What is the appropriate disposition? A 67-year-old retired police officer is brought in by his son for frequent crying and excessive sleeping. The patient has a history of lung cancer and 6 months earlier attempted suicide after his wife died. The patient has an odor of ethanol, has a flat affect, speaks slowly, and is evasive when questioned about suicidal ideation. He insists that he wants to go home.
A. Discharge him if he is able to state that he will not hurt himself B. Discharge him only if the son can provide close supervision C. Discharge him with close psychiatric followup D. Insist on psychiatric admission E. Prescribe an antidepressant medication
Insist on psychiatric admission-the answer is d, insist on psychiatric admission.suicide remains a major cause of death throughout the world, and emergency physicians are often in the position of determining the disposition of potentially suicidal patients. this patient is manifesting symptoms and signs of major depression (frequent crying, excessive sleep, flat affect, psychomotor retardation) and has multiple risk factors placing him at very high risk for suicide. these include his age, sex, presence of depression, possible alcoholism, prior suicide attempt, chronic illness, being widowed, and likely access to firearms. for this reason, insisting on psychiatric admission is the best option, even if he promises not to hurt himself. various scoring instruments that incorporate various risk factors are available to assess a patients likelihood of suicide. the presence of depression or hopelessness, rational thinking loss, an organized or serious attempt at suicide, and stated future intent to commit suicide are considered particularly heavy weighted risk factors. it is recognized that, although scoring systems are helpful, ultimately none is perfect, and that assessing suicide risk is an individualized process. although this patient might benefit from antidepressant medications, none of them acts immediately, and he would be at high risk of overdosing on them.(marx [rosens], 1737, 1767-1773; tintinalli, 1814-1815)