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Case Presentation07-09-2015Wake Forest School of MedicineA_16 y.o. female_ with a history significant for depression, ADHD, and Anxiety presented to the Pediatric ED via private transportation for SI. Psychiatry was consulted to evaluate the patient. The patient's mother accompanied her at this ED visit and was interviewed separately. 1Past Psychiatric / Medical HistoryAlways quiet and reserved3 months ago - sister found pictures on her phoneBegan to see a therapistShared decision to come to ED

Wake Forest School of MedicineWake Forest School of MedicineInterviewed mother first:

What happened recently:Sister found picturesMother signed her up for therapyStarted on ProzacRevealed in that days session that her suicidal ideation was becoming a real threat

According to the patient's mother she has always been a quiet child. However, she never suspected that she might be suicidal.

He mother has noticed in the past few weeks that Brenna has become more isolated. She states the patient is almost always in her room. She will get food and return immediately to her room. There has also been a worsening in Brenna's social anxiety. There were final projects that required oral presentations and the patient refused to attend school. 2Family HistoryFather passed away when she was in 3rd gradeMother has unstable relationshipsConstant fighting at homeWake Forest School of MedicineWake Forest School of MedicineHer father passed away from cancer when she was in 3rd grade and has been struggling with this loss since then. Also, her mother and ex-step-father, who she never liked, got divorced this past October. She described her step-father as an abusive alcoholic. Upon further questioning, she said he never laid hands on the patient or her siblings, but she did get physical with the mother.3History of Present Illness16 yo femalePast Medical History ADHDMajor DepressionAnxietyCutting BehaviorWould be easy to kill myself

Wake Forest School of MedicineWake Forest School of MedicineNext: Interviewed the patient - First thing I noticed was her facial expression

Hard to talk to her at first. Asked her what she like to do.

The patient reports suicidal ideation and cutting behavior since the 6th grade. She reported feelings of worthlessness, lack of energy, lack of interest in "everything", large fluctuations in sleep (from insomnia to 18 hours of sleep), increased appetite, and specific plans to kill herself. Her plans to kill herself include cutting herself deeply and bleeding to death and jumping off a bridge. She was able to describe a specific bridge from which she planned to jump. The patient describes her main stressors as anxiety when dealing with people, family issues, and intrusive feelings and thoughts. 4MedicationsProzac for 12 weeks

Wake Forest School of MedicineWake Forest School of MedicineThe patient was prescribed Prozac by her pediatrician and was taking it for the past twelve weeks. Upon further questioning she stopped taking it 2 weeks ago.

When asked why, she said there were no noticeable changes in her mood and it gave her headaches. She only notices that her sleep is decreased since she stopped the Prozac.

5Social HistoryI hate school Reclusive at school with few friendsMost friends have perfect lives1 friend who is also suicidal Im not good at anything. My grades are terrible.Wake Forest School of MedicineWake Forest School of MedicineShe says she hates going to school, hates the people, and describes her academic performance as terrible. She says she's "not good at anything." After encouragement, she admits that she got an A in animal sciences. She likes animals.

She says she hangs out with a few people at school. But they have perfect lives. It sounded like she couldnt really connect with them. She has another friend who also has suicidal ideation. Thats the one person she can talk to about her negative thoughts, but she describes this person as annoying and not really a friend.6Physical Exam - continuedLaceration on her right ankle

Wake Forest School of MedicineWake Forest School of MedicineThe patient's intrusive thoughts include feelings of worthlessness, a desire to cut herself, and ideas that "it would be so easy" to kill herself. Thoughts and plans of killing herself are most powerful while she is cutting. She says that she has been cutting since 6th grade, and while she has been cutting less frequently, she is cutting much deeper.

The patient had lacerations on the medial aspect of her right ankle.

She said she also had lacerations on her upper inner thigh. She was gonna show me but I told her I believed her.

I asked her how she treated herself after cutting. Superglue.

7Mental Status ExamGeneral Alert and oriented to person, place and time. Appearance normal body habitus, normal postureAttitude/behavior cooperative but with poor eye contactPsychomotor - normoactiveSpeech fluent, normal volume, normal tone, normal rate, normal prosody and normal amount good vocabularyMood slightly depressedAffect blunted, restrictedThought process linear, coherent, goal directedThought Content positive for suicidal thoughts. Denies homicidal ideation, paranoia, delusions, grandiosity. Cognition memory intact, attention intact, language normal and fund of knowledge intact.Insight goodJudgment she cuts herself

Wake Forest School of MedicineWake Forest School of MedicineInsight seemed to have good insight into her own depression. When asked about what her biggest stressors are she said, "it's not that bad and other families have it much worse". 8Assessment and PlanVoluntary commitment Referred to inpatient pediatric psychiatry unitWake Forest School of MedicineWake Forest School of MedicineAssessment and plan was pretty easy because the patient and her mother both requested admission.

The patient stated that she wants to be normal. Patient reports that she does not want to have panic attacks when going to the grocery store. She stated, "I don't want to feel like hurting myself."

Her demeanor made me take her more seriously and I did believe that she was a legitimate danger to herself.

9Learning IssueRisk factors for youth suicide:History of previous suicide attemptsFamily history of suicideHistory of depression or other mental illnessAlcohol or drug abuseStressful life event or lossEasy access to lethal methodsExposure to the suicidal behavior of othersIncarceration

Studies also showed that being adopted increased risk for adolescent suicide.Wake Forest School of MedicineWake Forest School of MedicineUncle and one of her sister had a history of self-harm10Learning IssuePhysical Examination:Within normal limitsPsychomotor retardationStooped postureSlow movementsSlow speechCognitive ImpairmentDecreased concentrationForgetfulnessWake Forest School of MedicineWake Forest School of MedicineAssessing a depressed patient can be tough because the physical exam is often within normal limits.11Learning IssueDifferential:HypothyroidismParkinsons DementiaMedicationsTumorsCVAGriefWake Forest School of MedicineWake Forest School of Medicine12