The patient was a 36-year-old man who came to a psychiatry clinic for outpatient evaluation of severe depression that had persisted for nearly two years. On initial interview, the patient reported chronic thoughts of suicide, stating, �If I had a good way to kill myself, I�d have done it already.� On screening for suicide risk factors, the patient admitted to possessing a handgun. She denied active plans for suicide, including using the gun, because �a friend or family member would have to clean up the mess.� The attending physician and resident performing the evaluation assessed the patient as at chronic risk for suicide, but not acute risk, and noted that prompt removal of the gun from the patient�s possession was paramount to her safety. Both also agreed that building a treatment alliance would be a critical factor in accomplishing that goal. For the patient�s depression, the treatment plan included starting an antidepressant, citalopram, as well as psychotherapy. The patient resisted plans to remove the handgun and refused multiple disposition plans proposed by the resident and the resident�s supervisor, who was not the evaluating attending physician during the initial assessment. Suicidal ideation continued and, as time passed in treatment, the supervisor viewed her as significantly higher risk to complete suicide than the resident did. Discussions with other faculty and the clinic�s risk manager ensued in an effort to delineate the resident�s legal options to remove the gun from the patient�s possession. Unfortunately, they were not able to develop a clear pathway to do so. The resident felt that forcing the issue legally would cause the patient to feel abandoned and unsafe, with a strong possibility of either suicide or termination of treatment, with concomitant increased risk of suicide. The supervisor felt that the institution�s primary responsibility was to keep the patient safe, and the longer it took to remove the gun, the more at risk the patient was for an adverse outcome. Both resident and supervisor agreed that prior to exploring any emotionally sensitive issues in treatment, the gun had to be removed. The gun was eventually removed from the patient�s residence, but it required nearly three months to achieve this goal. Though no harm occurred, this case was a �near miss� given the prolonged exposure of a potentially suicidal patient to such an obvious hazard. Take-home points Accurate diagnosis or assessment is the keystone to safe care. Standard assessment tools reduce the risk of misdiagnosis and misassessment. Patients should make every effort to remove lethal means, particularly firearms, from individual patients at risk for suicide. Suicide cannot be predicted. However, the standard of care requires that patients at risk for suicide be adequately assessed. Care settings can apply patient safety principles to prevent adverse effects and suicide attempts. Teams should not rely on defective processes. Suicide contracts are insufficient substitutes for care and assessment.

severe depression

chronic thoughts of suicide

psychiatry clinic

removing the gun

lethal means