Suicide Risk Assessment OSCE - Passive Suicidal Ideation | Free OSCE Practice

Case Overview

Age/Sex: 76-year-old male
Occupation: Retired post office worker
Setting: Presents to GP surgery after neighbour raised concerns
Chief complaint: "I've been having thoughts of self-harm"

Patient Script

Who I Am

I'm 76, retired, I live on my own in a flat near town — used to help out at the church on Sundays but haven't been going much lately.

What Brings Me In

I've been having thoughts that maybe I'd be better off dead and my neighbour said I should see someone about it.

My Story

For the last about three weeks I've felt lower than usual, and in the last week those thoughts have been coming back more often. I have chronic low back pain from an old injury which has been worse lately and I can't get about as well. I find myself thinking "I wouldn't mind if I died" — it pops into my head a few times a day, especially when I'm in pain or alone. I don't have a plan; I wouldn't take pills deliberately and I don't have any guns or anything like that, but sometimes I think life is just not worth the bother any more.

I sleep poorly — often I lie awake for a couple of hours before dropping off, and I'm not as interested in going out or seeing people. I've lost a little weight over the last couple of months because I don't fancy cooking for one. I've never tried to kill myself before. I've been staying inside more; the heating bills are getting higher so I eat less. I did have a small fall getting out of the shower about a week ago, but I'm okay now — just embarrassed.

I used to keep busy, but since I stopped volunteering I get very quiet. My neighbour Becks brings my shopping sometimes. I do worry about being a burden.

My Medical Background

Past medical history: chronic low back pain for ~10 years (radiates sometimes to right leg), osteoarthritis knees; hypertension.
Medications: paracetamol 1g up to 4 times daily; gabapentin 300 mg at night (started a year ago); lisinopril 10 mg daily; occasional ibuprofen (when pain worse).
Allergies: none known.
Social: lives alone, widowed 5 years ago, two adult children live abroad, former smoker (stopped 20 years ago), drinks one small glass of wine most evenings (1–2 units).
Family history: father died of MI at 70, mother had dementia in her 80s.

What I Think & Worry About

I think maybe I'm just old and this is how it goes; I don't want people fussing over me.
I'm worried I'll end up a burden to my children if I get worse.
I want the pain to be easier to live with and for someone to check on me so I don't feel so alone.

If You Ask Me About Other Symptoms...

Mood: "Mostly down and a bit tearful at times."
Sleep: "I can't get to sleep easily — I wake early and can't get back to sleep." (initial insomnia)
Appetite/weight: "I don't feel like cooking — I've dropped a few kilos over the last couple of months." (~3 kg)
Suicidal thoughts: "I sometimes think I'd be better off dead — I wouldn't actually take steps to kill myself, there's no plan or anything like that." (denies intent or previous attempts)
Alcohol/drugs: "Just a glass of wine on an evening; I don't use anything else."
Cognition: "Sometimes I forget names or where I put my glasses, but I'm managing fine — my neighbour said I looked a bit confused the other day but I think that was because of the fall." (no significant memory loss reported)
Pain: "My back is worse — it's constant and gets worse after walking; the gabapentin helps a bit at night but I still hurt."
Recent stressors: "My wife died five years ago; I stopped volunteering a year ago when I couldn't manage the stairs at the church anymore."
Red herrings/distractors I might mention if asked: "I've been needing the loo more often lately" (urinary frequency), "I felt light-headed last month" (one episode), "my hearing is worse — I think I should get new batteries for the hearing aid".

Clinical Summary

Examination

General: thin elderly man, appropriately dressed, appears withdrawn and tearful at times
Vitals: Temperature 36.6°C; HR 78 bpm regular; BP 138/82 mmHg; RR 16/min; SpO2 98% on air
Cardiovascular: normal S1/S2, no murmurs
Respiratory: clear, no crepitations
Abdominal: soft, non-tender
Neurological: cranial nerves grossly intact; no focal deficits
Musculoskeletal: reduced lumbar flexion, antalgic gait; mild knee osteo changes
Mental state: alert and oriented to time/place/person; mood low, affect constricted; tearful on discussion of isolation and pain; normal speech; no evidence of psychosis; denies active suicidal intent or plan
Cognitive screen: Mini-Mental State Exam 27/30 (or equivalent brief cognitive test preserved)

Investigations

Full blood count: Hb 13.0 g/dL (13.5–17.5), WBC 6.0 x10^9/L (4–11), platelets 220 x10^9/L (150–400) (mildly low-normal Hb for age)
U&E: Na 138 mmol/L, K 4.2 mmol/L, creatinine 100 µmol/L (eGFR ~55 mL/min/1.73m2)
Liver function tests: within normal limits
Thyroid function: TSH 1.8 mU/L (0.4–4.0)
Vitamin B12: 380 pg/mL (normal)
CRP: 3 mg/L (normal)
Urinalysis: negative for infection
ECG: sinus rhythm, no acute changes
PHQ-9 score: 16 (moderately severe depression), including positive response to item 9 (thoughts that you would be better off dead or of hurting yourself) — patient denies plan or intent

Diagnosis

Primary diagnosis: Passive suicidal ideation in the context of a depressive episode, likely secondary to chronic pain and social isolation.
- Evidence: patient reports recurrent thoughts of "being better off dead" without active plan or intent; PHQ-9 corroborates moderate–severe depressive symptoms; risk factors present (chronic pain, living alone, bereavement history, age).
Differentials:
- Major depressive disorder: likely contributory — low mood, sleep disturbance, decreased appetite, anhedonia and PHQ-9 consistent; needs formal assessment for DSM criteria.
- Adjustment disorder with depressed mood: possible if symptoms closely time-linked to identifiable stressors, but duration and severity suggest more than simple adjustment.
- Substance-induced mood disorder: less likely — alcohol intake low/moderate, not meeting dependence criteria.
- Early dementia with depressive symptoms: less likely given preserved cognition (MMSE 27/30) but consider if cognitive decline progresses.
- Underlying medical causes (hypothyroidism, B12 deficiency, infection): investigations currently not suggestive.

Management

Immediate safety/risk management:
- Conduct a focused suicide risk assessment: ask directly about suicidal thoughts, plans, intent, means, recent actions, protective factors and previous attempts.
- As patient denies plan/intent and has protective factors (no access to lethal means, expresses desire for help), manage as outpatient with close follow-up but document risk level and plan.
- Create a safety plan with patient: identify warning signs, coping strategies, emergency contacts (neighbour Becks, children), and crisis numbers; advise to seek urgent help if thoughts escalate or a plan forms.
Short-term treatment and support:
- Arrange urgent review by GP or liaison mental health within 24–72 hours.
- Consider starting an SSRI (e.g., sertraline) after discussing risks/benefits and monitoring plan; start low dose given age (e.g., sertraline 25–50 mg daily) and liaise with GP for monitoring and interaction with gabapentin and antihypertensive therapy.
- Optimize pain management: review analgesia (consider referral to pain clinic or physiotherapy), check adherence to gabapentin and consider dose review; avoid unmonitored opioid escalation.
- Refer to community mental health team or primary care psychological services for assessment and access to brief CBT or problem-solving therapy tailored to older adults.
- Social support: refer to social services/charity for older adults, encourage increased contact (neighbour, local day centre, church re-engagement if appropriate), consider home check-ins.
- Medication review: assess for any medications worsening mood (although none clearly implicated), ensure no dangerous stockpiles of medication at home.
Escalation criteria:
- If patient reveals active plan, intent, access to means, or deteriorates acutely -> arrange immediate psychiatric admission or crisis team intervention.

Key Learning Points

Distinguish passive suicidal ideation (thoughts of being better off dead without plan/intent) from active suicidal intent; assessment of plan, intent and means is essential.
Older adults with chronic pain and social isolation are at increased risk for depression and suicidal ideation; screening (PHQ-9), safety planning, optimizing pain control and social support are key components of management.
Always document a clear, individualised safety plan and arrange prompt follow-up; escalate to urgent inpatient care if there are any signs of active planning, intent, or increased risk.