of questioning about suicidality, suicide
assessment scales have no predictive value.
C. Because they document a specific suicide assessment, scales can reduce
physician and hospital liability for patient suicide.
D. Existing suicide assessment scales have good predictive value for patients at
high risk for suicide but low predictive value for patients at low risk.
3. As part of a patient safety initiative, a hospital administrator specializing in
risk management wants to develop a suicide assessment scale that must be
used on admission or discharge of any patient. The administrator asks for
your opinion. Which of the following general statements would be most
appropriate to make to the administrator?
A. Good clinical utility has been shown for a number of suicide assessment
scales developed for use in research, such as Beck's Scale for Suicide Ideation
and the Suicide Intent Scale.
B. Although they may help in opening communication with patients
or developing a thorough line of questioning about suicidality,
suicide assessment scales have no predictive value.
C. Because they document a specific suicide assessment, scales can reduce
physician and hospital liability for patient suicide.
D. Existing suicide assessment scales have good predictive value for patients at
high risk for suicide but low predictive value for patients at low risk.
4. The most significant risk factor for suicide is
which of the following?
A. Divorce
B. Unemployment
C. Psychiatric disorder
D. Psychic anxiety
E. Anhedonia
4. The most significant risk factor for suicide is
which of the following?
A. Divorce
B. Unemployment
C.Psychiatric disorder
D. Psychic anxiety
E. Anhedonia
5. A 25-year-old man comes to the emergency department at the urging of his
family, who is concerned about his recent statements that life does not seem
worth living. The family states that he rarely leaves the house, doesn't seem
to have any friends, and feels hopeless about his situation ever changing.
Assuming that this patient has one of the following diagnoses, which
diagnosis would be associated with the higher risk of suicide?
A.
B.
C.
D.
Alcohol abuse
Avoidant personality disorder
Adjustment disorder
Schizophrenia
5. A 25-year-old man comes to the emergency department at the urging of his
family, who is concerned about his recent statements that life does not seem
worth living. The family states that he rarely leaves the house, doesn't seem
to have any friends, and feels hopeless about his situation ever changing.
Assuming that this patient has one of the following diagnoses, which
diagnosis would be associated with the higher risk of suicide?
A. Alcohol abuse
B. Avoidant personality disorder
C. Adjustment disorder
D. Schizophrenia
6. A 59-year-old man comes to the emergency department at the urging of his
boss, who is concerned about his recent statements that ''I just cant take it
anymore.'' The patients wife of 38 years recently filed for divorce, and over
the past several months he has been increasingly estranged from his children.
His financial situation is also precarious. Assuming that this patient has one
of the following diagnoses, which diagnosis would be associated with the
higher risk of suicide?
A.
B.
C.
D.
Alcohol dependence
Antisocial personality disorder
Generalized anxiety disorder
Adjustment disorder
6. A 59-year-old man comes to the emergency department at the urging of his
boss, who is concerned about his recent statements that ''I just cant take it
anymore.'' The patients wife of 38 years recently filed for divorce, and over
the past several months he has been increasingly estranged from his children.
His financial situation is also precarious. Assuming that this patient has one
of the following diagnoses, which diagnosis would be associated with the
higher risk of suicide?
A. Alcohol dependence
B. Antisocial personality disorder
C. Generalized anxiety disorder
D. Adjustment disorder
7. A 27-year-old woman presents to the emergency department with a chief
complaint of feeling very depressed and suicidal. The psychiatric
assessment, which includes a review of her past psychiatric admissions, lists
the following diagnoses: Axis I: Major depressive disorder, recurrent, severe;
Sedative-hypnotic abuse, in remission; Anorexia nervosa, in remission; Axis
II: Borderline personality disorder Of the following statements about
comorbid psychiatric diagnoses and suicide risk, which most accurately
describes the weight her comorbid diagnoses should be given in this suicide
assessment?
A. A previous psychiatric diagnosis or one that is in remission does not need
to be considered as carefully as an active diagnosis.
B. Individuals with multiple comorbid diagnoses have a similar risk for
suicide as individuals with a single comorbid diagnosis.
C. Since individuals with mood disorders already have high suicide rates,
comorbid alcohol and substance use have little effect on mortality from
suicide.
D. The comorbid diagnoses that should receive the greatest attention are
major depression, alcohol and substance abuse, and cluster B personality
disorders.
7. A 27-year-old woman presents to the emergency department with a chief
complaint of feeling very depressed and suicidal. The psychiatric
assessment, which includes a review of her past psychiatric admissions, lists
the following diagnoses: Axis I: Major depressive disorder, recurrent, severe;
Sedative-hypnotic abuse, in remission; Anorexia nervosa, in remission; Axis
II: Borderline personality disorder Of the following statements about
comorbid psychiatric diagnoses and suicide risk, which most accurately
describes the weight her comorbid diagnoses should be given in this suicide
assessment?
A. A previous psychiatric diagnosis or one that is in remission does not need
to be considered as carefully as an active diagnosis.
B. Individuals with multiple comorbid diagnoses have a similar risk for
suicide as individuals with a single comorbid diagnosis.
C. Since individuals with mood disorders already have high suicide rates,
comorbid alcohol and substance use have little effect on mortality from
suicide.
D. The comorbid diagnoses that should receive the greatest
attention are major depression, alcohol and substance abuse,
and cluster B personality disorders.
8. A 36-year-old woman is being evaluated in the emergency department
for suicidal ideation. The hospital computer system notes that she has no
history of psychiatric care at the hospital but that she has received
treatment for Huntington’s disease. How does this fact influence her risk
for suicide?
A.
B.
C.
D.
It increases her risk.
It increases her risk only if an axis I disorder is present.
It decreases her risk.
It has no significant influence.
8. A 36-year-old woman is being evaluated in the emergency department
for suicidal ideation. The hospital computer system notes that she has no
history of psychiatric care at the hospital but that she has received
treatment for Huntington’s disease. How does this fact influence her risk
for suicide?
A. It increases her risk.
B. It increases her risk only if an axis I disorder is present.
C. It decreases her risk.
D. It has no significant influence.
9. If the same patient has received treatment for hypertension, how
does this fact influence her risk for suicide?
A.
B.
C.
D.
It increases her risk.
It increases her risk only if an axis I disorder is present.
It decreases her risk.
It has no significant influence.
9. If the same patient has received treatment for hypertension, how
does this fact influence her risk for suicide?
A. It increases her risk.
B. It increases her risk only if an axis I disorder is present.
C. It decreases her risk.
D. It has no significant influence.
10. Which of the following examples best characterizes a patient with
suicide intent?
A. A patient who describes being discovered accidentally by a hotel maid
after leaving a suicide note and ingesting a container of rat poison
B. A patient who describes loading a gun, putting it to his head, then not
''having the guts'' to pull the trigger
C. A patient who describes feeling hopeless about the future and having
thoughts of killing himself with carbon monoxide or a gun
D. A patient who describes wishing he were dead and thinking about
killing himself all the time
10. Which of the following examples best characterizes a patient with
suicide intent?
A. A patient who describes being discovered accidentally by a
hotel maid after leaving a suicide note and ingesting a
container of rat poison
B. A patient who describes loading a gun, putting it to his head, then not
''having the guts'' to pull the trigger
C. A patient who describes feeling hopeless about the future and having
thoughts of killing himself with carbon monoxide or a gun
D. A patient who describes wishing he were dead and thinking about
killing himself all the time
11. A psychiatrist treats a 39-year-old man who presented with depression and suicidal ideas,
including fleeting thoughts of shooting himself with a gun. After 1 year of treatment with
weekly psychotherapy, the patient recovers and even feels well enough to take up new
hobbies such as deep sea fishing. However, his depression recurs 6 months later after the
patient loses his job. His suicidal ideation and planning develop as follows in this timeline of
office visits: May 1:The patient first expresses a wish for death, saying he sometimes wishes
he could go to sleep and not wake up. May 8: The patient first alludes to suicidal intent.
When the psychiatrist asks if he is looking forward to an upcoming fishing trip, the patient
responds, ''I don’t know. The way my life is going, I might not be around.'' May 15: The
patient first suggests a suicide plan, repeating his assertion from 1 year ago that ''a gun is the
way to go.'' May 22: The patient first suggests specific preparations to enact a suicide plan,
saying, ''I went to a gun store and looked at shotguns.'' May 29: The patient first rehearses
suicide, reporting that on the recent fishing trip, he killed a shark with a gun. Later, when
nobody was looking, he practiced pointing the gun at himself. At this last visit, the
psychiatrist is alarmed to realize that although the patient does not own a gun, he might
have easy access to one through his hobby. At what point above would it have been
important for the psychiatrist to begin determining (e.g., by thorough questioning) if the
patient had such access?
A.
B.
C.
D.
When the patient first expressed a wish to die on May 1
When the patient first suggested suicidal intent on May 8
When the patient first suggested a suicide plan on May 15
When the patient first suggested preparations to enact the plan on May 22
11. A psychiatrist treats a 39-year-old man who presented with depression and suicidal ideas,
including fleeting thoughts of shooting himself with a gun. After 1 year of treatment with
weekly psychotherapy, the patient recovers and even feels well enough to take up new
hobbies such as deep sea fishing. However, his depression recurs 6 months later after the
patient loses his job. His suicidal ideation and planning develop as follows in this timeline of
office visits: May 1:The patient first expresses a wish for death, saying he sometimes wishes
he could go to sleep and not wake up. May 8: The patient first alludes to suicidal intent.
When the psychiatrist asks if he is looking forward to an upcoming fishing trip, the patient
responds, ''I don’t know. The way my life is going, I might not be around.'' May 15: The
patient first suggests a suicide plan, repeating his assertion from 1 year ago that ''a gun is the
way to go.'' May 22: The patient first suggests specific preparations to enact a suicide plan,
saying, ''I went to a gun store and looked at shotguns.'' May 29: The patient first rehearses
suicide, reporting that on the recent fishing trip, he killed a shark with a gun. Later, when
nobody was looking, he practiced pointing the gun at himself. At this last visit, the
psychiatrist is alarmed to realize that although the patient does not own a gun, he might
have easy access to one through his hobby. At what point above would it have been
important for the psychiatrist to begin determining (e.g., by thorough questioning) if the
patient had such access?
A. When the patient first expressed a wish to die on May 1
B. When the patient first suggested suicidal intent on May 8
C. When the patient first suggested a suicide plan on May 15
D. When the patient first suggested preparations to enact the plan on May 22
12. A 23-year-old woman comes to the emergency department after
taking an overdose of 20 aspirin tablets. She is surprised at being alive
but continues to feel that she has nothing to live for. She describes
thinking of suicide for several weeks since separating from her husband.
When police went to her house after being summoned by her mother,
they found a note apologizing to her family and asking them to care for
her cat after her death. In assessing the seriousness of the patients
suicidal intent and her risk for future suicide, which of the following
factors is least relevant?
A.
B.
C.
D.
The likelihood of death from the method
The patients belief about the lethality of the method
The patients expressed suicidal intent
The presence of a suicide note
12. A 23-year-old woman comes to the emergency department after
taking an overdose of 20 aspirin tablets. She is surprised at being alive
but continues to feel that she has nothing to live for. She describes
thinking of suicide for several weeks since separating from her husband.
When police went to her house after being summoned by her mother,
they found a note apologizing to her family and asking them to care for
her cat after her death. In assessing the seriousness of the patients
suicidal intent and her risk for future suicide, which of the following
factors is least relevant?
A. The likelihood of death from the method
B. The patients belief about the lethality of the method
C. The patients expressed suicidal intent
D. The presence of a suicide note
13. A 52-year-old man with no previous psychiatric illness is brought to
the emergency room by his sister. He attempted to shoot himself in front
of her, but she wrestled the gun out of his hand. The sister is alarmed
and upset but suggests that her brother may not really have wanted to die
because if he had, he should have been able to resist her. The patients
wife left him 1 month ago after discovering that he was having an
extramarital affair. Since that time, he has lost weight and been more
''moody.'' The patient describes feeling ''horrible guilt for ruining my
marriage.'' ''Sometimes,'' he says, ''I even think I don’t deserve to live.'' Of
the following treatment settings, which is the most appropriate for this
patient at this time?
A.
B.
C.
D.
Inpatient psychiatric hospitalization
Partial hospitalization
Outpatient psychiatric treatment
Outpatient follow-up with his family physician
13. A 52-year-old man with no previous psychiatric illness is brought to
the emergency room by his sister. He attempted to shoot himself in front
of her, but she wrestled the gun out of his hand. The sister is alarmed
and upset but suggests that her brother may not really have wanted to die
because if he had, he should have been able to resist her. The patients
wife left him 1 month ago after discovering that he was having an
extramarital affair. Since that time, he has lost weight and been more
''moody.'' The patient describes feeling ''horrible guilt for ruining my
marriage.'' ''Sometimes,'' he says, ''I even think I don’t deserve to live.'' Of
the following treatment settings, which is the most appropriate for this
patient at this time?
A. Inpatient psychiatric hospitalization
B. Partial hospitalization
C. Outpatient psychiatric treatment
D. Outpatient follow-up with his family physician
14. A 34-year-old woman is brought to the emergency department by police
after she called a suicide hotline and stated she was having thoughts of ''hurting
herself'' and wanted help. While she was speaking on the phone, the call was
traced, and police arrived at her door. Upon interview, she reports chronic
suicidal thinking and states that she became dejected this day because her boss
was critical of her work performance. She states that her job is not in jeopardy
but that she always has a hard time dealing with criticism. She reports no past
psychiatric hospitalization and no history of suicide attempts, although she has
occasionally scratched her wrists when feeling angry and frustrated but has
never ''actually wanted to die.'' The patients outpatient psychiatrist of many
years is contacted. He confirms that the patient has always experienced ''ups
and downs'' in her level of suicidal ideation in response to stress. He states that
she regularly keeps appointments with him and she has an appointment
scheduled 2 days hence. The patients sister, with whom she lives, is also
contacted and says she is willing to ''do whatever I can to be of help.'' Of the
following treatment settings, which is the most appropriate for this patient at
this time?
A.
B.
C.
D.
Inpatient psychiatric hospitalization
Partial hospitalization
Continuing day treatment program
Outpatient psychiatric treatment
14. A 34-year-old woman is brought to the emergency department by police
after she called a suicide hotline and stated she was having thoughts of ''hurting
herself'' and wanted help. While she was speaking on the phone, the call was
traced, and police arrived at her door. Upon interview, she reports chronic
suicidal thinking and states that she became dejected this day because her boss
was critical of her work performance. She states that her job is not in jeopardy
but that she always has a hard time dealing with criticism. She reports no past
psychiatric hospitalization and no history of suicide attempts, although she has
occasionally scratched her wrists when feeling angry and frustrated but has
never ''actually wanted to die.'' The patients outpatient psychiatrist of many
years is contacted. He confirms that the patient has always experienced ''ups
and downs'' in her level of suicidal ideation in response to stress. He states that
she regularly keeps appointments with him and she has an appointment
scheduled 2 days hence. The patients sister, with whom she lives, is also
contacted and says she is willing to ''do whatever I can to be of help.'' Of the
following treatment settings, which is the most appropriate for this patient at
this time?
A. Inpatient psychiatric hospitalization
B. Partial hospitalization
C. Continuing day treatment program
D. Outpatient psychiatric treatment
15. A 19-year-old female college sophomore is brought into the emergency
room following an overdose of perphenazine (32 mg) and fluoxetine (200
mg). She was discovered when her roommate returned 2 days early from a
trip. Under observation by medical staff, her vital signs become stable, and
she is able to speak coherently. A psychiatric evaluation discovers that she
has been diagnosed with borderline personality disorder and has been
hospitalized three times for anorexia nervosa and self-mutilation. The
patient, however, denies previous suicide attempts, saying her cutting is a
''basically harmless habit'' that makes her ''feel real.'' When asked if she
believed her overdose would be fatal, she says, ''I guess so. I don’t really
know what I was thinking. Everything would have been easier if it had
worked.'' She reports that her therapist for the past 2 years is in the process
of terminating treatment because of an impending move and is unable to
see the patient more frequently. Of the following treatment settings, which
is the most appropriate for this patient at this time?
A.
B.
C.
D.
Inpatient psychiatric hospitalization
Partial hospitalization
Outpatient psychiatric treatment
Referral to the student health infirmary
15. A 19-year-old female college sophomore is brought into the emergency
room following an overdose of perphenazine (32 mg) and fluoxetine (200
mg). She was discovered when her roommate returned 2 days early from a
trip. Under observation by medical staff, her vital signs become stable, and
she is able to speak coherently. A psychiatric evaluation discovers that she
has been diagnosed with borderline personality disorder and has been
hospitalized three times for anorexia nervosa and self-mutilation. The
patient, however, denies previous suicide attempts, saying her cutting is a
''basically harmless habit'' that makes her ''feel real.'' When asked if she
believed her overdose would be fatal, she says, ''I guess so. I don’t really
know what I was thinking. Everything would have been easier if it had
worked.'' She reports that her therapist for the past 2 years is in the process
of terminating treatment because of an impending move and is unable to
see the patient more frequently. Of the following treatment settings, which
is the most appropriate for this patient at this time?
A. Inpatient psychiatric hospitalization
B. Partial hospitalization
C. Outpatient psychiatric treatment
D. Referral to the student health infirmary
16. A 59-year-old recent widower is referred by his primary care physician for
evaluation of a 3-month history of low mood with occasional thoughts of
suicide. His daughter and her 5-year-old son recently moved in with the
patient, and the sons father has been making threatening phone calls to their
home. The patient describes feeling extremely anxious and hopeless about his
current situation. He also describes poor appetite with a 10-pound weight
loss, poor sleep with intermittent awakening, and poor concentration. His
family history includes severe depression in his maternal grandmother and
the suicide of a maternal uncle. In devising a plan of treatment, focus on
which of the following would be most likely to modify his risk for suicide?
A.
B.
C.
D.
Anxiety and hopelessness
Family history of completed suicide
Family history of depression
Marital status, recently widowed
16. A 59-year-old recent widower is referred by his primary care physician for
evaluation of a 3-month history of low mood with occasional thoughts of
suicide. His daughter and her 5-year-old son recently moved in with the
patient, and the sons father has been making threatening phone calls to their
home. The patient describes feeling extremely anxious and hopeless about his
current situation. He also describes poor appetite with a 10-pound weight
loss, poor sleep with intermittent awakening, and poor concentration. His
family history includes severe depression in his maternal grandmother and
the suicide of a maternal uncle. In devising a plan of treatment, focus on
which of the following would be most likely to modify his risk for suicide?
A. Anxiety and hopelessness
B. Family history of completed suicide
C. Family history of depression
D. Marital status, recently widowed
17. A 29-year-old woman is admitted to the hospital following a suicide
attempt by overdosing on acetaminophen. She has had two previous
hospitalizations for suicidal ideation and one for treatment of a manic
episode. Her family history is significant for suicide in her paternal
grandfather. At present she describes her mood as ''really down'' and says
that her sleep and appetite are poor. During the interview she also
exhibits prominent psychomotor retardation and states that she continues
to wish she were dead. In discussing available treatment options with the
patient and her family, which of the following maintenance medications
would you mention as having the most evidence for a reduction in the
rate of suicide attempts and suicides in similar patients?
A.
B.
C.
D.
E.
Carbamazepine
Divalproex
Fluoxetine
Imipramine
Lithium
17. A 29-year-old woman is admitted to the hospital following a suicide
attempt by overdosing on acetaminophen. She has had two previous
hospitalizations for suicidal ideation and one for treatment of a manic
episode. Her family history is significant for suicide in her paternal
grandfather. At present she describes her mood as ''really down'' and says
that her sleep and appetite are poor. During the interview she also
exhibits prominent psychomotor retardation and states that she continues
to wish she were dead. In discussing available treatment options with the
patient and her family, which of the following maintenance medications
would you mention as having the most evidence for a reduction in the
rate of suicide attempts and suicides in similar patients?
A.
B.
C.
D.
Carbamazepine
Divalproex
Fluoxetine
Imipramine
E. Lithium
18. A 29-year-old man is admitted to the hospital following a suicide
attempt in which he severely lacerated his neck in response to an
auditory command hallucination. Since age 21, he has had six
hospitalizations in association with suicidal ideas or suicide attempts.
In discussing available treatment options with the patient and his
family, which of the following antipsychotic medications would you
mention as having the most evidence for a reduction in the rate of
suicide attempts and suicides?
A.
B.
C.
D.
E.
Aripiprazole
Clozapine
Olanzapine
Risperidone
Ziprasidone
18. A 29-year-old man is admitted to the hospital following a suicide
attempt in which he severely lacerated his neck in response to an
auditory command hallucination. Since age 21, he has had six
hospitalizations in association with suicidal ideas or suicide attempts.
In discussing available treatment options with the patient and his
family, which of the following antipsychotic medications would you
mention as having the most evidence for a reduction in the rate of
suicide attempts and suicides?
A. Aripiprazole
B. Clozapine
C. Olanzapine
D. Risperidone
E. Ziprasidone
19. A resident who is treating a 34-year-old woman for anxiety and
depression seeks consultation from his supervising psychiatrist. The
patient has described her anxiety as ''becoming intolerable'' and has stated
''I just don’t think I can go on like this any longer.'' She has been in
outpatient psychotherapy since age 23 for treatment of borderline
personality disorder and has had several hospital admissions for suicide
attempts by cutting her wrists. Although she reports no personal history of
alcohol or substance use, a maternal uncle has a history of alcohol
dependence. The resident asks if he should prescribe this patient a shortacting benzodiazepine such as alprazolam. The supervising psychiatrist
suggests that a benzodiazepine should be used cautiously in this patient if
at all. Which of the following is the most legitimate reason for his caution?
A. Benzodiazepines cannot be expected to alter short-term suicide risk in
patients with intolerable anxiety.
B. This patients suicide risk may be decreased by short-term benzodiazepine
treatment but is likely to increase when the treatment is discontinued.
C. A benzodiazepine could enhance impulsivity in this patient.
D. This patients family history of alcohol abuse makes it likely that she will
become dependent on and abuse a benzodiazapine.
19. A resident who is treating a 34-year-old woman for anxiety and
depression seeks consultation from his supervising psychiatrist. The
patient has described her anxiety as ''becoming intolerable'' and has stated
''I just don’t think I can go on like this any longer.'' She has been in
outpatient psychotherapy since age 23 for treatment of borderline
personality disorder and has had several hospital admissions for suicide
attempts by cutting her wrists. Although she reports no personal history of
alcohol or substance use, a maternal uncle has a history of alcohol
dependence. The resident asks if he should prescribe this patient a shortacting benzodiazepine such as alprazolam. The supervising psychiatrist
suggests that a benzodiazepine should be used cautiously in this patient if
at all. Which of the following is the most legitimate reason for his caution?
A. Benzodiazepines cannot be expected to alter short-term suicide risk in
patients with intolerable anxiety.
B. This patients suicide risk may be decreased by short-term benzodiazepine
treatment but is likely to increase when the treatment is discontinued.
C. A benzodiazepine could enhance impulsivity in this patient.
D. This patients family history of alcohol abuse makes it likely that she will
become dependent on and abuse a benzodiazapine.
20. A 36-year-old woman in her 23rd week of pregnancy is admitted to the hospital
after police rescued her from a bridge as she was preparing to jump. Despite being
placed on one-to-one observation, she has continued to try to find sharp objects in
her hospital room with which to kill herself. During the interview, the patient
reports feeling extremely depressed for about 8 weeks and having repeated thoughts
of suicide during that time. She has been sleeping 4 to 5 hours each night and often
awakens at 4 a.m. unable to return to sleep. During the course of the pregnancy,
her weight gain has been minimal. Her husband notes that she paces constantly
about the house saying she will be ''a bad mother.'' She has been unable to enjoy any
of their usual activities and has stopped going to her job as a real estate agent. She
has continued to see her therapist of 4 years, who has been treating her for
borderline personality disorder. In discussing treatment options, the patients
husband asks about ECT. Which of the following statements is most correct about
the use of ECT in this patient?
A. ECT is not indicated because of the patients history of borderline personality
disorder.
B. ECT is not indicated because the anesthetic agents used with ECT would be toxic
to the fetus.
C. ECT may be indicated since it has long-term effects in decreasing mortality from
suicide.
D. ECT may be indicated since its use is associated with short-term decreases in
suicidality.
20. A 36-year-old woman in her 23rd week of pregnancy is admitted to the hospital
after police rescued her from a bridge as she was preparing to jump. Despite being
placed on one-to-one observation, she has continued to try to find sharp objects in
her hospital room with which to kill herself. During the interview, the patient
reports feeling extremely depressed for about 8 weeks and having repeated thoughts
of suicide during that time. She has been sleeping 4 to 5 hours each night and often
awakens at 4 a.m. unable to return to sleep. During the course of the pregnancy,
her weight gain has been minimal. Her husband notes that she paces constantly
about the house saying she will be ''a bad mother.'' She has been unable to enjoy any
of their usual activities and has stopped going to her job as a real estate agent. She
has continued to see her therapist of 4 years, who has been treating her for
borderline personality disorder. In discussing treatment options, the patients
husband asks about ECT. Which of the following statements is most correct about
the use of ECT in this patient?
A. ECT is not indicated because of the patients history of borderline personality
disorder.
B. ECT is not indicated because the anesthetic agents used with ECT would be toxic
to the fetus.
C. ECT may be indicated since it has long-term effects in decreasing mortality from
suicide.
D. ECT may be indicated since its use is associated with short-term
decreases in suicidality.
21. A 25-year-old graduate student calls the university clinic for a psychotherapy
referral. She reports having occasional thoughts of ''throwing myself in front of
a train'' when she is overwhelmed at school and when she has conflicts when
speaking by phone with a significant other who lives in another city. She also
reports that she cuts her arms and upper thighs as a way of relieving tension.
Since relocating 3 months ago to begin her graduate studies, she has not had
any follow-up. She now wishes to resume treatment and asks what kind of
psychotherapy is best for her kind of problems. In addition to assisting her
with referrals, which of the following types of therapy could you mention as
having some evidence for a reduction in suicide attempts in patients with
similar symptoms?
A.
B.
C.
D.
Cognitive behavior therapy
Dialectical behavior therapy
Interpersonal therapy
Psychodynamic therapy
21. A 25-year-old graduate student calls the university clinic for a psychotherapy
referral. She reports having occasional thoughts of ''throwing myself in front of
a train'' when she is overwhelmed at school and when she has conflicts when
speaking by phone with a significant other who lives in another city. She also
reports that she cuts her arms and upper thighs as a way of relieving tension.
Since relocating 3 months ago to begin her graduate studies, she has not had
any follow-up. She now wishes to resume treatment and asks what kind of
psychotherapy is best for her kind of problems. In addition to assisting her
with referrals, which of the following types of therapy could you mention as
having some evidence for a reduction in suicide attempts in patients with
similar symptoms?
A. Cognitive behavior therapy
B. Dialectical behavior therapy
C. Interpersonal therapy
D. Psychodynamic therapy
22. As part of a physician peer assessment program, a psychiatrist reviews the
inpatient record of a 23-year-old woman who was involuntarily hospitalized
following a medically serious suicide attempt. The chronology of the patients
hospital course was as follows: Hospital Day 1: Initial evaluation leads to the
diagnosis of major depressive disorder, and antidepressant therapy is initiated.
Hospital Day 3: Antidepressant dosage is increased. Hospital Day 6: Patient
reports seeing people on the parking lot who are planning to have her killed.
Hospital Day 7: Antipsychotic treatment is initiated. Hospital Day 11: Patient
reports that her mood is improved and that she no longer worries people are
plotting to kill her. Hospital Day 14: Patient receives privileges to leave the
unit with her family. Hospital Day 18: Patient is discharged home, and followup is arranged. At a minimum, on which of these hospital days would the
peer reviewer want to see evidence that a suicide risk assessment had been
documented?
A.
B.
C.
D.
E.
Hospital Days 1 and 18
Hospital Days 1, 6, and 18
Hospital Days 1, 6, 14, and 18
Hospital Days 1, 3, 7, and 18
Hospital Days 1, 3, 7, 14, and 18
22. As part of a physician peer assessment program, a psychiatrist reviews the
inpatient record of a 23-year-old woman who was involuntarily hospitalized
following a medically serious suicide attempt. The chronology of the patients
hospital course was as follows: Hospital Day 1: Initial evaluation leads to the
diagnosis of major depressive disorder, and antidepressant therapy is initiated.
Hospital Day 3: Antidepressant dosage is increased. Hospital Day 6: Patient
reports seeing people on the parking lot who are planning to have her killed.
Hospital Day 7: Antipsychotic treatment is initiated. Hospital Day 11: Patient
reports that her mood is improved and that she no longer worries people are
plotting to kill her. Hospital Day 14: Patient receives privileges to leave the
unit with her family. Hospital Day 18: Patient is discharged home, and followup is arranged. At a minimum, on which of these hospital days would the
peer reviewer want to see evidence that a suicide risk assessment had been
documented?
A. Hospital Days 1 and 18
B. Hospital Days 1, 6, and 18
C. Hospital Days 1, 6, 14, and 18
D. Hospital Days 1, 3, 7, and 18
E. Hospital Days 1, 3, 7, 14, and 18
23. A hospital risk manager speaks with you about developing an educational
seminar on suicide prevention contracts for emergency department staff. As
part of the seminar, which of the following would be a most appropriate point
to emphasize?
A. A patients willingness to enter into a suicide prevention contract indicates
readiness for discharge from an emergency setting.
B. In emergency settings, suicide prevention contracts are a helpful method for
reducing suicide risk but should not be used to determine discharge.
C. Using suicide prevention contracts in emergency settings is not recommended.
D. Suicide prevention contracts can be useful for assessing the physician-patient
relationship with individuals who are intoxicated, agitated, or psychotic.
23. A hospital risk manager speaks with you about developing an educational
seminar on suicide prevention contracts for emergency department staff. As
part of the seminar, which of the following would be a most appropriate point
to emphasize?
A. A patients willingness to enter into a suicide prevention contract indicates
readiness for discharge from an emergency setting.
B. In emergency settings, suicide prevention contracts are a helpful method for
reducing suicide risk but should not be used to determine discharge.
C. Using suicide prevention contracts in emergency settings is not
recommended.
D. Suicide prevention contracts can be useful for assessing the physician-patient
relationship with individuals who are intoxicated, agitated, or psychotic.
24. A 45-year-old man is interviewed in the emergency department after his
wife discovered him seated in his car with the garage closed and the car
engine running. Although the patient was initially unconscious, he is now
awake and alert and able to respond to questions. Toward the end of the
interview while discussing follow-up options, he mentions that he is insured
under his wife’s health plan. He also asks whether the conversation will be
confidential. Which of the following statements would be most appropriate
for the psychiatrist to answer:
A. 'As a general rule, our conversation is confidential. Rarely, however, I may
need to share information if your safety would otherwise be at risk.’’
B. 'I will need to speak to the other physicians treating you in the emergency
department, but otherwise our conversation is just between us.’’
C. 'Our conversation is completely confidential. I am not allowed to share
any information with anyone unless you give me permission.’’
D. 'Since you’re being treated under your wife’s insurance plan, she may need
to know some of the things that we will discuss.''
24. A 45-year-old man is interviewed in the emergency department after his
wife discovered him seated in his car with the garage closed and the car
engine running. Although the patient was initially unconscious, he is now
awake and alert and able to respond to questions. Toward the end of the
interview while discussing follow-up options, he mentions that he is insured
under his wife’s health plan. He also asks whether the conversation will be
confidential. Which of the following statements would be most appropriate
for the psychiatrist to answer:
A. 'As a general rule, our conversation is confidential. Rarely,
however, I may need to share information if your safety would
otherwise be at risk.’’
B. 'I will need to speak to the other physicians treating you in the emergency
department, but otherwise our conversation is just between us.’’
C. 'Our conversation is completely confidential. I am not allowed to share
any information with anyone unless you give me permission.’’
D. 'Since you’re being treated under your wife’s insurance plan, she may need
to know some of the things that we will discuss.''
25. A 32-year-old woman who is being treated for depression does not arrive
for her scheduled Thursday appointment. When you call and speak with her
by phone, she apologizes for oversleeping. She notes that she has been feeling
better since the recent adjustments in her antidepressant medication, and she
reports no thoughts of suicide. You reschedule her appointment for the
following Monday morning and write a quick note that reads, ''No-show.
Overslept. Rescheduled for Monday.'' On Monday morning you learn that
this patient has killed herself over the weekend. Of the following actions
concerning her record, which is the most appropriate?
A. Add ''Feeling better, denies suicidal ideation'' to the note for Thursday,
using the same pen you used on Thursday.
B. Add to Thursday’s note and initial the addition with todays date.
C. Seal the entire chart in an envelope and send it to your attorney.
D. Write a contemporaneously dated note that further describes Thursday's
conversation.
25. A 32-year-old woman who is being treated for depression does not arrive
for her scheduled Thursday appointment. When you call and speak with her
by phone, she apologizes for oversleeping. She notes that she has been feeling
better since the recent adjustments in her antidepressant medication, and she
reports no thoughts of suicide. You reschedule her appointment for the
following Monday morning and write a quick note that reads, ''No-show.
Overslept. Rescheduled for Monday.'' On Monday morning you learn that
this patient has killed herself over the weekend. Of the following actions
concerning her record, which is the most appropriate?
A. Add ''Feeling better, denies suicidal ideation'' to the note for Thursday,
using the same pen you used on Thursday.
B. Add to Thursday’s note and initial the addition with todays date.
C. Seal the entire chart in an envelope and send it to your attorney.
D. Write a contemporaneously dated note that further describes
Thursday's conversation.