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<< The Depressed Patient And Suicidal Patient In The Emergency Department: Evidence-Based Management And Treatment Strategies

Case Presentation & Conclusion

Case Presentation

Between managing a hypotensive patient with sepsis and another with an acute stroke, you note 3 patients waiting to be seen: a 28-year-old, apparently healthy man with a URI, an elderly man with a sprained ankle, and a woman needing a medication refill. These seem easy enough . . .

The young man indeed has a URI, but you also find out that he recently moved to the city and states that he is just feeling “overwhelmed” and “sad” and at times thinks he would be “better off dead.” He has never seen a psychiatrist and has never been told by his primary care clinician that he has any sort of psychiatric illness. You start thinking to yourself: “Is this person pathologically depressed? Can I diagnose this in the ED? And is this person safe to go home or does he require a psychiatric consultation and possible psychiatric admission?

Hoping for a faster case, you enter the next bay to manage the patient with the ankle sprain. As you enter, you are met by an anxious-appearing woman stating that she is concerned that her father, who twisted his ankle, has been increasingly depressed and had said to her on several occasions,”Maybe I’d be better off dead.” When talking to the patient, he states he does occasionally have thoughts of wishing
he was dead but has not had any specific plan to carry out his intentions. The ankle ends up being inconsequential, but you now wonder: is the patient safe to go home? You also wonder what steps you should take to ensure his safety.

Fulfilling the rule that things come in threes, the next patient is an elderly woman whose family is also
concerned that she is “depressed.” On your examination, you note some psychomotor retardation as well as blunted affect. When asking her about her mood, she states that she feels “There is a heavy weight on my mind, and I feel really sad.” She has a history of hypothyroidism and medication noncompliance, hence the medication refill. You wonder if the clinical presentation could be due to her thyroid disease and if there is anything that needs to be done in the ED . . .

At the end of the shift, you reflect on the 35 patients you managed: neither the hypotensive septic patient nor the acute stroke ended up being your most challenging patient; instead, the 3 depressed patients were the biggest management dilemmas, and you reflected on how their outcomes were directly related to the decisions you made.

Case Conclusion

After a more detailed psychiatric history and examination, you discern that the 28-year-old man has been having thoughts of hurting himself on and off over the last 3 months and has been feeling worse over the last 3 weeks with thoughts increasingly of “drinking himself to death.” In fact, the weekend before, he said he attempted to drink a liter of vodka by himself to “put myself out of my misery.” With this concerning history for possible dysthymia with an overlying major depressive episode history and suicide attempt, you formally consult psychiatry and the patient was evaluated for safety. Given his active suicidal ideation and depressed mood, the patient is placed for psychiatric hospitalization. The patient is cooperative and amenable to the plan but given his active suicidal ideation and your concern for his wellbeing, the patient is formally sectioned (ie, placed on a temporary involuntary hold).

After discussing with the elderly patient his thoughts of hurting himself, you flesh out his comments. It appears he does not wish himself dead at this time, although he states that when he is home alone, at times he thinks “Perhaps I would be better off dead.” There is no plan, he has not had a history of suicide attempts in the past, and he has no known comorbid psychiatric illness. He does not see a psychologist/psychiatrist, and on your evaluation of his depressive symptoms using the PHQ-9, his score is an 8 (ie, mild depression). While you are not concerned that he is actively suicidal and do not think he needs to be involuntarily held against his will, because of his presenting symptoms and his lack of psychiatric follow-up, you formally consulted psychiatry. They evaluated him and agreed that he did not require an involuntary hold; however, he was placed in a voluntary outpatient partial hospitalization program.

While the lady seeking the medication refill stated that she felt depressed, she was not suicidal and had no thoughts of hurting herself or others. You sent a complete metabolic panel including TSH levels to the lab. The results showed her TSH level was nearly 3 times higher than previously recorded for her 45 days ago. With this concerning presentation and lab values consistent with hypothyroidism, you returned to the bay, and she stated that she doesn’t remember whether or not she has been taking her thyroid medication. You contacted her primary care physician, who recommended restarting her home regimen of synthroid and would be seeing the patient in her clinic the next day. After reviewing her most recent
set of vital signs and ensuring she does not want to harm herself or others and feeling that the depressed mood is not overwhelming her functional status, you discharge her home with 24-hour follow up in her primary care provider’s clinic.

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Last Modified: 12/12/2017
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