How can I ensure safety and manage suicide risk in a teenager with severe depression, generalized anxiety disorder, mood lability, and impulse‑control problems when a relative is refusing to obtain the prescribed medication?

Managing Suicide Risk in a Teenager When Family Refuses Medication

When a relative refuses to obtain prescribed psychiatric medication for a high-risk teenager with severe depression, generalized anxiety, mood lability, and impulse control problems, you must immediately arrange psychiatric hospitalization—this adolescent meets multiple criteria for inpatient admission regardless of medication access, and hospitalization provides the safest environment while addressing both the acute crisis and the family barrier to treatment. 1

Immediate Risk Stratification and Disposition

This teenager presents multiple high-risk features that mandate psychiatric hospitalization rather than outpatient management: 1

• Severe depression with impulse control problems creates dangerous unpredictability 1
• Mood lability increases risk of impulsive self-harm during dysphoric episodes 1
• Family unwillingness to commit to treatment (evidenced by medication refusal) is itself a specific criterion for hospitalization 1
• The combination of low impulse control with psychiatric illness substantially elevates suicide risk 1

Hospitalization is the only appropriate disposition because it accomplishes three critical goals simultaneously: places the adolescent in a protected environment, allows complete psychiatric evaluation with medication initiation in a controlled setting, and provides time to address family resistance through psychoeducation and possible involvement of child protective services if medical neglect is occurring. 1

Actions Required During Your Current Visit

Arrange Immediate Transfer

Do not allow this teenager to leave your office without securing psychiatric admission. Options include: 1, 2

• Direct admission to psychiatric inpatient unit if you have established relationships
• Transfer to emergency department for psychiatric evaluation and admission
• Same-day appointment with psychiatrist who can admit directly (only if admission can be guaranteed same day)

Maintain Continuous Supervision

• Provide 1:1 observation from the moment you identify high risk until transfer occurs 2
• Remove all medical equipment, sharps, medications, and potential weapons from the examination room 2
• Search the patient's belongings for pills, sharp objects, or other means of self-harm 2

Call 911 If Necessary

Immediately call emergency services if the teenager: 2

• Expresses active suicidal intent with specific plan during your visit
• Becomes severely agitated or demonstrates behavioral dyscontrol
• Refuses voluntary transport but clearly meets involuntary hospitalization criteria
• Has psychotic symptoms or altered mental status

Addressing the Medication Refusal Barrier

Document Medical Neglect Concerns

The relative's refusal to obtain prescribed psychiatric medication for a high-risk teenager may constitute medical neglect. 1

• Document explicitly that medication was prescribed, the relative refused to obtain it, and this refusal places the adolescent at increased risk
• State in your documentation that this refusal contributed to your decision to hospitalize
• Consider whether the situation warrants a report to child protective services (varies by jurisdiction, but generally required when a parent's refusal to provide necessary medical treatment places a child at substantial risk of harm)

Involve Hospital Social Work and Psychiatry

Once hospitalized, the inpatient team can: 1

• Initiate medication in the controlled hospital setting without requiring family cooperation for pharmacy pickup
• Conduct family psychoeducation about the necessity of psychiatric medication
• Assess whether the refusal stems from misunderstanding, cultural beliefs, financial barriers, or more concerning neglect
• Arrange for medication assistance programs if cost is the barrier
• Involve legal counsel if the family continues to refuse necessary treatment

Mandatory Safety Interventions (Regardless of Hospitalization)

Even though the teenager will be hospitalized, you must still provide means restriction counseling because it applies post-discharge: 1, 2

Firearms

• Explicitly instruct the family to remove ALL firearms from the home immediately—not lock them, but remove them entirely 1, 2
• Adolescents frequently access locked guns; parents consistently underestimate their children's ability to locate keys and combinations 1
• Having a gun in the home doubles youth suicide risk 1
• If the family refuses permanent removal, insist on temporary relocation to a relative's home or law enforcement storage 1

Medications and Other Means

• Lock up all prescription and over-the-counter medications 1, 2
• Restrict access to alcohol and illicit substances 1
• Secure all knives and sharp objects 2

What NOT to Do: Critical Pitfalls

Do Not Use "No-Suicide Contracts"

Suicide contracts have no proven efficacy in preventing suicide and provide false reassurance. 1, 2

• Refusal to sign actually provides useful risk information (ominous sign), but signing does not reduce risk 1
• These contracts may harm the therapeutic alliance by creating a legalistic rather than collaborative relationship 1

Do Not Underestimate Risk Based on Family Reassurance

When high-risk features are present (as in this case), family promises to "watch closely" are insufficient. 1, 2

• Families routinely overestimate their supervision ability 2
• A family already refusing medication demonstrates poor judgment about psychiatric treatment needs 1
• Continuous 24-hour observation is impossible in a home setting

Do Not Discharge Based on Absence of Current Suicidal Statements

If the teenager denies suicidal thoughts during your visit, this does not eliminate risk when: 1

• None of the precipitating factors have changed (the underlying psychiatric conditions remain untreated)
• The family barrier to treatment persists
• High-risk features (impulsivity, mood lability, severe depression) remain present

Involuntary Hospitalization if Family Refuses Voluntary Admission

You have legal authority to initiate a psychiatric hold if the family refuses voluntary hospitalization. 1

• Every state permits physicians to admit patients involuntarily for brief periods (typically 24-72 hours, though ranging from 1-30 days depending on jurisdiction) 1
• Criteria generally require: (1) presence of mental disorder, and (2) imminent danger to self 1
• This teenager clearly meets both criteria 1
• After the initial hold period, the psychiatric facility can pursue court-ordered civil commitment if ongoing hospitalization is needed and the family still objects 1

Safety Planning (Not Contracts) for Post-Discharge

Work with the inpatient team to ensure a collaborative safety plan is developed before discharge: 1, 2

The plan must include: 1

1. Warning signs and triggers specific to this teenager (e.g., particular mood states, situations that worsen depression)
2. Internal coping strategies the teenager can use independently when suicidal thoughts emerge
3. Healthy distraction activities (exercise, creative outlets, specific safe people to contact)
4. Identified social supports with specific names and contact information
5. Professional contacts including 24/7 crisis numbers (National Suicide Prevention Lifeline: 988) and instructions for re-accessing emergency services
6. Means restriction verification confirming firearms removed, medications secured

Your Ongoing Role After Hospitalization

Do not consider your responsibility complete once the teenager is admitted. 1, 2

Maintain Collaborative Care

• Contact the teenager even after psychiatric referral—collaborative care between pediatricians and mental health professionals produces greater reduction in depressive symptoms than fragmented care 1
• Request discharge summaries and medication lists from the inpatient team
• Schedule a follow-up appointment in your office within days (not weeks) of hospital discharge 2

Monitor Medication Adherence Post-Discharge

• At follow-up visits, verify the teenager is actually receiving prescribed medications
• If the family continues to refuse, this may require another child protective services report
• Consider directly observed therapy models or long-acting injectable formulations if available and appropriate

Address the Highest-Risk Period

The weeks immediately following hospital discharge carry the highest risk for suicide completion. 2

• Ensure frequent contact during this window
• Verify the family has actually implemented means restriction
• Confirm mental health follow-up appointments are scheduled and attended

Documentation Requirements

Your medical record must include: 2

• Specific suicidal ideation, plan, and intent assessment (even if denied, document that you asked)
• Mental status examination findings (mood, affect, thought content, judgment, impulse control)
• Previous suicide attempts or self-harm history
• All psychiatric comorbidities (depression, anxiety, mood lability, impulse control problems)
• Family support assessment including the medication refusal
• Means restriction counseling provided with specific instructions given
• Disposition decision rationale (why hospitalization was necessary)
• Whether voluntary or involuntary admission was pursued
• Follow-up arrangements made

This documentation protects both patient safety and your medicolegal interests. 2