![]() ![]() After the patient was determined to be at risk, an oral or written contract could have been proposed, requiring that the patient safely dispose of his gun. Even with the truncated information presented in this case, I believe that the therapeutic impasse and the danger to the patient were foreseeable.Ī suicide prevention contract might have been useful in this case. It is also vital to review the psychiatric history and current life information to develop a systematic suicide risk assessment, and from there a comprehensive treatment plan. In assessing suicidal patients, it is important to ask whether the problem is a manifestation of a single or recurrent episode of major depression, a bipolar condition, or dysthymia. Patients at significant risk for suicide usually have a combination of Axis I and Axis II disorders.( 1) Much of the difficulty in managing this patient may have arisen from an unrecognized personality disorder. A diagnostic impression and the suitability of the patient for outpatient treatment also can be determined from the initial evaluation. The creation of this safe environment (for both patient and clinician) often requires an initial period of evaluation before outpatient therapy commences. Metaphorically, clinicians in situations like this can feel like they themselves are operating “under the gun.” It is vital that they work with the patient to diffuse the tension and create a safe environment in which therapy can proceed. However, some general rules of thumb may help clinicians balance these issues.Ĭlinicians must set reasonable treatment terms and boundaries. Since these situations are so challenging, charged, and nuanced, it is difficult to offer precise guidelines. One can easily sympathize with clinicians struggling with multifaceted issues in cases like this one. Although they correctly identify gun possession as the central management issue, the gun was not removed from the home until after nearly 3 months of psychotherapy. The attending physician and resident determine that he is at chronic risk for suicide and note that “prompt removal” of the gun is a top priority. This case describes a severely depressed patient, who admits to possessing a handgun. Though no harm occurred, this case was a “near miss,” given the prolonged exposure of a potentially suicidal patient to such an obvious hazard. The gun was eventually removed from the patient’s residence, but it required nearly 3 months to achieve this goal. Both resident and supervisor agreed that prior to exploring any emotionally sensitive issues in treatment, the gun had to be removed. The supervisor felt that the institution’s primary responsibility was to keep the patient safe, and the longer it took to remove the gun, the more at risk the patient was for an adverse outcome. The resident felt that forcing the issue legally would cause the patient to feel abandoned and unsafe, with a strong possibility of either suicide or termination of treatment (with concomitant increased risk of suicide). Unfortunately, they were not able to develop a clear pathway to removing the handgun. Discussions with other faculty and the clinic’s risk manager ensued in an effort to delineate the resident’s legal options to remove the gun from the patient’s possession. ![]() Suicidal ideation continued and, as time passed in treatment, the supervisor viewed him as a significantly higher risk to complete suicide than the resident did. The patient resisted plans to remove the handgun and refused multiple disposition plans proposed by the resident and the resident’s supervisor (who was not the evaluating attending physician during the initial assessment). For the patient’s depression, the treatment plan included starting an antidepressant (citalopram) as well as psychotherapy. Both also agreed that building a treatment alliance would be a critical factor in accomplishing that goal. The attending physician and resident performing the evaluation assessed the patient as at chronic risk for suicide, but not acute risk, and noted that prompt removal of gun from the patient’s possession was paramount to his safety. ![]() He denied active plans for suicide, including using the gun, because “A friend or family member would have to clean up the mess.” On initial interview, the patient reported chronic thoughts of suicide, stating “If I had a good way, I’d have done it already.” On screening for suicide risk factors, the patient admitted to possessing a handgun. The patient is a 36-year-old man who came to a psychiatry clinic for outpatient evaluation of severe depression that had persisted for nearly 2 years. ![]()
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