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Stem
A 38-year-old divorced man, Mr R, is brought to the emergency department by his sister after she found a farewell note and an empty blister pack of paracetamol at his home. He has a 10-year history of recurrent depressive disorder, two previous suicide attempts (the last requiring ICU admission after a tricyclic overdose), and drinks 40 units of alcohol per week. He was discharged from a psychiatric admission 11 days ago. On assessment he is withdrawn, hopeless, and admits to ongoing suicidal thoughts with a plan to "finish the job" but says he "probably won't" act tonight. He lives alone, is unemployed, and has a firearm (licensed, for farm pest control) at home. He asks to go home.
Questions
a) What are the key risk factors in this patient, and which is the single strongest predictor of completed suicide? (2 marks)
Key risk factors: male sex; divorced/lives alone/unemployed (social isolation); recurrent depressive disorder; previous suicide attempts (the single strongest predictor — 5 to 10-fold increased risk); alcohol misuse (a proximal disinhibitor); recent discharge from psychiatric admission (highest-risk window, first 1 to 2 weeks); active suicidal ideation with a plan; hopelessness; and access to lethal means (a firearm). (1 mark for ≥4 risk factors, 1 mark for identifying previous attempt as the strongest predictor.)
b) Outline your structured suicide risk assessment of this patient. (3 marks)
- Engage privately and non-judgementally; ask directly about suicide (asking does not increase risk).
- Characterise the ideation: frequency, intensity, duration, controllability.
- Elicit the plan: method, time, place, rehearsal, preparatory acts (he has written a note and hoarded means).
- Estimate intent: how likely is he to act? What has stopped him so far?
- Assess access to means: firearm, medication hoards, alcohol.
- Weigh protective factors: reasons for living, dependants, social support, therapeutic engagement (here, weak).
- Obtain collateral from the sister and prior records (with consent / best-interest).
- Mental state examination: hopelessness, agitation, insomnia, anhedonia, any psychotic features.
- Formulate and document a stratified risk level with explicit reasoning and a safety plan. (1 mark for the principle of direct enquiry and engagement; 1 mark for ideation/plan/intent/means/preparatory acts; 1 mark for collateral, protective factors, formulation and documentation.)
c) What is your immediate management and disposition? Justify. (3 marks)
This patient is at HIGH risk: active ideation + specific plan + access to a lethal means (firearm) + the strongest predictors (previous attempts, recent discharge, alcohol misuse, hopelessness). He requires urgent psychiatric admission, involuntary under the Mental Health Act / Mental Healthcare Act 2017 if he refuses, because the duty of care overrides autonomous refusal when risk is imminent.
Immediate measures: one-to-one (constant) nursing observation; remove access to all means (the firearm must be secured by family/police; medications removed; ligature points addressed); treat the alcohol withdrawal if present; review and intensify treatment of the depressive disorder; obtain collateral; do not rely on a no-suicide contract (no protective value). Do not discharge him on the basis that he "probably won't" act tonight — ambivalence in the presence of a plan and means is high risk, not low risk. (1 mark for HIGH risk with justification; 1 mark for urgent admission +/- involuntary if refused; 1 mark for means restriction and constant observation.)
d) Name two evidence-based interventions that specifically reduce suicide or repeat attempts, and the populations for which they are indicated. (2 marks)
- Lithium — reduces suicide in mood disorders (Cipriani meta-analysis, BMJ 2013).
- Clozapine — reduces suicide in schizophrenia (InterSePT trial, Meltzer et al., 2003); the only antipsychotic with a proven anti-suicide effect.
(Also acceptable: dialectical behaviour therapy for borderline personality disorder and recurrent self-harm; cognitive-behavioural therapy for suicide prevention; brief follow-up contact / caring letters after discharge; structured safety planning.) (1 mark each, maximum 2.)