A 34-year-old married woman with a 2-year history of major depressive disorder presents to the psychiatry outpatient clinic. She reports persistent low mood, anhedonia, and poor sleep for the past 6 months despite adequate trials of sertraline and escitalopram. Over the last 3 weeks, she has begun giving away her jewelry and important documents to family members. She denies current suicidal ideation but admits to passive death wishes. Her husband reports she has become increasingly withdrawn and has stopped attending social gatherings. On mental status examination, she appears psychomotor retarded with restricted affect. What is the single most important immediate action in suicide risk assessment?

Explanation

## Suicide Risk Assessment in Treatment-Resistant Depression ### Clinical Context This patient exhibits multiple high-risk features despite denying active suicidal ideation: - **Treatment-resistant depression** (failed 2 adequate SSRI trials) - **Behavioral warning signs**: giving away possessions (preparation behavior) - **Passive death wishes** (ideation spectrum) - **Social withdrawal and anhedonia** (hopelessness markers) - **Psychomotor retardation** (associated with high lethality) ### Why Direct Inquiry Is Essential **Key Point:** Passive denial of suicidal ideation does NOT exclude imminent risk. Behavioral preparation (giving away possessions) is a stronger predictor of suicide attempt than stated intent. **High-Yield:** The SAD PERSONS mnemonic captures key risk factors: - **S**ex (female, but higher lethality in males) - **A**ge (peak risk 15–24 and 65+; this patient is in mid-range) - **D**epression (major depressive disorder present) - **P**revious attempts (not mentioned, but must ask) - **E**thanol/substance abuse (must screen) - **R**ational thinking loss (psychomotor retardation suggests yes) - **S**ocial support loss (withdrawn, isolated) - **O**rganized plan (must assess directly) - **N**o spouse (she is married, but assess quality) - **S**ickness (chronic depression, treatment-resistant) ### Structured Suicide Risk Assessment Framework | Domain | What to Ask | Red Flags in This Case | |--------|------------|------------------------| | **Ideation** | Frequency, duration, content | Passive death wishes present | | **Intent** | Desire to die vs. wish to escape pain | Must clarify despite denial | | **Plan** | Specificity, feasibility, access | Giving away possessions suggests planning | | **Means** | Access to lethal methods (pesticides, firearms, medications) | Critical in India (pesticide access common) | | **Preparatory behavior** | Saying goodbye, arranging affairs | **Present** — giving away valuables | | **Protective factors** | Family support, religious beliefs, future plans | Assess quality of marriage | **Clinical Pearl:** In Indian settings, pesticide poisoning is the most common method of suicide. Direct inquiry about access to pesticides, medications, or other means is mandatory, even in patients who deny intent. ### Why Other Options Are Inadequate - **ECT** may be indicated for treatment-resistant depression, but risk assessment precedes treatment escalation. - **Benzodiazepines** do not address underlying risk and may disinhibit impulsive behavior. - **Outpatient follow-up in 2 weeks** is unsafe given behavioral warning signs; hospitalization or intensive monitoring is needed. **Mnemonic:** **RAMP UP** = **R**isk assessment first, **A**sk directly, **M**eans access, **P**lan specificity, **U**rgent action (hospitalization if high risk), **P**rotective factors. [cite:Harrison 21e Ch 397]