NR 548 Week 4 Suicide Risk Assessment Note Example

Risk Assessment Note: Nightly Thoughts of Using a Handgun in a 52-Year-Old With Depression and Heavy Drinking, Factors Weighed Rather Than Counted, and the Specific Actions Taken Before the Patient Left

Student Name

College of Nursing, Chamberlain University

NR 548: Psychiatric Assessment for Psychiatric-Mental Health Nurse Practitioner

Instructor Name

Month Day, Year

Risk Assessment Note: Nightly Thoughts of Using a Handgun in a 52-Year-Old With Depression and Heavy Drinking, Factors Weighed Rather Than Counted, and the Specific Actions Taken Before the Patient Left

Reason for Assessment

During a first psychiatric evaluation at a community mental health clinic, a 52-year-old patient with a depressive syndrome disclosed thoughts of suicide on most nights over the past two weeks, focused on a handgun at home. This note records the risk assessment completed during the same visit with my preceptor present. The inquiry followed the order of the Columbia Suicide Severity Rating Scale screen (Posner et al., 2011), but the note does not end at a score.

What Was Asked and Answered

Wish to be dead: Asked whether, in the past month, the patient had wished to be dead or to fall asleep and never wake. "Every night, pretty much."

Suicidal thoughts: "Have you actually had thoughts of killing yourself?" "Yeah. Most nights for the last couple of weeks."

Method: Asked whether a particular method had come to mind. "The gun. It's in the closet."

Intent: "Have you had these thoughts and had some intention of acting on them?" "No. I wouldn't do that to my kids. But I think about it."

Plan: "Have you started to work out the details of how, when or where?" "No."

Preparatory behavior: "Have you done anything, started to do anything, or prepared to do anything to end your life?" After a pause: "I took it out of the case once. Two weeks ago. Put it back." The patient had not loaded it and had not held it since.

Past attempts: None.

Access: A 9 mm handgun, stored locked in its case in a bedroom closet; the patient holds the key. Ammunition stored in the same closet. No other firearms. The patient lives alone since the separation.

Static Factors

These cannot be changed but raise the baseline: age over 50, a group with high rates of suicide by firearm in the United States; a parent who died by suicide when the patient was 19; recent job loss and marital separation.

Dynamic Factors

These are current and can change before the next review: a major depressive syndrome with hopelessness and a belief of being a burden; nightly suicidal thoughts with an identified method; one episode of handling the weapon two weeks ago, which counts as preparatory behavior; heavy alcohol use, six to eight beers on most nights, which lowers inhibition and worsens sleep and mood; living alone; and access to a firearm. The combination of alcohol and an accessible firearm is the most urgent feature, because it is the one most amenable to change tonight.

Protective Factors, Weighed

Children. The patient named two adult children, especially a daughter who visits weekly, as the reason for not acting. This is strong: it was offered spontaneously and brought tears. Its reliability is moderate, since the thought of being a burden to them is also part of the depression.

Brother. A younger brother lives 15 minutes away and, according to the patient, "would come if I called." Untested until today.

Engagement. The patient came to the appointment, answered difficult questions and disclosed the preparatory behavior when asked directly. This suggests willingness to work with the clinic.

Dog. The patient's dog depends on the patient. Mentioned lightly but meaningfully.

Faith. The patient described being "raised Catholic" but not currently practicing. Given little weight.

Formulation

The patient's risk of suicide is elevated and requires same-day action, though not, on the evidence here, emergency hospitalization. That conclusion rests on nightly ideation with a specific, lethal and accessible method, recent preparatory behavior, heavy nightly drinking, living alone and a parental suicide, set against the absence of current intent or a plan, a strong stated reason for living, a relative who can help tonight and the patient's engagement and willingness to act on safety steps. If the patient had declined to separate from the firearm, or if intent or a plan had emerged, the conclusion would change to a need for emergency evaluation. A reader could reasonably judge the risk higher because of the preparatory behavior; I weighed it against the fact that the patient disclosed it freely and has not repeated it.

The level of concern stated here is a clinical judgment, not a score. The Columbia screen organized the questions and made sure none were skipped, but the formulation weighs the answers against each other and against the patient's circumstances. Two patients with the same screen responses could warrant different actions, depending on access to means, drinking, support and engagement. This note records why this patient's combination led to same-day action without emergency transfer.

Actions Taken

Lethal means. With the patient's agreement, my preceptor called the brother from the office with the patient present. The brother agreed to collect the handgun, ammunition and key that evening and keep them at the brother's home, and to text the preceptor when done. The text arrived at 7:40 p.m. The patient agreed not to obtain another firearm.

Safety plan. The patient and I wrote a safety plan together using the Stanley and Brown model: warning signs (lying awake after drinking, thinking about the closet); internal coping strategies (walking the dog, a television program the patient enjoys); people and places for distraction (a coworker, the hardware store); people to ask for help (brother, daughter); professional contacts (the clinic number, the 988 crisis line, the nearest emergency department); and making the environment safe (firearm removed, no drinking alone at night) (Stanley & Brown, 2012). The patient took a copy and photographed it.

Alcohol. The patient agreed to try not drinking at home alone for the next three days and to tell the brother if that was not possible.

Follow-up. The clinic nurse will call the patient tomorrow afternoon. A return appointment is booked in three days. Safety planning with structured follow-up contact has been associated with fewer suicidal behaviors after emergency department visits (Stanley et al., 2018), which is why the call is scheduled rather than left to the patient.

Communication. With the patient's consent, the primary care provider will be informed of the assessment and plan.

Review

Risk will be reassessed at the phone call tomorrow and at the three-day visit, with the same direct questions. The formulation will be revised if drinking continues, if the brother reports any difficulty, or if the patient misses the call.

References

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

Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256-264. https://doi.org/10.1016/j.cbpra.2011.01.001

Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., Chaudhury, S. R., Bush, A. L., & Green, K. L. (2018). Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75(9), 894-900. https://doi.org/10.1001/jamapsychiatry.2018.1776