58-year-old man with weight loss and withdrawn behavior
A 58-year-old man comes for a routine 3-month follow-up for hypertension and hyperlipidemia. He is a recently retired accountant. He states his wife scheduled the appointment because she was worried he was becoming more withdrawn. On review of systems, he endorses low mood, loss of interest in his hobbies, poor appetite with a 10-lb (4.5-kg) weight loss over two months, and difficulty concentrating. A PHQ-9 questionnaire score is 21. When asked about item 9 regarding self-harm, he hesitates before quietly admitting, "I've thought about how to do it." With gentle probing, he reveals a plan to overdose on his son's leftover opioid pain medication. His vital signs are temperature 37.0°C (98.6°F), blood pressure 142/88 mmHg, heart rate 84/min, and respirations 16/min. The physical examination is unremarkable. Which of the following is the most appropriate next step in management?
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D
Explanation
Clinical Pearl:
The presence of suicidal ideation with a specific plan and access to lethal means constitutes a psychiatric emergency. The immediate priority is to ensure patient safety, which typically requires urgent psychiatric evaluation for hospitalization.
Explanation:
This patient has severe major depressive disorder, evidenced by his symptoms and a PHQ-9 score of 21, and is at high, imminent risk for suicide. He has articulated not just ideation but a specific, lethal plan and has access to the means. This situation requires immediate action to secure his safety. The standard of care is to arrange for an immediate psychiatric evaluation for hospitalization, which may be voluntary or involuntary, to provide a safe environment and initiate intensive treatment. The patient should not be allowed to leave the clinic alone. Starting an antidepressant, while eventually necessary, does not address the acute safety risk and has a delayed onset of action. Providing a hotline number is grossly insufficient for a patient with a specific plan who is currently in a healthcare setting. Adjusting his blood pressure medication is incorrect as his mildly elevated blood pressure is not the life-threatening priority. Relying on a 'contract for safety' is not an evidence-based practice and provides a false sense of security in a high-risk individual whose judgment is impaired by severe depression.
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