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cd /tmp/workspace && python3 -c " from docx import Document doc = Document('/tmp/workspace/attachments/c67fccd8-7c76-469b-af64-4b64fbd1e606/UGHE Mental Health - homework.docx') for p in doc.paragraphs: style = p.style.name if p.style else 'None' if p.text.strip(): print(f'[{style}] {p.text}') for t in doc.tables: print('TABLE:') for row in t.rows: print(' | '.join(c.text for c in row.cells)) "
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Mr. R Case - Answers
1. Passive vs. Active Suicidal Ideation
Passive SI is a wish to be dead or a sense that life isn't worth living, without any thought, plan, or intent to act ("I wish I wouldn't wake up," "I'd be better off dead"). Active SI involves current thoughts of killing oneself, and exists on a spectrum of increasing severity: thoughts without a plan → thoughts with a method but no intent → a specific plan → intent to act, with or without a timeline (Rosen's Emergency Medicine, Kaplan & Sadock's Comprehensive Textbook of Psychiatry).
Key point for risk stratification: active ideation with a specific, lethal, and available plan (like Mr. R's plan to jump off a rooftop) confers much higher acute risk than passive ideation, but passive SI is not benign - it is still associated with increased risk of future suicidal behavior and should never be dismissed as "just words" (Tintinalli's Emergency Medicine).
2. Relevant HPI and Psychiatric History Questions
About this attempt/ideation (HPI):
- What specifically happened today - what triggered going to the rooftop? Was there a precipitant (breakup, job loss, legal trouble, humiliation, substance use)?
- Was this planned or impulsive? How long had he been thinking about it?
- Did he take any concrete steps (writing a note, giving away possessions, choosing a specific method/location, researching lethality)?
- Does he still want to die right now, or has the crisis passed? Is he relieved or angry/disappointed that he was stopped?
- Access to lethal means (firearms, stockpiled medications, other means at home)?
- Any alcohol or substance use at the time (disinhibition is a major risk multiplier)?
- Command hallucinations or psychotic symptoms driving the behavior?
Past psychiatric history:
- Prior suicide attempts (the single strongest predictor of completed suicide) - method, lethality, medical severity, circumstances, hospitalization?
- Prior psychiatric diagnoses (depression, bipolar disorder, psychotic disorder, substance use disorder, PTSD, personality disorder)?
- Current or past psychiatric treatment - medications, adherence, recent changes, outpatient therapist/psychiatrist?
- Any prior psychiatric hospitalizations?
Past medical history:
- Chronic or terminal illness, chronic pain, recent diagnosis of serious illness?
- Current medications (some, e.g., certain antidepressants early in treatment, isotretinoin, corticosteroids, can affect mood/suicidality)?
- Head injury or neurologic disease?
Family history: Family history of suicide, mood disorder, or psychosis (genetic loading raises risk).
Social history/risk and protective factors: Living situation, recent losses (relationship, job, financial, legal problems), social isolation vs. supportive relationships, religious/cultural beliefs about suicide, reasons for living (children, future plans), access to firearms.
Mental status exam: mood, affect, thought content (delusions, hallucinations), insight/judgment, cognition.
3. Illness Scripts
| Disorder | Key symptoms | Additional symptoms |
|---|---|---|
| Major Depressive Disorder | Depressed mood and/or anhedonia (loss of interest/pleasure), present most of the day, nearly every day, for ≥2 weeks | - feelings of worthlessness or guilt - fatigue/low energy - change in sleep (insomnia or hypersomnia) - change in appetite/weight - psychomotor agitation or retardation - poor concentration/indecisiveness - recurrent thoughts of death, passive and/or active suicidal ideation - requires ≥5 symptoms total (must include depressed mood or anhedonia), causing functional impairment, not attributable to substances/medical illness |
| Bipolar I | At least one manic episode: abnormally elevated, expansive, or irritable mood plus increased energy/activity lasting ≥1 week (or any duration if hospitalization required), with symptoms severe enough to cause marked impairment, psychosis, or hospitalization | - inflated self-esteem/grandiosity - decreased need for sleep - pressured/rapid speech - flight of ideas/racing thoughts - distractibility - increased goal-directed activity or psychomotor agitation - excessive involvement in risky activities (spending sprees, sexual indiscretion, impulsive decisions) - may include psychotic features; most patients also have recurrent major depressive episodes, but a manic episode alone is sufficient for diagnosis |
| Bipolar II | Hypomanic episodes (same symptom list as mania but milder, lasting ≥4 days, and NOT severe enough to cause marked impairment, require hospitalization, or include psychosis) plus at least one major depressive episode | - Many patients with Bipolar II will spend a much greater proportion of time in depression compared to patients with Bipolar I - hypomania is often not recognized by the patient as pathological (may feel like "their best self") - history from family/collateral informants is often essential - no history of a full manic episode (if one ever occurs, diagnosis becomes Bipolar I) |
| Schizophrenia | Delusions AND/OR hallucinations AND/OR disorganized speech (non-linear, frequent derailment) | - grossly disorganized or catatonic behavior - negative symptoms (affective flattening, avolition/abulia, apathy, social withdrawal, alogia) - decline in functioning (occupational, social, self-care) below prior baseline - continuous signs of disturbance for ≥6 months (with ≥1 month of active-phase symptoms); shorter durations = brief psychotic disorder (<1 month) or schizophreniform disorder (1-6 months) - typical onset late adolescence to early adulthood; must exclude mood disorder with psychotic features and substance/medical causes |
Contrast summary: MDD is a pure mood disorder (no manic/psychotic episodes). Bipolar I requires a full manic episode (severe, impairing, possibly psychotic); Bipolar II requires hypomania (milder, non-impairing) plus depression, and patients often present clinically depressed with an under-recognized history of "highs." Schizophrenia is fundamentally a primary psychotic disorder - mood symptoms, when present, are secondary to (or coexist with) persistent positive/negative psychotic symptoms lasting ≥6 months, distinguishing it from mood disorders with psychotic features, where psychosis only occurs during mood episodes.
Sources: Kaplan and Sadock's Synopsis of Psychiatry; Kaplan & Sadock's Comprehensive Textbook of Psychiatry; Goldman-Cecil Medicine; Tintinalli's Emergency Medicine; Rosen's Emergency Medicine.
A quick check of recent literature (PubMed, meta-analyses/systematic reviews, last 2 years) didn't surface findings that contradict these core diagnostic frameworks - the DSM-5 criteria for MDD, Bipolar I/II, and schizophrenia described above remain current. If you want, I can also pull the AAFP suicidal patient article's specific structured risk-assessment framework (SAD PERSONS, etc.) to compare against what's in the library.
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