What is the approach to taking a history for a patient who has attempted suicide with drugs?

History Taking for Drug Overdose Suicide Attempts

When evaluating a patient who has attempted suicide with drugs, you must immediately establish rapport while systematically gathering information from both the patient AND a third party—regardless of how mild the attempt appears—as this collateral information is essential and mandatory for safe disposition. 1

Essential Components of the Suicide History

Direct Assessment of Suicidal Intent and Planning

• Ask directly about suicidal thoughts: Begin with "Have you ever thought about killing yourself or wished you were dead?" followed immediately by "Have you ever done anything on purpose to hurt or kill yourself?" 1
• Determine current suicidal state: Assess whether the patient is still thinking of suicide, as this represents the highest risk factor for future attempts 1
• Elicit specific suicide plans: Ask explicitly "If you were to kill yourself, how would you do it?" to determine if a concrete plan exists 1
• Assess intent at time of attempt: Determine whether the patient truly wanted to die or was seeking help/relief from distress 1
• Evaluate timing and impulsivity: Most adolescent overdoses are impulsive and occur during disputes with family or romantic partners 1

Details of the Current Attempt

• Identify the specific substances ingested: Document all medications taken, including over-the-counter analgesics (most common), benzodiazepines (34% of cases), neuroleptics (23%), and paracetamol/acetaminophen (23%) 2
• Determine quantity and timing: Establish how much was taken and when, as this guides medical management 2
• Assess lethality of method chosen: Recognize that while ingestion is the most common attempt method in adolescents, firearms remain the most lethal means 1, 3
• Clarify how substances were obtained: Were they prescribed to the patient, taken from family members, or purchased over-the-counter? 4, 5

Psychiatric History and Mental State Examination

Look systematically for signs of clinical depression 1:

• Depressed mood most of the time or loss of interest/pleasure in activities
• Weight changes, sleep disturbances (insomnia or hypersomnia)
• Psychomotor agitation or retardation, fatigue
• Feelings of worthlessness, guilt, or hopelessness about the future
• Difficulty concentrating, indecisiveness
• Recurring thoughts of death
• Critical caveat: Adolescents may present with irritability rather than depressed mood as the primary manifestation 1

Screen for mania or hypomania 1:

• Elated, expansive, or irritable mood with inflated self-esteem
• Decreased need for sleep, pressured speech, racing thoughts
• Distractibility, excessive goal-directed activities
• Impulsive behaviors (hypersexuality, foolish spending, uninhibited remarks)

Assess for psychotic symptoms: Patients who are delusional, hallucinating, or threatening violence to others require psychiatric evaluation before discharge 1

Document substance use: Substance abuse alone or combined with mood disorders dramatically increases risk, and alcohol/drugs have dangerous disinhibiting effects 1

Prior Suicide Attempts and Family History

• Document all previous suicide attempts: Prior attempts are among the strongest predictors of future attempts and completed suicide 1
• Obtain family history of suicide: Suicidal behaviors in biological relatives increase risk 6
• Assess for self-harm behaviors: Ask about cutting, burning, or other non-suicidal self-injury 1

Critical Risk Factors to Identify

Demographics and social factors 1:

• Male gender (higher lethality), living alone
• Recent separation, divorce, or interpersonal conflicts 4
• Gay, lesbian, or bisexual orientation (2-7 fold increased risk for attempts) 1
• Runaway status or homelessness 1

Abuse and trauma history 1:

• Physical and sexual abuse must be assessed routinely: 15-20% of female attempters have abuse history, and abuse increases attempt risk even when controlling for other factors
• Conversely, any patient with known abuse history requires assessment for suicidality

Access to lethal means 1:

• Explicitly ask about firearms in the home: This is mandatory, as firearms are the most common method for completed adolescent suicide in the United States
• Document availability of medications, both prescription and over-the-counter
• Assess whether the patient knows where these items are stored

Mandatory Third-Party Information

You must obtain collateral information from family, friends, or other sources regardless of how mild the attempt appears 1:

• Verify the patient's account of events and mental state
• Assess family dynamics and level of supervision available
• Determine whether responsible adults can "sanitize" the environment by removing firearms and lethal medications
• Evaluate family's understanding of the seriousness and their commitment to safety planning

Important note on confidentiality: While confidentiality is important in adolescent care, safety takes precedence—explain this to the patient at the outset so they understand information will be shared with parents/guardians 1

Disposition-Critical Assessment

Indicators for Psychiatric Hospitalization

Admit patients who have 1:

• Persistent wish to die despite intervention
• Clearly abnormal mental state (psychosis, severe depression, mania)
• Inadequate supervision or support at home
• Refusal to agree to safety measures (though contracts alone are insufficient)

Requirements Before Discharge Consideration

Discharge is only appropriate when ALL of the following are met 1:

• Adequate supervision and support confirmed for the next several days
• A responsible adult has agreed to remove all firearms and secure/dispose of potentially lethal medications
• Follow-up appointment scheduled before leaving the emergency department (or telephone contact established with plan for staff to initiate contact if family doesn't follow through)
• Patient's mental state has stabilized sufficiently

Critical Pitfalls to Avoid

• Never dismiss suicidal statements as attention-seeking or unimportant: Even seemingly minor attempts require full evaluation 1
• Never rely on "no-suicide contracts": These have no proven efficacy and create false reassurance; the patient may not be in a mental state to understand the contract 1, 7, 8
• Never discharge without third-party information: The patient's self-report alone is insufficient for safe disposition 1
• Never assume over-the-counter medications are "safe": Acetaminophen and other OTC analgesics are commonly used and can be lethal 2, 5
• Do not overlook substance use: Alcohol and drugs dramatically increase risk through disinhibition 1