Attempted suicide | OCP Overdose & Wrist cutting

Casebank History
1

Where You are:
You are working as a Foundation Year 2 doctor in a psychiatric department.

Who the patient is:
Your next patient is Emily Jones, a 16-year old girl who took overdose of oral contraceptive pills last night and cut her wrists this morning.

Other information you have about the patient:
The A&E doctors have seen the patient and she is medically fit for discharge.

What you must do:
Assess the patient and address her concerns.

Patient Information

  • You are Emily Jones, a 16 year old lady who took an overdose of oral contraceptive pills after your periods came one week late.
  • Your partner is 16 year old.
  • You told your boyfriend that you could be pregnant but he acted angrily and was not interested in your pregnancy, that annoyed you and you cut your wrists and took an overdose.
  • You took 16 tablets of OCPs yesterday of your mother’s OCP
  • You thought you were pregnant
  • Your boyfriend got angry when you told him you could be pregnant
  • You live with your mum
  • Your mum does not live very far away
  • If you want you could go to your mums place, you can simply do so.
  • You talk only to your mum about such issues but you did not discuss this issue with your mum. But you are sure that your mum will find out once she start looking for her pills.
  • You regret your actions and you feel stupid about it.
  • You came to the hospital on your own and you are sure that you would not do it again
  • All treatment done by the emergency department.
  • She is 1 week late on her period
  • You missed your periods you were afraid that you would get pregnant
  • You didn’t tell your mom, as you do not think that your mom would understand.
  • You are normally fit and well and not on any medication
  • You took the OCP in order to prevent yourself from getting pregnant.
  • You had an argument with your boyfriend, because he was not interested in your pregnancy
  • You came to the hospital on your own.
  • You took overdose of OCPs because you thought you were pregnant and you wanted to get rid of the pregnancy.
  • You cut your wrist this morning because you wanted to get the attention of your boyfriend.

Comment:

  • “Doctor, I feel stupid about what I have done”
  • I just freaked out when I found out that my periods were late by 2 weeks.
  • If the doctor suggests that you should talk to your parents or friends tell him/her that you will think about it.

Questions:

  • Can I go home now?
  • Will I be pregnant?
  • When can I go home?

Emotions and Attitude:

  • You speak with very low voice and you don’t maintain eye contact
  • You are sitting on a chair with your feet on the chair.
  • You have a bandage on your wrist.

Examiner’s Prompt (the key issue in this task are the following points):

  • Did she do a pregnancy test?
  • How old was the boyfriend?
  • Can I go home?

APPROACH: (negotiating approach)

GRIPS ( Normal facial expressions, use a supportive approach)

  • Be loud and confident
  • Avoid shaking hands

HOW TO START: Can you tell what happened today OR What made you come to the hospital today?

  • I understood that you took some overdose of some medications?
  • Can you tell me which medications?
  • How many tablets did you take?
  • When did you take them?
  • Where did you take the medications from?
  • Did you plan to take it?
  • Did you write a note?
  • Did you tell anyone?
  • Why did you take the overdose of the medications?
  • Who brought you to the hospital?
  • I can see that you have a bandage on your wrist. What happened to your wrist?
  • Did you cut your wrists?
  • What did you use to cut yourself?
  • Why did you cut yourself?
  • When did you do that?
  • Is this the first time you have taken an overdose of any medication and cut your wrists?
  • Do you have any medical problems?
  • What was your intention of taking the medication?
  • Did you know that this number of OCP was going to get rid of the pregnancy?
  • So did you take these pills in order to prevent yourself from getting pregnant?

Risks of suicide: History of alcohol, IVDU, menstrual history,family history of suicide, previous attempts of harming herself? (FAMISH Hx)

Pregnancy history:

  • When was your LMP?
  • Did you perform a pregnancy test at home?
  • Did the A & E doctors perform a pregnancy test ?
  • When did you have unprotected sexual intercourse?

Management (this patient has low suicide risk)

  • Arrange a pregnancy test now!
  • Explain that there is no contraception which is recommended because of your late periods. Contraception can prevent pregnancy but they would not get rid of the pregnancy.
  • Because if you were already pregnant, none of the contraception would work.
  • Allow discharge home, after taking a second opinion, from a senior colleague.
  • Your last menstrual period was 6 weeks ago.
  • Arrange community psychiatry follow up.
  • Do your parents know that you are in a sexual relationship?
  • Ask if there is any particular reason she didn’t tell her parents?
  • Explain that the parents were also of her age and they may understand.
  • Advice to see the GP to discuss long term contraception to avoid similar situations in the future.
  • Explain that you will take a second opinion before she goes home
  • And that you will give her a crisis card.
  • It has the name and telephone number of someone you can call if you feel low and you feel like talking to someone.
2

Setting: Psychiatry department, 16-year-old girl Context: Patient came to A&E, received
dressing, and was referred to psychiatry

Approach:

Initial Greeting: “I understand that you have taken some tablets and also cut your wrist. I’m
sorry to hear about that. Can I please ask you some questions about this?”

Assessment of Tablet Ingestion:

  • “What sort of tablets have you taken?” Expected response: Contraceptive pills
  • “Why did you take them?” Expected response: Thought she was pregnant
  • “How many tablets did you take?”
  • “When exactly did you take them?” Expected response: Last night
  • “Did you take any other tablets with that?”
  • “Were you under the influence of alcohol at the time?”
  • “What happened immediately after? Did you vomit?”
  • “Have you had any symptoms like tummy pain or psychotic symptoms?”
  • “Where did you get the tablets from?” Expected response: Mother’s tablets
  • “Does your mother know about this?” Possible response: She will find out soon

Assessment of Wrist Cutting:

Pre-attempt:

  • “Have you ever planned this before?”
  • “Have you ever had ideas of hurting yourself?”
  • “Was this impulsive or planned?”
  • “Did you do any preparation?”
  • “Did you write any suicide note or will?”
  • “Did you call or text anyone before?”
  • “Did you switch off your phone?”
  • “Did you close any bank accounts or leave social media groups?”

During attempt:

  • “Where were you when this happened?”
  • “Was anyone else there?”
  • “Were you in your room? Did you close the door?”
  • “Did you wait for everyone to leave the house?”
  • “Did you put the curtain down or switch off the light?”
  • “What did you use to cut?”
  • “What was going through your mind before and during the cutting?”
  • “When you saw the blood, what did you think? How was your reaction?”

Post-attempt:

  • “How did you stop the bleeding?”
  • “Did you faint?”
  • “How did you come to the hospital?”
  • “What sort of treatment did they offer in A&E?”

Current Feelings and Future Outlook:

  • “How do you feel about everything you’ve done so far?”
  • “If you had a similar situation in the future, would you repeat this?”
  • If she says no: “Why would you say no? What would you do differently?”

Past History:

  • “Have you done similar things in the past?”
  • “Do you take any alcohol or recreational drugs?”
  • “Do you sometimes feel low? How is your mood generally?”
  • “Have you ever been diagnosed with any mental health conditions, like depression?”

Relationship Assessment:

  • “How is your relationship generally, apart from this incident?”
  • “Is your boyfriend supportive?”
  • “Has he ever been abusive or aggressive?”

Family History:

  • “Has anyone in your family been diagnosed with any mental health conditions?”
  • “Has anyone in your family done something similar?” Note: Suicide and depression can run in families

Pregnancy Concerns:

  • “When was your last menstruation?”
  • “Have you done any pregnancy test?”
  • “Did the doctors in A&E do a pregnancy test?”
  • “Have you had any unprotected sexual intercourse since your last period?”

Additional Information:

  • Ask about medical conditions, medications, allergies
  • Social history: Who do you live with? Who is at home? Is your family supportive?

Management Plan

Explanation about OCP:

  • “I understand you took the pills to try to end a possible pregnancy. If you are already pregnant, contraceptive pills won’t work for that purpose.”
  • “To prevent similar situations, we advise you to speak to your GP about long- term contraception options.”

Pregnancy Test:

  • “We would like to do a pregnancy test for you.”
  • “If you are pregnant, we’ll advise you to seek the right advice. You can speak to your GP or the National Unplanned Pregnancy Advisory Service for guidance.”

Risk Assessment Outcome:

  • “From the information I’ve gathered, it is highly unlikely you may repeat this again.”
  • “Therefore, you should be able to go home today.”
  • “Before you go home, I would like to speak to my seniors before we discharge you.”

Follow-up Plan:

  • “If we discharge you today, you’ll be followed up in community psychiatry.”
  • “They’ll offer you a card called a crisis card.”
  • “If you ever come across a similar situation in the future, you don’t need to do the same again. You can just call the number on the card and talk to somebody.”

Important points

  1. Distinguish between actions intended for self-harm and those for other purposes: In this scenario, taking OCP was to end potential pregnancy, not for self-harm
    • Cutting wrist was for self-harm and requires full suicidal risk assessment
  2. Approach to greeting:
    • Don’t say “How may I help you?” to someone who has attempted suicide
    • Instead, acknowledge their actions and express empathy
  3. Assessment should cover before, during, and after the suicide attempt
  4. Pay attention to details that distinguish high-risk from low-risk behaviour:
    • Planning vs. impulsive action
    • Isolation vs. seeking attention
    • Lethal methods vs. less lethal methods
    • Genuine desire to die vs. cry for help
  5. Always assess for suicidal ideation in psychiatric conditions, regardless of presenting
    complaint
  6. Be thorough in your assessment, covering all aspects mentioned
  7. In your management plan, don’t directly tell the patient they are low-risk. Instead, phrase it as “it is highly unlikely you may repeat this again”
  8. Always consult with seniors before discharging a patient who has attempted suicide
3

Pt in th A&E , ocp overdose to get rid of the pregnancy
Thinks she’s pregnant , frustrated after her bf ignored her and cut her wrist bandage here. Tr

Greet ,
I understand that u have taken some tbs and also u have cut ur writs am sorry to hear about that
Can u tell me what happen
What tabs?
How many?
When ?
What u take with ?
Why u took them?
After u take the tbs what happen ?

Can u tell me about the cut ?
What happen?
Why you do it?
Before u cut ur wrist
Did u write any note?
Tell anyone?
Have u done any preparation?
Did u wait everyone to leave the house ?
Did u close the door?
Close the curtain?
What sort of equipment u use to cut?
When u were cutting what was going on ur mind?
What thought do u had ?
What u did after that?
Did u come to the hospital by ur own?
In terms of going forward in the fiture if u had similar situation what would u do ?
Same ? Or differently?

Sucidal risk factor :
Have u done it in the past ?
Alcohol rec drugs?
Anyone in the family has comiited anu sucide or selffarm?
Do u feeel low ?
Any hx of mental illness?
How is ur relationship?
How old is ur partner ?
Is he supportive other wise ?
How is IN family?
Who is at home
What do u do?

Obviously u did everything bcz u feel u r pregnant
Have u had any pregnancy test ?
In the Ed ?
Have u had any unprotected sexual inter?
Is ur period regular?

MAM

EXPLAIN
As we understand u have taken tbs inorder to get red of the preg, if u r already pregnant cocs
will not work
They only prevent the pregnancy
We need to do pregnancy test and if it positive we’ll refer u to GP
FROM MY ASSESSMENT
It seems like its highly unlikely that u may repeat this bcz u regret what u have done and u
understand that its not right , u should be able to go home
We’ll arrange follow up
Before u go I will discuss this with my senior

Vista GP in order to give u contraception options
Offer crisis card