Suicide Risk Assessment OSCE - Active Suicidal Ideation with Plan

Case Overview

• Age/Sex: 25-year-old male
• Occupation: Personal trainer / gym instructor
• Setting: Emergency Department psychiatric assessment after presenting with friends
• Chief complaint: "I've been having thoughts about hurting myself"

Patient Script

Who I Am

I'm 25, I work as a personal trainer and I live with a mate near the gym where I work.

What Brings Me In

I told my friend I might do something to myself last night and he insisted I come in — I keep thinking about it and I'm scared I might do it.

My Story

About two weeks ago my girlfriend broke up with me. It started okay at first but over the last week I've felt worse and worse. I can't sleep — I've been getting about three to four hours a night for the past six nights. Over the last three days I've had constant thoughts about hurting myself, and last night I made a plan. I keep thinking about getting some pills from my dad's medication drawer and taking a lot of them so I sleep and don't wake up. I wasn't sure I would do it, but I planned it for tonight and that scares me.

I train clients most days and have a marathon training block coming up (I still have been going to the gym — helps me clear my head). I did roll my ankle at training three days ago but it's mostly fine now. I sometimes smoke weed at the weekends — a few times a month. I had a few beers the night before I planned this, more than I usually drink.

My Medical Background

• Past medical history: mild childhood asthma, sprained ankle 3 days ago (still walks on it)
• Past psychiatric history: no formal diagnosis, I had some low mood as a teenager but never saw anyone about it
• Medications: none regularly; occasional ibuprofen for aches
• Allergies: none known
• Social: lives with a roommate, single, recently separated, works full-time as a trainer, regular gym user
• Substance use: drinks socially, increased alcohol in past week; uses cannabis occasionally (1-2 times/month)
• Family history: mum has anxiety treated with therapy; no family history of suicide that I know of

What I Think & Worry About

• I think I'm a failure because the relationship ended and I can't see how things will get better.
• I'm worried people will think I'm weak or overreacting if I tell them how bad it is.
• I'm scared I might actually do what I planned and I want someone to stop me.

If You Ask Me About Other Symptoms...

• Sleep: "Not sleeping well — only 3–4 hours for the past week."
• Appetite: "Eating less. I don't feel like cooking; I skip meals sometimes."
• Energy: "I feel tired but restless — I still go to the gym because it helps, but it's harder."
• Concentration: "Can't focus on work sometimes; I zone out when clients talk."
• Previous self-harm: "Never done anything like this before — only thoughts when I was a teen but nothing real."
• Hallucinations/delusions: "No voices — I hear my own thoughts. I don't think anyone's out to get me."
• Access to means: "My dad has tablets in a drawer at home — I know where they are."
• Support: "I told one friend and he made me come here; I haven't told my parents yet."
• Legal/finance: "No legal issues — just the breakup and some weeks of missed shifts while sorting things out."
• Red herrings (if asked): "I sprained my ankle at training three days ago, and I have a minor dispute with a client this week, but those aren't why I'm here."

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Clinical Summary

Examination

• General: Young male, athletic build, casually dressed, slightly dishevelled, tearful but communicative
• Vitals: HR 100 bpm, BP 120/78 mmHg, RR 16/min, Temp 36.7°C, SpO2 98% on air
• Behaviour: Alert, occasionally agitated, pacing in the room
• Speech: Normal rate and volume, some short answers but elaborates when asked
• Mood: Describes mood as "terrible/overwhelmed"
• Affect: Constricted, tearful at times
• Thought content: Active suicidal ideation with a specific plan (intent to overdose on pills, planned for tonight), expresses some intent and has access to means
• Perception: No auditory or visual hallucinations reported
• Cognition: Orientation intact to time/place/person; attention slightly reduced but able to engage
• Insight & judgement: Limited insight into severity; judgement impaired by emotional state and recent alcohol use
• Risk impression: High short-term risk due to specific plan, expressed intent, access to means, recent alcohol use, and limited support

Investigations

• Blood alcohol level: 0.03% (mild recent alcohol use; not grossly intoxicated)
• Urine toxicology: THC positive (interpretation: recent cannabis use)
• Full blood count: Hb 15 g/dL, WBC 7.2 x10^9/L, platelets 250 x10^9/L (within reference ranges)
• U&E: Na 140 mmol/L, K 4.1 mmol/L, Cr 85 µmol/L (renal function normal)
• TSH: 1.8 mU/L (euthyroid)
• ECG: Sinus rhythm, rate 98 bpm, QTc 410 ms (no acute abnormalities)

Diagnosis

• Primary: Active suicidal ideation with a specific plan and expressed intent (high imminent suicide risk)

  • Evidence: patient reports constant suicidal thoughts over 3 days, made a plan last night, intends to use pills available at home, expresses some intent to carry it out, limited social support and recent alcohol use.

• Differential diagnoses:

  • Major depressive episode: consistent with low mood, insomnia, anhedonia, poor appetite and functional impairment — may underlie current presentation.
  • Acute stress reaction / adjustment disorder: close temporal relationship to relationship breakdown 2 weeks ago could explain acute symptom onset.
  • Substance-induced mood disorder: recent increased alcohol and cannabis use could be contributing to mood symptoms and disinhibition.

Management

• Immediate safety:

  • Ensure patient is not left alone; place on constant observation / 1:1 supervision while risk is assessed further.
  • Secure and remove access to means (confirm whereabouts of medications, arrange for them to be taken away safely).
  • If imminent risk persists and patient refuses voluntary admission, consider legally sanctioned admission per local mental health legislation.

• Medical and psychiatric actions:

  • Urgent psychiatric liaison / crisis team assessment in ED.
  • Complete a formal suicide risk assessment (cover intent, plan, means, previous attempts, protective factors) and document thoroughly.
  • Consider medical admission if concern about overdose or intoxication; otherwise arrange expedited psychiatric admission if required.
  • Baseline bloods and ECG performed (results as above); repeat or additional tests if overdose suspected.

• Short-term supportive steps:

  • Involve the nominated support person (friend or family) with patient consent; if patient refuses and risk is high, follow local safeguarding policy.
  • Develop a temporary safety plan if patient remains outpatient: crisis contacts, remove means, follow-up within 24–48 hours.
  • Avoid prescribing large quantities of potentially toxic medications; if starting antidepressant, ensure close follow-up and minimal supply initially.

• Follow-up:

  • Arrange urgent outpatient psychiatric follow-up or inpatient psychiatric admission depending on risk and patient preference.
  • Consider referral to psychological therapies (CBT) and social supports for relationship loss and coping strategies.

Key Learning Points

• Always ask directly about suicidal thoughts, plans, intent and access to means — a specific plan and intent indicate high short-term risk.

• Immediate management focuses on ensuring safety (do not leave alone, remove means, arrange observation) and urgent psychiatric assessment rather than definitive long-term treatment decisions.

• Consider both psychiatric diagnoses (major depression, adjustment disorder) and contributing factors (recent alcohol use, relationship breakdown, social supports) when formulating risk and management.