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Submitted without comment:
Outpatient psychiatrist: Patient came to her routine psychopharm visit expressing profound hopelessness and a desire for her life to end. She described recent incidents at the shelter where she is staying, including one where another guest took an overdose of medication and she (the patient) was distraught that she hadn’t recognized this (clinically) sooner. She repeatedly said, “I can’t survive this…I want it to end.” In addition to feeling overwhelmed and anxious about her state of homelessness, she expressed concern that she “would never feel safe anywhere.” She denied suicidal intent but was unable to find any reason to continue her life and made numerous self-disparaging remarks. She became increasingly distraught, crying and almost moaning in her chair.
Since stopping her antipsychotic medication (intolerable EPS per patient) and decreasing her antidepressant medication on discharge from the hospital (to the street), the patient is faced with the reality of limited housing options and may likely face daily uncertainty about where she will sleep once she completes her time at current shelter – and is overwhelmed, panicked, despairing and hopeless about her life. Her paranoid ideation has increased. She sees no meaning in anything and wishes to die. She denies immediate suicidal intent, but mostly due to lack of energy rather than lack of desire.
With much persuasion, patient walked with me to the A(cute)P(sychiatry)S(ervice) where she will be evaluated for inpatient hospital admission.
APS psychology fellow note 4 hours after arrival:
Patient was tearful, depressed with poor eye contact. Patient refused to talk to writer stating “I can’t talk, go away.” Writer was unable to complete full exam due to patient refusing to be evaluated at this time. Patient is intermittently sobbing uncontrollably, saying nothing more than “I can’t” and “you have to let me go”, refusing medication and refusing to participate in interview. Perseverating on “you have to let me go” “nothing will help” TP – perseverative -Insight poor Judgment poor Patient requires ILOC to establish safety, containment, and aftercare planning.
36 hrs later – Psychiatry fellow and attending consultation note:
Fellow: This patient was admitted for altered mental state with bradycardia and a serum diphenhydramine level of 489 mcg/l (toxic range). Psychiatric consultation was requested for ? suicide attempt. The patient reports that she left the hospital yesterday, returned to the shelter at which she was staying to discover that her belongings (aside from medications) had been removed. Pt reports having felt more hopeless and ingested unspecified number of her prescribed medications. She reports that she did not want to hurt herself but hoped that this ingestion would kill her. She denies having anything to live for at this point, denies intent to harm herself but feels “regret” for the outcome of this medication ingestion and reportedly “want(s) to die.” Pt does report that much of her feeling hopeless is related to lack of shelter and job. She attributes her “life situation” to being ostracized “for being a whistleblower” (related to prior living and job situation per medical record review).
Attending: I have reviewed the events/notes of earlier this week. At present, she explains to me that yesterday, when she left here, she wanted to die and took pills in order to bring about her death and thought the pills she took would effect that outcome. When she realized she did not die, she felt regret. She still feels regret because she still wants to die and kill herself. Asked why she did not acknowledge this yesterday before she left here, she said that she knew she would be hospitalized psychiatrically if she had and she didn’t want to be. I explained to her that caretakers are able to help her only to the extent that she is honest with them. She is pessimistic that pharmacotherapy and psychotherapy can help her deal better with her problems even if they cannot take them away. I explained further that both can help her to be more optimistic. She denies any thought of wanting to hurt anyone else. She denies that anyone here is trying to hurt her. She feels her thinking is clear and in its usual state.
Impression: Delusional and depressive disorders. She is pessimistic, despondent, and suicidal at present and meets criteria for involuntary psychiatric admission. Continue suicide precautions. Continue 1:1 observation.