PMH/504 Week 8: Integrated Longitudinal Case and Safety Planning, sample paper

A Hunting Rifle in the Closet and a Visit for Back Pain: An Integrated Suicide Risk Assessment and Lethal Means Plan for a 58-Year-Old Man With Depression, Six Months Into Care

[Student Name]

University of Phoenix

PMH/504: Psychiatric Management Of Adult And Geriatric Patients

Week 8 Assignment

[Instructor Name]

[Date]

The patient is a composite written for a model paper.

Mr. B., a 58-year-old former machinist, has been in care for six months for major depression after a work injury ended his career. He takes sertraline 150 mg, attends therapy and had improved: his PHQ-9 fell from 21 to 11. Last week he saw his primary care clinician for back pain. Today, his PHQ-9 is 18, and item 9, thoughts of being better off dead, is marked "more than half the days." His wife mentions that he has been "cleaning his rifle a lot." The sections below review his six months in care, then set out the assessment and the plan made with him and his family.

Background

Mr. B. worked for 30 years as a machinist until a fall injured his back. He is married, has two adult children and has hunted with his brother-in-law since his teens. He has no prior psychiatric treatment, no past suicide attempts and no family history of suicide. Men of his age, recently disabled, living with chronic pain and drinking more, are at elevated risk of suicide, and firearms are the most common method among men in the United States.

Six Months in Review

The first months brought improvement with sertraline, behavioral activation and cognitive therapy. Setbacks followed a denial of disability benefits two months ago and increasing back pain. His drinking, previously two beers on weekends, has risen to several a night. Each change, financial stress, pain and alcohol, raises risk.

Structured Assessment

Posner et al. (2011) developed the Columbia-Suicide Severity Rating Scale and found good validity and internal consistency across adolescent and adult samples. Using it, I learn that Mr. B. has had thoughts of killing himself daily for two weeks, has thought about using his rifle, has no specific plan for when and has not rehearsed or prepared. He denies past attempts. His ideation is active with method, without plan or intent, which is serious.

Protective Factors

He loves his grandchildren, attends church with his wife and says he would not want his family to find him. These reasons for living are recorded and become part of his safety plan. Protective factors do not cancel risk, but they give him and his clinicians something to build on.

Why Routine Visits Matter

Ahmedani et al. (2014) examined health care use in the year before suicide and found that 83% of people who died by suicide had a health care visit in the prior year, often in primary care or medical specialties, and that half had no mental health diagnosis. Mr. B.'s visit for back pain last week was such an opportunity. I contact his primary care clinician to share the concern and coordinate care.

He came in for his back; the rifle was the reason the visit mattered.

Firearms and Suicide

Anglemyer et al. (2014) meta-analyzed 16 observational studies and found that access to firearms was associated with about three times the odds of suicide. Firearm suicide attempts are usually fatal, while attempts by other means are more often survived, and many suicidal crises are brief. Reducing access to a firearm during a period of high risk can therefore prevent death.

Talking With His Wife

With his consent, I speak with his wife. She confirms that the rifle and ammunition are in a closet, not locked, and that he has been sleeping poorly and drinking alone in the garage. She agrees to help remove the rifle and to call if she sees warning signs, and she is given the 988 Suicide and Crisis Lifeline number.

Lethal Means Counseling

I raise the rifle directly and without judgment: "Many people in your situation store their guns away from home for a while until things are better. Would you be willing to do that?" Mr. B., a hunter, is reluctant but agrees when I frame it as temporary and his choice. His brother-in-law, who also hunts, will store the rifle and ammunition. His wife will confirm by text when it is out of the house. We also discuss locking up medications and limiting alcohol, which increases impulsivity.

Alcohol and Risk

Alcohol increases impulsivity and lowers inhibition, and intoxication is present in many suicide deaths. Mr. B.'s increase to several beers a night is addressed directly: he agrees to keep no alcohol at home for the next month, and his wife supports this. If he cannot cut down, treatment for alcohol use disorder will be added, including medication such as naltrexone after his liver function is checked.

Safety Plan

We update his written safety plan: his own warning signs, such as sleeplessness and drinking alone; things he can do on his own to ride out the urge, such as working in his garage; friends and settings that take his mind off things; the people he will call, including his brother-in-law; professional and crisis contacts; and the lethal means steps.

Why Direct Questions Help

Asking about suicide does not plant the idea. Mr. B. says he was relieved that someone finally asked.

Documenting the Plan

The note records the C-SSRS findings, his risk and protective factors, the lethal means agreement and who will confirm the rifle's removal, the safety plan and the follow-up schedule. Clear documentation lets every clinician involved see the plan and act on it.

Treatment Adjustments

Pain management is coordinated with his primary care clinician, avoiding opioids stored in quantity at home. Alcohol is addressed directly. Therapy frequency increases to weekly, and I schedule a visit in three days and a phone call tomorrow. Sertraline has reached a reasonable dose, so augmentation or a switch will be considered once safety is established, and a referral to a vocational rehabilitation program is made, since loss of work is central to his depression.

Follow-Up Over the Next Month

The rifle's removal is confirmed by his wife the same evening. At the three-day visit, the C-SSRS is repeated, and it is repeated at each visit after. Once his ideation eases, we discuss when and how the rifle might return, a decision made with him and his family rather than by default.

Level of Care

Because his ideation is active but without plan or intent, his family is engaged and he has agreed to remove the rifle, he can remain in outpatient care, provided contact is frequent. If he develops intent or a plan, or cannot secure the rifle, emergency evaluation is needed.

Conclusion

Six months into care, Mr. B.'s depression worsened with pain, financial loss and alcohol, and structured assessment revealed active suicidal ideation with a firearm method. Most people who die by suicide have had recent health care visits, and firearm access roughly triples suicide odds, so the plan centered on temporary removal of the rifle, an updated safety plan, closer follow-up and coordinated treatment of pain and drinking.

References

Ahmedani, B. K., Simon, G. E., Stewart, C., Beck, A., Waitzfelder, B. E., Rossom, R., Lynch, F., Owen-Smith, A., Hunkeler, E. M., Whiteside, U., Operskalski, B. H., Coffey, M. J., & Solberg, L. I. (2014). Health care contacts in the year before suicide death. Journal of General Internal Medicine, 29(6), 870-877. https://doi.org/10.1007/s11606-014-2767-3

Anglemyer, A., Horvath, T., & Rutherford, G. (2014). The accessibility of firearms and risk for suicide and homicide victimization among household members: A systematic review and meta-analysis. Annals of Internal Medicine, 160(2), 101-110. https://doi.org/10.7326/M13-1301

Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., Currier, G. W., Melvin, G. A., Greenhill, L., Shen, S., & Mann, J. J. (2011). The Columbia-Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168(12), 1266-1277. https://doi.org/10.1176/appi.ajp.2011.10111704