As the psychiatrist, what is an appropriate inpatient treatment plan for a patient with major depressive disorder presenting with suicidal ideation and a specific plan to hang themselves?

Inpatient Treatment Plan for Major Depressive Disorder with Active Suicidal Ideation and Specific Plan

This patient requires immediate psychiatric hospitalization given the presence of active suicidal ideation with a specific, high-lethality plan (hanging), which represents an acute psychiatric emergency. 1, 2

Immediate Actions Upon Admission

Psychiatric Hospitalization Justification

• Hospitalization is mandatory because this patient meets multiple high-risk criteria: persistent suicidal intent with a specific plan, high-lethality method (hanging), and likely severe depression requiring controlled evaluation and treatment initiation 3, 1
• The inpatient setting provides a safe, protected environment for complete medical and psychiatric evaluation while preventing access to lethal means 3, 1
• Although no controlled studies prove hospitalization saves lives, it represents the safest course of action for patients at this risk level 3

Environmental Safety Measures

• Place patient on continuous one-to-one observation initially, with close monitoring especially during the first few days when risk is highest 1, 4
• Remove all potentially dangerous items from the patient's environment, including belts, shoelaces, cords, and any objects that could be used for hanging 1, 5
• Conduct thorough room searches and maintain ligature-free environment throughout hospitalization 5
• Ensure patient is never left alone during transport or transitions between units 4

Comprehensive Psychiatric Assessment

Mental Status Examination

• Evaluate current suicidal intent, including whether the wish to die persists after admission 1, 2
• Document level of hopelessness, which is a critical risk factor for completed suicide 2, 6
• Assess for signs of clinical depression, including severity of depressive symptoms, presence of psychosis, agitation, or mixed states 2, 6
• Evaluate thought content for hallucinations, delusions, or command auditory hallucinations directing self-harm 6
• Assess cognitive function and impulse control 6

Risk Factor Documentation

• Previous suicide attempts, which are the strongest predictor of future attempts 2
• Substance use history and active substance use disorder, which significantly increases risk 3, 2
• Access to lethal means in the home environment (firearms, medications) 1, 2
• Family psychiatric history and current family support system 3
• Recent psychosocial stressors or losses 2

Treatment Interventions

Pharmacological Management

• Initiate SSRI antidepressant therapy for major depressive disorder, as SSRIs combined with psychotherapy decrease suicide risk among depressed patients 1
• Monitor closely for treatment-emergent suicidal ideation, particularly in the first weeks of treatment, with direct questioning at each clinical contact 3
• For treatment-resistant cases with persistent acute suicidal ideation, consider ketamine infusion, which provides rapid improvement in suicidal ideation within 24 hours lasting at least one week 1
• Ensure all medications are administered under direct observation to prevent hoarding 5

Evidence-Based Psychotherapy

• Initiate cognitive-behavioral therapy (CBT) focused on suicide prevention, which reduces post-treatment suicide attempts by half compared to treatment as usual 1, 6
• If patient has borderline personality disorder features, consider dialectical behavior therapy (DBT), which is superior to standard therapy for reducing suicidal ideation and self-directed violence 1
• Begin therapy in the controlled inpatient setting to establish therapeutic alliance before discharge 3

Safety Planning Development

• Create a collaborative crisis response plan that includes:
  • Identification of warning signs and triggers for suicidal thoughts 1, 6
  • Self-management coping strategies and healthy distraction activities 1, 6
  • Social support contacts the patient can reach out to 1, 6
  • Professional crisis resources and instructions for accessing emergency services 1, 6
• Do not use "no-suicide contracts" as they have no proven efficacy in preventing suicide and may impair therapeutic engagement 1, 2, 6

Discharge Planning Criteria

Requirements Before Discharge Consideration

• Resolution of active suicidal intent with specific plan 1, 2
• Ability to engage meaningfully in safety planning discussions 1, 6
• Reduction in hopelessness and severe agitation 1
• Adequate outpatient support structure confirmed 1, 2
• Responsible adult supervision arranged who can monitor patient 2, 6

Mandatory Lethal Means Restriction

• Confirm that all firearms have been removed from the home before discharge, as adolescents and adults frequently find access to supposedly secured weapons 3, 1, 6
• Verify that all medications (prescription and over-the-counter) are locked up and controlled by a responsible adult 3, 1
• Address access to lethal means in homes of friends and family members the patient may visit 1
• Document that a responsible adult has agreed to these restrictions 2

Follow-Up Arrangements

• Schedule definite, closely-spaced outpatient appointments before discharge, as the greatest risk of reattempting suicide occurs in the months immediately after hospitalization 1, 2
• Arrange same-day or next-day appointment with outpatient mental health professional 3, 6
• Implement periodic caring communications (postcards or phone calls) for at least 12 months to reduce rates of suicide death and attempts 1
• Maintain collaborative care with primary care provider to enhance continuity and treatment adherence 3

Critical Pitfalls to Avoid

• Never discharge a patient who continues to endorse persistent desire to die, remains severely agitated or hopeless, or shows inability to engage in safety planning 1, 6
• Do not rely on structured suicide risk scales alone, as they have limited predictive value and must be combined with comprehensive clinical assessment 1, 2
• Avoid coercive communications such as "you can't leave until you say you're not suicidal," which encourages deceit and undermines therapeutic alliance 2, 6
• Do not underestimate the patient's ability to access locked firearms or medications in the home 6
• Never discharge without confirmed psychiatric follow-up and verified means restriction 6

Documentation Requirements

• Document comprehensive suicide risk assessment including specific factors influencing current risk level 2, 7
• Provide clear rationale for hospitalization decision and treatment selection 2, 7
• Record mental status examination findings, particularly hopelessness and suicidal intent 2, 6
• Document safety planning discussions and means restriction counseling provided 1, 6
• Note follow-up arrangements and responsible adult supervision confirmed before discharge 2, 6