What is the management plan for a patient who attempted suicide last night and is under family medicine care?

Management of Patient Who Attempted Suicide Last Night

This patient requires immediate psychiatric evaluation to determine if inpatient hospitalization is necessary, with the decision based on ongoing suicidal intent, psychiatric illness severity, and availability of adequate monitoring and follow-up care. 1

Immediate Risk Assessment

Conduct a comprehensive suicide risk evaluation focusing on these critical factors:

High-Risk Indicators Requiring Psychiatric Hospitalization 1, 2

• Persistent wish to die or clearly abnormal mental state 1
• Continued suicidal intent or plan to kill themselves 1
• High-lethality attempt with clear expectation of death 1
• Current agitation or severe hopelessness 1
• Inability to engage in safety planning discussions 1
• Serious depression or other psychiatric illness 1
• Active substance use disorder or intoxication 1
• Low impulse control or high levels of anger/impulsivity 1
• Inadequate support system or inability to be monitored 1
• Family unwilling to commit to counseling or monitoring 1

Additional Risk Factors to Document 3

• Prior suicide attempts (associated with 7% repeat attempt rate) 3
• Family history of suicide 3
• Schizophrenia or psychotic symptoms 3
• Unstable living situation (not living at home) 3
• Younger age 3

Disposition Decision Algorithm

Inpatient Psychiatric Hospitalization 1

Admit to psychiatric facility if ANY high-risk indicator is present. Although no controlled studies prove hospitalization saves lives, this is the safest course of action, providing a protected environment for complete medical and psychiatric evaluation with initiation of therapy in a controlled setting. 1

Use involuntary commitment if patient or family refuses necessary hospitalization. Most states allow physicians to hold patients for brief periods (typically up to 72 hours) when the patient has a mental disorder and is at immediate risk of harm to self. 1

Outpatient Management Criteria 1

Consider outpatient treatment ONLY if patient:

• No longer endorses wish to die 1
• Can engage meaningfully in safety planning 1
• Has adequate support system and monitoring 1
• Has reliable follow-up arranged 1
• Shows no evidence of serious psychiatric illness requiring immediate treatment 1

Where available, consider partial hospital programs, intensive outpatient services, or in-home crisis stabilization as intermediate options. 1

Mandatory Safety Interventions

Means Restriction (Critical Component) 1, 2

All firearms must be removed from the home immediately. Simply having a gun in the home doubles youth suicide risk, and parents consistently underestimate children's ability to access locked firearms. 1

• Instruct family to relocate firearms to relative, friend, or law enforcement for safekeeping 1
• If family refuses removal, counsel on maximum security: unloaded firearms in tamper-proof safe, ammunition locked separately, restricted access to keys/combinations 1
• Lock up all medications (prescription and over-the-counter) 1, 2
• Secure knives and other sharp objects 1
• Restrict alcohol access given high rates of intoxication in suicide attempts 1
• Address means in homes of friends and family where patient may visit 1

Safety Planning Intervention 1

Develop a structured safety plan collaboratively with patient and family (evidence shows this reduces suicidal behavior compared to treatment as usual). 1

The safety plan must include:

1. Warning signs and triggers for recurrence of suicidal ideation 1
2. Coping strategies patient can use when ideation returns 1
3. Healthy distraction activities to suppress suicidal thoughts 1
4. Social support contacts to turn to if urges recur 1
5. Professional crisis resources with explicit instructions on accessing emergency services 1
6. Means restriction plan 1

Note: No-suicide contracts are NOT effective and should not be relied upon for safety. 1

Follow-Up Care Structure

Immediate Psychiatric Referral 1, 2

• Arrange mental health evaluation during or immediately after this visit 2
• Options include same-day appointment with mental health professional, emergency department transfer, or direct hospitalization 2
• The greatest risk of reattempt is in the months after initial attempt 1

Ongoing Monitoring 1, 2

• Maintain contact even after psychiatric referral is made (collaborative care results in greater reduction of depressive symptoms) 1, 2
• Schedule definite, closely-spaced follow-up appointments 2
• Be flexible in arranging crisis appointments 2
• Arrange follow-up calls as part of safety planning intervention 1

Evidence-Based Psychotherapeutic Interventions

Cognitive-Behavioral Therapy (CBT) 2

CBT reduces risk of post-treatment suicide attempt by half compared to treatment as usual. It helps identify and change problematic thinking patterns and is effective for reducing suicidal ideation and behavior. 2

Dialectical Behavior Therapy (DBT) 2

DBT reduces both suicidal and non-suicidal self-directed violence. It combines CBT, skills training, and mindfulness techniques to develop emotion regulation, interpersonal effectiveness, and distress tolerance. 2

Pharmacological Considerations

Antidepressant Prescribing 1, 4

If prescribing antidepressants (e.g., fluoxetine):

• Monitor closely for clinical worsening and suicidality, especially during initial months and after dose changes 4
• Write prescriptions for smallest quantity to reduce overdose risk 4
• Screen for bipolar disorder before initiating antidepressants, as treating unrecognized bipolar depression may precipitate manic episodes 4
• Educate families to monitor daily for agitation, irritability, unusual behavior changes, and emergence of suicidality 4
• Vigorous treatment of underlying psychiatric disorder is important in decreasing short-term and long-term suicide risk 1

Critical Pitfalls to Avoid

• Do not discharge without ensuring means restriction - many suicide attempts are impulsive (24% occur within 0-5 minutes of decision) 1
• Do not rely on no-suicide contracts - these have not been proven effective 1
• Do not underestimate access to locked firearms - parents consistently misjudge this 1
• Do not assume low risk based on method lethality - patients often misjudge lethality of their attempts 1
• Do not discharge without confirmed psychiatric follow-up - many patients struggle to obtain care after ED visits 1
• Do not abruptly discontinue antidepressants if prescribed - taper gradually to avoid discontinuation symptoms 4