What is the best step to ensure confidentiality for a 20-year-old female patient with major depressive disorder (MDD) symptoms, including suicidal ideation, who has discontinued her medications?

Best Step to Ensure Confidentiality in a Suicidal Patient

Discuss her case with the mental health team immediately to arrange urgent psychiatric evaluation, as safety takes precedence over confidentiality when a patient is at imminent risk of self-harm. 1

Understanding the Confidentiality Exception

When adolescents or young adults are at risk to themselves or others, safety takes precedence over confidentiality. 1 The American Academy of Pediatrics explicitly states that although confidentiality is important in adolescent health care, for patients at risk to themselves, the patient should have this explained so they understand that safety concerns override confidentiality protections. 1

Key Clinical Context

This 20-year-old female presents with:

• Active suicidal ideation 1
• Major depressive disorder 1
• Medication discontinuation (increasing risk) 1
• Already called emergency dispatch (indicating crisis severity) 1

These factors constitute high-risk criteria requiring immediate mental health professional evaluation. 1, 2

The Correct Action: Mental Health Team Consultation

For patients with moderate to high suicide risk, the American Academy of Pediatrics recommends arranging immediate mental health professional evaluation during the encounter, with options including hospitalization, emergency department transfer, or same-day appointment with a mental health professional. 1, 2

Why This Approach is Correct:

• Direct communication between emergency services and psychiatry attending physicians is specifically recommended for patients with concerning psychiatric symptoms 1
• Evaluation by a clinician experienced in evaluating mental health conditions is considered best practice for patients reporting current suicidal ideation 1
• Collaborative care results in greater reduction of depressive symptoms and improved outcomes 1
• The mental health team has the expertise to conduct proper risk stratification and determine appropriate level of care 1

Why Other Options Are Inappropriate

Asking Colleagues for Input

• This delays definitive psychiatric evaluation 1
• Non-psychiatric colleagues may lack expertise in suicide risk assessment 1
• Time is critical—patients at high risk require immediate specialized evaluation, not general consultation 1, 2

Telling Associated Person or Calling Relatives Immediately

• While family involvement is important, the first priority is ensuring immediate safety through professional psychiatric evaluation 1, 2
• Family notification should occur as part of a coordinated safety plan developed by mental health professionals, not as an isolated first step 1
• Premature family contact without proper assessment may compromise the therapeutic relationship or escalate the crisis 1

Documentation Alone

• Documentation is necessary but insufficient 1
• This patient requires active intervention, not passive record-keeping 1, 2

Risk Stratification Factors Present

This patient demonstrates multiple high-risk features requiring immediate intervention: 1, 2

• Persistent suicidal ideation 1, 2
• Medication discontinuation (loss of protective treatment) 1
• Already reached out to emergency services (indicating distress severity) 1
• Evidence of serious depression 1

Patients who continue to endorse desire to die, remain severely hopeless, or cannot be adequately monitored are at high risk and require consideration for inpatient psychiatric admission. 1

Proper Confidentiality Management

The appropriate approach balances confidentiality with safety: 1

• Explain to the patient that safety concerns require breaking confidentiality 1
• Involve mental health professionals who can conduct comprehensive risk assessment 1, 2
• Coordinate family involvement as part of a structured safety plan 1, 2
• Document all actions and communications 1

Obtaining collateral information from caregivers often has significant clinical utility, as patients frequently minimize symptom severity, but this should be coordinated through the mental health team's assessment process. 1

Critical Safety Measures

Once mental health team involvement is secured, additional safety measures include: 1, 2

• Personal and belongings search 1
• Placement in safe environment with close supervision 1
• Assessment for access to lethal means (firearms, medications) 1, 2
• Development of collaborative crisis response plan 2

The greatest risk of reattempting suicide occurs in the months after initial presentation, making immediate expert evaluation and ongoing follow-up essential. 1