Case Studies

Case 2 - An unemployed man who has previously attempted suicide

While working as a psychiatric liaison doctor, you are called to the orthopaedic ward to assess John Baker, an unemployed 44-year-old with no previous psychiatric history who jumped off a motorway bridge three months ago in an apparent suicide attempt. He is physically well and about to be discharged. He was diagnosed with HIV some years ago. His partner recently died from AIDS. He tells you he tried to kill himself because he did not want to go on without her and still does not. The nurses report he has been quiet, withdrawn and tearful. They are concerned that he has been eating and drinking little. On examination he reports feeling worthless and says that there is no point to his life, as his partner was his only friend. He wants to die.

• a. What is the likely diagnosis?

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  Correct answer:

  Although three months after the death of his partner normal grieving would be expected, because of his negative thoughts about himself and his life and severe suicidal risk this would appear to meet criteria for a (severe) depressive episode.

• b. What is the current suicide risk?

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  Correct answer:

  High; he has recently made a serious attempt on his life, nothing has changed since then and he says he wants to die. He is depressed, unemployed, male, socially isolated and has been diagnosed with HIV – all of these are risk factors for suicide.

He says that he recently saw his partner walk into the ward kitchen and momentarily felt comforted, although now he is worried that he is ‘seeing things’.

• c. What would you advise him about his concerns regarding seeing his dead partner?

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  Correct answer:

  Recently bereaved people without mental illness often report visual pseudo-hallucinations and hallucinations of the dead person and these should not be pathologized (see Chapter 10). However, as he has a severe depression, you should be alert for other symptoms which may indicate the development of a psychotic depression.

• d. What treatment would you advise in this case?

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  Correct answer:

  Antidepressants. Psychological treatment (e.g. cognitive behavioural therapy) of his depression would also be indicated. Membership of a support organization for people with HIV could also be helpful.

You decide to prescribe mirtazapine, but Mr Baker is reluctant to take it as he sees no point and believes nothing will help him. He has been told that he is fit for discharge and plans to go home the next day. You are concerned about this, place him on a section 5(2) and call the Approved Social Worker to arrange a Mental Health Act assessment.

• e. Under which section of the Mental Health Act would he be placed if he was detained at the assessment and why?

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  Correct answer:

  He would most likely be placed under section 2, because he has no psychiatric history and the admission would be for assessment of his psychiatric disorder. If he had an established diagnosis of depression, section 3 would be appropriate.

• f. He makes good progress on the ward, and the consultant asks you to plan a meeting to plan his care after discharge. What is this type of meeting called?

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  Correct answer:

  A Care Programme Approach (CPA) meeting.