What is the appropriate management for a patient with chronic left shoulder pain, suicidal ideation, and poor dietary habits?

Management of a Patient with Left Shoulder Pain and Suicidal Ideation

The patient requires immediate safety planning, intensive outpatient psychiatric treatment, and comprehensive pain management, with close follow-up within 24-48 hours. 1

Suicide Risk Assessment and Management

Initial Risk Assessment

• The patient has expressed active suicidal ideation with a specific method (holding a knife to her throat), which requires urgent intervention 2, 1
• A crisis evaluation has already been conducted, determining that inpatient commitment is not necessary
• The patient is being set up with intensive outpatient treatment, which is appropriate for patients with:
  • Suicidal ideation without immediate intent to act
  • Adequate support systems
  • Ability to engage in safety planning 1

Safety Planning Components

1. Identify warning signs and triggers for suicidal thoughts (such as increased shoulder pain, stress from school, or feelings of being a burden) 2, 1
2. Develop internal coping strategies the patient can use when experiencing suicidal thoughts 1
3. Create healthy distracting activities that can help manage both pain and emotional distress 1
4. List social supports the patient can contact when in crisis 2
5. Provide professional resources, including crisis hotlines and emergency contacts 2
6. Implement means restriction planning by discussing with the father the importance of securing potential means of self-harm (especially knives) 2

Pain Management Approach

Assessment of Shoulder Pain

• Evaluate the left shoulder pain in context of:
  • Duration (one year with recent worsening)
  • Aggravating factors (backpack carrying, extended drawing sessions)
  • Impact on daily activities and quality of life
  • Relationship to psychological distress 3

Pain Management Strategies

• Physical interventions:

  • Proper backpack ergonomics education
  • Activity modification for drawing (time limits, proper positioning)
  • Physical therapy referral for shoulder strengthening and posture correction
  • Consider non-opioid analgesics if appropriate

• Psychological approaches:

  • Cognitive Behavioral Therapy (CBT) targeting both pain catastrophizing and suicide prevention 1, 4
  • Pain coping skills training, as catastrophizing is strongly associated with suicidal ideation in chronic pain patients 4

Nutritional Concerns

• Poor dietary habits require assessment and intervention:
  • Screen for possible eating disorder
  • Evaluate for depression-related appetite changes
  • Consider nutritional consultation
  • Monitor weight and nutritional status during follow-up

Integrated Treatment Plan

1. Immediate interventions:

   • Complete safety planning with both patient and father 2, 1
   • Ensure follow-up appointment within 24-48 hours 1
   • Provide crisis resources and emergency contacts

2. Short-term plan:

   • Initiate intensive outpatient psychiatric treatment as planned
   • Begin physical therapy for shoulder pain
   • Educate on ergonomic modifications for backpack and drawing

3. Long-term management:

   • Regular psychiatric follow-up
   • Pain management with focus on functional improvement
   • Address nutritional concerns
   • Consider family therapy to strengthen support system

Important Considerations

• Pain-suicide connection: Chronic pain doubles the risk of suicidal behavior, requiring ongoing monitoring of both conditions 3
• Self-perceived burden: Patients with chronic pain who feel they are "a burden to others" have increased suicide risk 5
• Meaning in life: Help the patient identify domains that provide meaning (relationships, personal activities) as this can mitigate suicidal ideation 6

Common Pitfalls to Avoid

• Focusing solely on physical pain without addressing psychological factors 3
• Neglecting pain when treating mental health issues, as they are interconnected 1, 3
• Insufficient treatment duration or inadequate follow-up 1
• Overlooking family involvement in both safety planning and treatment 2
• Failing to address pain catastrophizing, which is a significant predictor of suicidal ideation in chronic pain patients 4