Severe depression with a suicide plan: admission
The case
A 45-year-old man is brought to the emergency department after his wife found him contemplating suicide by overdose. He describes 12 weeks of profound low mood, loss of pleasure, early morning waking, 8 kg of weight loss and marked psychomotor retardation, evident as slowed speech, reduced arm swing and delayed answers. He denies psychotic symptoms but endorses suicidal ideation with a specific plan involving paracetamol he has stockpiled. He has type 2 diabetes on metformin and no psychiatric history. Mental state examination confirms a flat affect, poor concentration and suicidal ideation without immediate intent. What is the most appropriate next management step?
Options
- AAdmit to hospital, involuntarily if he will not consent, for safety and treatment
- BNortriptyline 50 mg and GP review in a week
- CReferral for community cognitive behavioural therapy
- DKetamine infusion under specialist supervision
- ESertraline 50 mg and review in 48 hours
Think it through before you read on. Which single option is best, and why are the other four wrong?
Show the answer and explanation
Answer
A. Admit to hospital, involuntarily if he will not consent, for safety and treatment
Why this is the right answer
This man has a severe major depressive episode with melancholic features: early morning waking, marked weight loss, psychomotor retardation and anhedonia. On its own that would justify urgent treatment. What decides the next step is risk. He has a specific plan and has already obtained the means. That combination places him at high short-term risk of suicide, even though he denies intent at this moment.
The first task in any psychiatric emergency is safety. A patient with a formulated plan and access to means needs a safe environment, close observation and removal of the means. That means inpatient admission. If he agrees, he is admitted voluntarily. If he refuses, he meets the criteria for involuntary assessment and treatment under the state Mental Health Act, because he has a mental illness, needs immediate treatment, and there is a serious risk to his safety without it. The exact wording differs between states, but the principle is the same everywhere in Australia.
Treatment starts once he is safe. For severe melancholic depression, an antidepressant is started in hospital, and electroconvulsive therapy is considered if he is not eating or drinking, is psychotic, or needs a rapid response. The RANZCP mood disorders guideline (2020) supports this approach.
Antidepressants take 2 to 6 weeks to work and provide no protection in the meantime. A tricyclic such as nortriptyline is particularly dangerous, because it is lethal in overdose.
His wife should be involved, with his consent where possible, and a safety plan drawn up before discharge.
Why the other options are wrong
- B
A tricyclic is lethal in overdose and a week's delay ignores the immediate risk.
- C
Psychological therapy is appropriate later; it does not manage an acute suicide risk with a plan and means.
- D
Ketamine is for treatment-resistant depression under specialist care, not first-line acute risk management.
- E
An SSRI takes weeks to act and does nothing for safety over the next 48 hours.
High-yield takeaway
A suicide plan with access to the means calls for admission first, involuntarily if needed under the Mental Health Act; antidepressants and therapy follow once the patient is safe.
Reference: RANZCP Clinical Practice Guidelines for Mood Disorders (and the relevant state Mental Health Act) (2020)
Common questions
What makes suicide risk high in the short term?
A specific plan, access to the means, recent preparation, hopelessness and a severe depressive episode, all present here.
Which antidepressants are dangerous in overdose?
Tricyclics such as nortriptyline and amitriptyline. They are avoided in anyone at risk of overdose.
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