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| Hospital day | Key events |
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| First hospitalization |
| Day 1 | (i) Initial differential diagnoses based on the initial interview and psychological testing
(a) Major depressive disorder
(b) Bipolar disorder
(c) Cyclothymic disorder (mood fluctuation with impulsivity).
(ii) Started citalopram 10 mg PO once daily for depression.
(iii) Started gabapentin 100 mg PO three times daily for anxiety. |
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| Day 2 | (i) Patient reports improvement in his depression and anxiety.
(ii) Patient unsuccessfully seeks to be discharged. |
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| Day 3 | (i) Patient reports having nightmares about him hanging himself with an extension cord in the backyard of his home.
(ii) Patient reports having intrusive, recurrent, distressing thoughts about suicide.
(iii) Gabapentin 300 mg PO three times a day replaced with carbamazepine 200 mg PO twice a day for impulsivity. |
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| Day 4 | (i) Patient upset at his family for not consenting to his discharge.
(ii) Patient reports that while in his room to “cool off” having another sudden intrusive thought of hanging himself and unsuccessfully attempts to hang himself in the shower.
(iii) Patient treated for a scalp laceration resulting from the unsuccessful suicide attempt but was found to be not otherwise physically harmed. |
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| Day 5 | (i) Patient reevaluated following the suicide attempt to clarify the diagnosis.
(ii) Patient reports having prominent symptoms reflective of PTSD for 2 months
(a) Recurrent flashbacks of multiple traumatic scenes witnessed while working as a firefighter
(b) Patient reports having recurrent images of others hanging
(c) Patient reports feeling like he is on edge, feeling physically ill, and having avoided work as a firefighter to prevent having recurrent images of death.
(iii) Started prazosin 1 mg PO at bedtime for PTSD.
(iv) Bipolar disorder and cyclothymic disorder ruled out after continuing assessment.
(v) Discontinued carbamazepine 200 mg PO twice a day. |
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| Day 6 | (i) Patient reports continuing recurrent suicidal thoughts which causes him significant distress.
(ii) Patient attempts to clear his head of those intrusive thoughts by repeatedly punching his own head.
(iii) Patient further screened for other possible diagnoses including self-injurious behavior and obsessive suicidal thoughts.
(iv) Starting a trial of divalproex sodium 500 mg extended release PO twice a day and olanzapine 10 mg oral tablet at bedtime for impulsive thoughts. |
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| Day 7 | (i) Patient remains worried about intrusive suicidal thoughts and expresses hopelessness with regard to keeping his intrusive suicidal thoughts under control.
(ii) Discontinued citalopram 10 mg oral tablet once daily due to mood lability and persisting suicidal ideations. |
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| Day 8 | (i) Patient reports decreased frequency of intrusive suicidal thoughts.
(ii) Started clonazepam 0.5 mg oral tablet three times a day for anxiety. |
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| Days 9–12 | (i) Patient reports improvement with intrusive suicidal thoughts and denies suicidal intent.
(ii) Patient discharged with
(a) olanzapine 10 mg PO once daily,
(b) divalproex sodium 500 mg extended release PO twice a day,
(c) prazosin 1 mg PO at bedtime for PTSD,
(d) clonazepam 0.5 mg PO three times a day,
(e) new appointment for therapy,
(f) follow-up appointment for psychiatry. |
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| Second hospitalization |
| Day 1 | (i) Readmitted within 48 hours after discharge with recurrent intrusive suicidal thoughts.
(ii) EEG r/o dysrhythmias and epileptiform activity. |
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| Day 2 | (i) The patient describes suicidal thoughts as unwanted and intrusive and happening “about 5-6 times a day.” These obsessive suicidal thoughts started suddenly three months before, after he witnessed a scene of a car wreck. They are short in duration “not very long, a few minutes” but are “very strong” and disturbing to him. He reports becoming overwhelmed and panicked. He tries to block them “by thinking of anything else…trying to distract myself.” That only works for a while and then the pattern repeats. He said that as they continue to return, he gets more upset and begins to think about “hanging myself” to make them go away.
(ii) The patient denies any previous suicidal thoughts even though he had been feeling depressed, prior to seeing the carnage of the car wreck.
(iii) The patient denies thinking that his family would be better off without him. He reports that he has not given any possessions away; he has not written a suicide note; he has not done anything else to prepare for death (will, insurance, property, or practicing).
(iv) The patient notes that he does not want to kill himself and one reason is the effect on his wife and family adding, “That’s why I let them know I have these thoughts.” He noted, “I can control it sometimes but they keep coming back.”
(v) He reports he is hopeful about the future, “I hope I can get better…isn't there a medication that can help?”
(vi) The patient is stable with depression. He reports extreme anxiety due to obsessive suicidal thoughts. He denies any psychotic symptoms and also denies any homicidal ideations.
(vii) The patient is diagnosed with OCD based on DSM-5 criteria.
(viii) The patient agreed to start exposure and response prevention (ERP) therapy.
(ix) Medications
(a) Stopped divalproex sodium ER
(b) Sertraline 50 mg PO once daily
(c) Clonazepam 0.5 mg PO twice daily
(d) Olanzapine to 5 mg PO twice daily |
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| Day 3 | (i) The patient participates in additional ERP therapy.
(ii) The patient states, “I am hopeful.”
(iii) The patient verbalizes improvement in obsessive suicidal thoughts with decreased anxiety and distress stemming from suicidal thoughts.
(iv) Medications
(a) Increased sertraline to 100 mg PO once daily
(b) Clonazepam 0.5 mg PO twice daily
(c) Olanzapine to 5 mg PO twice daily |
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| Day 4 | (i) The patient participates in more prolonged exposure therapy.
(ii) The patient reports overall improvement in his mood and less anxiety about his obsessive suicidal thoughts. He rates his anxiety at 4 out of 10, with 10 being the maximum.
(iii) Medications
(a) Increased sertraline to 150 mg PO once daily
(b) Clonazepam 0.5 mg PO twice daily
(c) Olanzapine to 5 mg PO twice daily |
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| Day 5–8 | (i) The patient reports being able to manage his obsessive suicidal thoughts and rates his anxiety regarding suicidal thoughts at 0 out of 10.
(ii) He then reports no suicidal thoughts three days in a row. He continuously participates in therapy.
(iii) Family members notice improvement with patient’s anxiety and depression. The patient is discharged home with psychiatry and psychology follow-up as out-patient.
(iv) Discharge medications
(a) Sertraline 150 mg PO once daily
(b) Olanzapine to 5 mg PO twice daily
(c) Clonazepam tapered off |
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