Reference no: EM133304127

What the Standard of Care is for the treatment of Suicidal Patients

Specifically, how many of the known risk factors were present before the subject died?
What would you have done differently if you were the principal therapist?

The decedent was a 27-year-old Caucasian male who died in October of 2008 by a self- inflicted gunshot wound. The subject's death occurred in his bedroom of his home that

he shared with one roommate and, frequently, his roommate's girlfriend. The roommate's girlfriend was home at the time of his death. However, it is unclear if the roommate was home at the time of death; he went out in the middle of the night as required by his on-call job. The roommate discovered the decedent dead in the decedent's bedroom after growing impatient with the television volume in the subject's room being too loud for too long.

The decedent lived as a healthy person experiencing common ailments such as chicken pox, pneumonia, and asthma during his early childhood and adolescent years. During his adult years, he experienced frequent heartburn, an episode of venereal warts, neck pain, a rash, and pharyngitis. In the months leading up to his death, the decedent experienced extremely high cholesterol and significant weight gain. According to the autopsy, at the time of death the decedent had advanced coronary disease. There is a significant history of mental health concerns, substance use, and suicide ideations and attempts in the decedent's family. There was evidence of mental health issues, suicidal ideation, and substance use of the decedent. The decedent did have alcohol in his system at the time of his death and was above the legal threshold for intoxication. In April 2007, the first mental health issues were noted in the decedent's medical record.

The decedent reported to his primary care physician (PCP) that his anxiety (with panic attacks) had worsened over the past years. The decedent noted that panic attacks occurred four times per day lasting one hour. Depression and anxiety disorder were diagnosed in this visit. An antidepressant (Celexa) and anxiolytic (Xanax) were prescribed. The patient's PHQ-9 during this visit noted severe depression, thoughts of suicide nearly every day, and it being extremely difficult to carry out daily functioning. In November 2007, the decedent presented to his PCP and reported that his medication was no longer working. In July 2008, the decedent presented to his doctor for anxiety. The patient reported that his medication was working well, and his PHQ-9 score indicated moderate depression.

The PHQ-9 Patient Depression Questionnaire was developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues. The self-administered instrument is commonly used in primary care settings and was administered to the decedent on multiple occasions. This PHQ-9 includes nine items on a four-point scale ranging from "not at all" to "nearly every day." Following the nine items is an additional question regarding the impact of these symptoms on the person's daily life.

In April 2007, the decedent had a score of 27 and noted that it was extremely difficult to progress through daily life. After this visit, the PCP noted that the patient was "not currently suicidal" and had "passing thoughts of harming himself." Medication was prescribed, and the patient was to return in two weeks if the problem worsened. Item No. 9 on the PHQ-9 states, "Thoughts that you would be better off dead, or of hurting yourself." The decedent marked "nearly every day" on this item. In July 2008, the decedent had a score of 14 and noted that it was somewhat difficult in his daily life. The PCP noted that the patient was, "not currently suicidal" and had "passing thoughts of harming himself."

Multiple informants reported the decedent was a "jokester" and the "life of the party." The decedent had many strong relationships with friends and family, especially his mother. He had a long-term romantic heterosexual relationship at the time of his death and had several heterosexual romantic relationships throughout his life.

The decedent had a history of steady employment as a chef. In the months leading up to his death, he had decided on a career change and had gone back to school to become a law enforcement officer. There is evidence of financial stress, reckless spending, and moderate debt belonging to the decedent.

The decedent's family found a piece of paper with a list of types of guns that the decedent was collecting. The decedent's roommate told the responding police offers that the decedent had purchased five guns within the three months prior to his death. Three days prior to the decedent's death, a family member gave him a gun safe and was concerned about his recent gun purchases and level of alcohol consumption. The decedent jokingly commented, "Don't you trust me? Do you think I'm going to hurt myself with the guns?"