Psychiatry · Moderate
This case is fictional and exists for study. It describes no real patient.
42 years · male
A 42-year-old male is brought to the emergency department by his partner due to a six-week history of worsening low mood, severe anhedonia, and profound hopelessness. He reports waking up at 4:00 AM daily, poor concentration, and an unintentional weight loss of 5 kg. During the assessment, he tearfully reveals that he feels like a burden to his family. He admits to stockpiling paracetamol over the past two weeks with active plans to take a overdose tonight. He mentions regretting surviving a similar overdose three years ago. Physical examination and neurological assessment are unremarkable.
Vital signs
- HR
- 76 bpm
- BP
- 124/82 mmHg
- RR
- 15/min
- Temp
- 36.7 °C
- SpO₂
- 99%
Examination findings
- Psychomotor retardation with reduced eye contact and delayed speech latency
- Depressed affect, congruent with reported mood
- No active psychotic symptoms such as hallucinations or delusions
Investigations
| Thyroid Stimulating Hormone (TSH) | 2.1 mIU/L | reference: 0.4-4.0 |
| Haemoglobin | 14.5 g/dL | reference: 13.0-17.0 |
Question 1 of 3
Which of the following is the most appropriate immediate management step for this patient?
The patient exhibits severe depression with high suicide risk, active planning, stockpiled means, and past history of attempts. Immediate specialist mental health assessment (e.g., Crisis Resolution and Home Treatment Team or inpatient psychiatric evaluation) is required for safety. Prescribing antidepressants alone without immediate risk containment (option D) is unsafe, particularly giving a 28-day supply of potentially dangerous or ineffective immediate medication. Discharging home with helpline numbers (option A) fails to mitigate imminent risk. Outpatient CBT (option C) is inappropriate as a standalone initial measure in acute, life-threatening crisis.
Teaching point: Patients presenting with active suicidal intent, concrete plans, and high risk factors require immediate emergency mental health referral and risk containment.
Question 2 of 3
Which feature from this patient's presentation represents the strongest single predictor of completed suicide?
A history of a previous suicide attempt is epidemiologically established as the strongest single risk factor for completed suicide. While somatic symptoms of depression such as weight loss (option D), early morning awakening (option A), and psychomotor retardation (option C) indicate severe depression, they are not as predictive of completed suicide as a history of prior self-harm or attempts.
Teaching point: A previous suicide attempt is the single most powerful predictor of future completed suicide.
Question 3 of 3
What is the most likely diagnosis for this patient?
The patient meets criteria for a severe depressive episode: low mood for >2 weeks, marked loss of interest, early morning awakening, weight loss, feelings of worthlessness, psychomotor retardation, and explicit suicidal ideation. Adjustment disorder (option D) involves short-term emotional distress linked to an identifiable stressor without meeting full criteria for severe depression. Dysthymia (option A) requires continuous low-grade depressive symptoms for at least two years. Bipolar I disorder (option C) requires a history of at least one manic episode, which is absent here.
Teaching point: Severe depression is characterized by core depressive features along with somatic/neurovegetative symptoms and high suicide risk.
Key learning points
- Prior suicide attempts represent the strongest single clinical predictor of completed suicide.
- Immediate safety containment and emergency psychiatric assessment are required for patients with active suicidal plans and stockpiled means.
- Somatic symptoms of depression (e.g., early morning awakening, weight loss, psychomotor retardation) typically indicate a severe depressive episode.
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