Here the author presents the case of Mr P, a 40-year-old man with bipolar disorder and substance use disorder, including the patient's symptomatology, treatment subsequent to hospitalization, concerns for risk on release, and the outcome. We invite your comments below. Dr Knoll will review your responses and give his feedback in coming weeks.
CASE VIGNETTE
Mr P was admitted to an inpatient unit after he attempted suicide by shooting himself in the head. He had been adherent to lithium(Drug information on lithium) therapy, but he had also been abusing substances. After becoming severely depressed, he developed a plan to kill himself, but also believed he should kill his 12-year-old son to spare him the misery of the fallout from his own suicide.
He drove to his ex-wife’s home with the intent to shoot his son and then himself. At the last minute, Mr P decided he could not bring himself to shoot his son, and instead went to an isolated location and shot himself in the head. By chance, a passerby saw Mr P and called 911. Miraculously, the bullet did not take a fatal course, nor did it penetrate his brain. After neurosurgical intervention, Mr P was transferred to the psychiatry inpatient unit.
Mr P had no history of violent behavior and had never owned a firearm until he purchased one to commit suicide. Mr P had significant stressors in his life, which included substance abuse resulting in the loss of his last job. After a 3-week inpatient stay, his psychiatric medications were augmented and he responded very well to treatment. He reported wanting to find a new job and enter substance use treatment. His mood was stable and he reported no further suicidal or homicidal ideas. His inpatient team held several meetings with Mr P in attendance to discuss his future plans and to address the issue of his suicide attempt. In particular, the issue of his plan to kill his son was discussed. His inpatient team was concerned that they might have a duty to warn Mr P’s son before discharging Mr P.
Mr P was adamant that he did not want his son to be told about his previous plans for committing a homicide-suicide, because he believed this information would cause serious damage to their relationship. He added that he now felt embarrassed about his former plans and that he was not thinking clearly when he made them. He emphatically stated to his team that there was no chance he would harm his son, or anyone else. When the treatment team persisted in discussing the issue, Mr P became moderately upset and said he would retain an attorney should the team go forward with its plans to warn his son.
Question to consider
