A 19-year-old female college student is brought into the emergency department by her boyfriend. The boyfriend reports that the patient got caught stealing from the company she works for and subsequently got fired. The boyfriend received a text that evening saying “I’ll miss you.” When he arrived at her dorm room, the patient was slumped in the shower covered in blood. The patient agreed to be driven to the emergency room. When asked about what happened, the patient replies “I just want out of this life.” The patient has bipolar disorder, and takes lithium as prescribed. She has a psychiatrist she sees every week, which the boyfriend confirms. She has never had a prior suicide attempt nor has she ever been hospitalized for a psychiatric disorder. The patient’s vitals are stable. Upon physical examination, a 4 centimeter vertical incision is noted on the patient’s left forearm. During the patient’s laceration repair, she asks if she will be admitted. She states, “these ups and downs are common for me, but I feel better now.” She verbalizes that she understands that she overreacted. She asks to go home, and her boyfriend insists that he will stay with her. They both confirm that neither of them have guns or know any peers with access to guns. Which of the following is the most appropriate management for the patient?

Involuntarily admit the patient

Have the patient sign a suicide contract before discharge

Set up a next-day appointment with the patient’s psychiatrist

Discontinue lithium and start valproate

A 17-year-old white female with a history of depression is brought to your office by her parents because they are concerned that she is acting differently. She is quiet and denies any changes in her personality or drug use. After the parents step out so that you can speak alone, she begins crying. She states that school has been very difficult and has been very depressed for the past 2 months. She feels a lot of pressure from her parents and coaches and says she cannot handle it anymore. She says that she has been cutting her wrists for the past week and is planning to commit suicide. She instantly regrets telling you and begs you not to tell her parents. What is the most appropriate course of action?

Explain to her that she will have to be hospitalized as she is an acute threat to herself

Prescribe an anti-depressant medication and allow her to return home

Tell her parents about the situation and allow them to handle it as a family

Prescribe an anti-psychotic medication

An 82-year-old woman comes to the physician because of difficulty sleeping and increasing fatigue. Over the past 3 months she has been waking up early and having trouble falling asleep at night. During this period, she has had a decreased appetite and a 3.2-kg (7-lb) weight loss. Since the death of her husband one year ago, she has been living with her son and his wife. She is worried and feels guilty because she does not want to impose on them. She has stopped going to meetings at the senior center because she does not enjoy them anymore and also because she feels uncomfortable asking her son to give her a ride, especially since her son has had a great deal of stress lately. She is 155 cm (5 ft 1 in) tall and weighs 51 kg (110 lb); BMI is 21 kg/m2. Vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, she is tired and has a flattened affect. Cognition is intact. Which of the following is the most appropriate initial step in management?

Begin cognitive-behavioral therapy

Notify adult protective services

Recommend relocation to a nursing home

A 24-year-old woman visits her psychiatrist a week after she delivered a baby. She is holding her baby and crying as she waits for her appointment. She tells her physician that a day or so after her delivery, she has been finding it difficult to contain her feelings. She is often sad and unable to contain her tears. She is embarrassed and often starts crying without any reason in front of people. She is also anxious that she will not be a good mother and will make mistakes. She hasn’t slept much since the delivery and is often stressed about her baby getting hurt. She makes excessive attempts to keep the baby safe and avoid any mishaps. She does not report any loss of interest in her activities and denies any suicidal tendencies. Which of the following is best course of management for this patient?

Come back for a follow-up in 2 weeks

Start on a small dose of fluoxetine daily

Give her child to child protective services

Schedule an appointment for electroconvulsive therapy

A 16-year-old boy comes to the physician for the evaluation of fatigue over the past month. He reports that his energy levels are low and that he spends most of his time in his room. He also states that he is not in the mood for meeting friends. He used to enjoy playing soccer and going to the shooting range with his father, but recently stopped showing interest in these activities. He has been having difficulties at school due to concentration problems. His appetite is low. He has problems falling asleep. He states that he has thought about ending his life, but he has no specific plan. He lives with his parents, who frequently fight due to financial problems. He does not smoke. He drinks 2–3 cans of beer on the weekends. He does not use illicit drugs. He takes no medications. His vital signs are within normal limits. On mental status examination, he is oriented to person, place, and time. Physical examination shows no abnormalities. In addition to the administration of an appropriate medication, which of the following is the most appropriate next step in management?

Instruct parents to remove guns from the house

Contact child protective services

In 2006, three researchers from North Carolina wanted to examine the benefits of treating the risk of suicidality in children and adolescents by looking at randomized, multicenter, controlled trials of sertraline usage compared to placebo. Their analysis found clinically significant benefits of the drug and a positive benefit-to-risk ratio for sertraline in adolescents with major depressive disorder. They also found that 64 depressed children and adolescents need to receive the drug for 1 extra patient to experience suicidality as an adverse outcome. In other words, if 64 treated individuals received sertraline, some would experience suicidality due to their illness, some would not experience suicidality, and 1 individual would become suicidal due to the unique contribution of sertraline. Which of the following statements is true for this measure (defined as the inverse of the attributable risk), which aims to describe adverse outcomes this way?

Input values must be probabilities of the events of interest.

Higher measures indicate greater risk.

Multiple risks can be contained and described within one result.

The final metric represents proportions in percentage terms.

The measure can include multiple events at one time.

A 29-year-old man with post-traumatic stress disorder is admitted to the hospital following an intentional opioid overdose. He is a soldier who returned from a deployment in Afghanistan 3 months ago. He is divorced and lives alone. His mother died by suicide when he was 8 years of age. He states that he intended to end his life as painlessly as possible and has also contemplated using his service firearm to end his life. He asks the physician if assisted suicide is legal in his state. He does not smoke or drink alcohol but uses medical marijuana daily. Mental status examination shows a depressed mood and constricted affect. Which of the following is the strongest risk factor for suicide in this patient?

Family history of completed suicide

A 27-year-old woman is brought to the physician by her parents because they are concerned about her mood. They say that she has “not been herself” since the death of her friend, who was killed 3 weeks ago when the fighter jet he piloted was shot down overseas. She says that since the incident, she feels sad and alone. She reports having repeated nightmares about her friend's death. Her appetite has decreased, but she is still eating regularly and is otherwise able to take care of herself. She does not leave her home for any social activities and avoids visits from friends. She went back to work after taking 1 week off after the incident. Her vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, she appears sad, has a full range of affect, and is cooperative. In addition to taking measures to evaluate this patient's anxiety, which of the following is the most appropriate statement by the physician at this time?

I understand that the sudden loss of your friend has affected you deeply. Sometimes in situations like yours, people have thoughts that life is not worth living; have you had such thoughts?

I can see that you have gone through a lot recently, but I think that your reaction is especially severe and has persisted for longer than normal. Would you be open to therapy or medication to help you manage better?

I am worried that you may be having an abnormally severe reaction to what is an understandably stressful event. I recommend attending behavioral therapy sessions to help you deal with this challenge.

Your grief over the loss of your friend appears to have a negative effect on your social and functional capabilities. I recommend starting antidepressants to help you deal with this challenge.

I'm so sorry, but the loss of loved ones is a part of life. Let's try to find better ways for you to deal with this event.

Suicide risk assessment and management for USMLE Step 3: High-Yield Psychiatry Lessons

Risk Factors & Protective Factors - Danger Signals

Risk Factors:
- 📌 SAD PERSONS scale: Sex (male), Age (>45), Depression, Previous attempt, Ethanol/substance use, Rational thinking loss, Social support lacking, Organized plan, No spouse, Sickness.
- Hopelessness, access to lethal means, recent psychiatric discharge.
Protective Factors:
- Strong therapeutic alliance
- Family & social support
- Reasons for living (e.g., children, future goals)
- Problem-solving skills
⚠️ Danger Signals (Immediate Hospitalization):
- Specific plan with intent
- Command hallucinations

⭐ A history of a previous suicide attempt is the strongest predictor of future suicide.

Clinical Assessment - The Suicide Inquiry

Direct Inquiry: Always ask directly and non-judgmentally about suicidal thoughts, plans, and intent. Normalizes the topic and is essential for safety.
Core Components: Assess severity and acuity.
- Ideation: Passive (e.g., "wish I were dead") vs. Active (e.g., "thinking of killing myself").
- Plan: Specificity, lethality, and preparedness.
- Intent: Strength of desire to die; presence of ambivalence.
- Access: Availability of lethal means.
Risk Stratification (📌 SAD PERSONS scale):
- Sex (male), Age (<19/>45), Depression, Previous attempt, Ethanol/drug use, Rational thinking loss, Social support lacking, Organized plan, No spouse, Sickness.
- Score >8 suggests high risk; consider hospitalization.

⭐ The single most important risk factor for suicide is a prior suicide attempt. This history dramatically increases the risk of future attempts and completion.

Management & Interventions - Safety Scaffolding

Core Principle: The level of intervention must match the level of acute risk.

Safety Planning (Moderate/High Risk):
- Collaborative, written plan for managing future suicidal thoughts.
- Includes coping strategies, social support contacts, and professional help numbers (e.g., 988 Suicide & Crisis Lifeline).
- 📌 Means Restriction: Limiting access to lethal methods (firearms, medications) is a critical, evidence-based step.

⭐ Exam Favorite: Simply providing a patient with a crisis hotline number is insufficient for managing acute, high-risk suicidality; direct, active intervention like hospitalization is required.

High-Yield Points - ⚡ Biggest Takeaways

A prior suicide attempt is the strongest predictor of future risk.

Directly ask about suicidal ideation, intent, and plan; this is essential for assessment.

Hopelessness is the psychological state most strongly correlated with suicidal intent.

Immediate hospitalization is warranted for patients with a specific plan and intent.

SSRIs carry a black-box warning for ↑ suicidal thinking in individuals aged <25.

"No-suicide contracts" are not effective and no substitute for a thorough risk assessment.

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