Emergency Psychiatry Consultation

Identification

J.T. is a 34-year-old divorced male with no children. His highest educational attainment is a Bachelor of Commerce. He is employed full-time as a financial analyst but has been on short-term disability leave for the past 3 weeks. He currently lives alone in a rented apartment in Toronto, where he has resided for the past 8 months; previously, he lived in a shared condominium with his ex-wife for 4 years.

Reason for Referral

Emergency department physician requested an urgent psychiatric consultation for assessment of acute suicidal ideation, manic symptoms, and necessity for involuntary admission.

Chief Complaint

"My brain won't shut off and I can't keep living in this chaos."

History of Presenting Illness

The patient has a history of Bipolar I Disorder and presents with a 2-week history of escalating mood elevation, decreased need for sleep, and subsequent mixed depressive features culminating in acute suicidal ideation today. He stopped taking his prescribed lithium and quetiapine approximately 4 weeks ago due to feeling well and experiencing mild sedation.

Situation

On 04/05/2026, the patient began experiencing decreased need for sleep, averaging 2 to 3 hours per night, accompanied by increased goal-directed activity. By 12/05/2026, he began day-trading stocks erratically and depleted $25,000 from his savings. On 17/05/2026 at 22:00, he contacted his sister expressing overwhelming guilt, racing thoughts, and an intent to jump from his apartment balcony. Police and EMS were dispatched under a Form 1 (Application by Physician for Psychiatric Assessment) initiated by his family physician earlier that day following a missed appointment and concerning voicemail. He arrived at the Emergency Department on 18/05/2026 at 00:30. In the ED, the triage nurse noted the patient was pacing, agitated, and verbally intrusive. The ED physician administered lorazepam (Ativan®) 2 mg PO at 01:15 with moderate reduction in agitation prior to this psychiatric consultation at 08:30.

Stressors

The patient finalized a contentious divorce 8 months ago, which resulted in significant legal fees and relocation to a smaller apartment. Additionally, he faces impending financial insolvency due to his recent manic spending spree and is anxious about his job security while on short-term disability leave.

Symptoms

• Mood: Endorses labile mood, oscillating rapidly between irritability and profound despair. Endorses hopelessness and worthlessness regarding recent financial losses.
• Anxiety: Endorses severe psychic anxiety and restlessness. Denies panic attacks, phobias, or obsessive-compulsive symptoms.
• Psychosis: Endorses auditory hallucinations consisting of indistinct whispers calling his name over the past 48 hours. Exhibits grandiose delusions regarding his ability to predict global market crashes, though these are currently wavering into nihilistic guilt. Denies visual hallucinations or ideas of reference.
• Mania: Endorses decreased need for sleep (2 hours per night with high energy), pressured speech, flight of ideas, distractibility, and reckless financial spending over the past 14 days.
• Personality disorder: NOT REPORTED.
• Trauma-related disorder: Denies current nightmares, flashbacks, or hypervigilance.
• Eating disorder: Endorses decreased appetite over the past week with a 3 kg weight loss due to being "too busy to eat." Denies bingeing, purging, or body image distortion.

Safety

Endorses active suicidal ideation with a specific plan to jump from his 14th-floor balcony. Endorses ongoing intent if discharged home today, stating he cannot face his financial ruin. Denies active or passive homicidal ideation.

Substance Use

• Alcohol: Consumes 4 to 6 standard drinks of whiskey daily for the past 10 days to "slow down" his thoughts; last use was 17/05/2026 at 20:00.
• Cannabis: Smokes 1 g of dried cannabis daily; last use was 17/05/2026.
• Stimulants: Denies current use of cocaine, amphetamines, or prescribed stimulants.
• Opioids: Denies current use.
• He has never required formal addiction treatment or detoxification.

Current Supports

The patient is currently under the care of community psychiatrist Dr. E. Vance, whom he sees every 3 months, though he missed his scheduled appointment last week. He does not currently attend psychotherapy.

Collateral

Collateral was obtained from the patient's sister, M.T., by telephone. She confirmed that the patient has been sending erratic, lengthy text messages at 03:00 daily for the past two weeks. She reported he sounded rapid and irritable on the phone yesterday, followed by a tearful call at 22:00 stating he was going to end his life. She confirmed he has access to his apartment balcony and lives alone.

Past Psychiatric History

1. Bipolar I Disorder, diagnosed in 2019.
2. History of non-suicidal self-injury involving superficial forearm cutting at age 19; no episodes in the past 10 years.
3. Unreported suicide attempt in 2018 via ingestion of 10 tablets of paracetamol (acetaminophen, Tylenol®); he slept it off at home and did not seek medical attention.
4. Wellness check by police in 2021 after posting erratic, grandiose statements on social media; he was assessed by mobile crisis at home and not brought to hospital.

Past Psychiatric Hospitalizations

14/11/2019 to 02/12/2019: Admitted to the Centre for Addiction and Mental Health (CAMH) under Dr. R. Patel following a 3-week manic episode characterized by insomnia, paranoia, and running into traffic. He was admitted involuntarily for 18 days, diagnosed with Bipolar I Disorder, and stabilized on lithium and olanzapine. He was discharged in stable condition with outpatient follow-up at the mood disorders clinic.

Medical History

1. Hypothyroidism, diagnosed in 2022, managed with daily levothyroxine.
2. Appendectomy, 10/06/2015, uncomplicated.

Medications

1. Lithium carbonate 900 mg PO QHS (non-adherent for past 4 weeks)
2. Quetiapine (Seroquel®) 300 mg PO QHS (non-adherent for past 4 weeks)
3. Levothyroxine (Synthroid®) 50 mcg PO daily (adherent)

Allergies

Penicillin (maculopapular rash).

Family History

• Mother: Major Depressive Disorder.
• Maternal uncle: Bipolar I Disorder, died by suicide at age 45.
• Father: Alcohol Use Disorder.

Brief Psychosocial History

The patient was born in Ottawa, Ontario, and raised as the older of two children in a middle-class household. He describes a supportive upbringing with no history of physical, emotional, or sexual abuse. He excelled academically, completing a Bachelor of Commerce at age 22, and has worked steadily in the financial sector since graduation. He married his university partner at age 28, but the marriage deteriorated due to stress surrounding his mood episodes, leading to divorce 8 months ago.

Mental Status Exam (MSE)

• Appearance: Tall, thin male wearing a hospital gown and mismatched socks, appearing slightly dishevelled with dark circles under his eyes.
• Behaviour: Psychomotor agitation noted; frequently shifts in chair and taps feet, though cooperative with the interview.
• Speech: Pressured rate, loud volume, difficult to interrupt, though clear articulation.
• Mood: "Wired and completely broken."
• Affect: Labile, shifting rapidly from irritable and expansive to tearful and dysphoric; congruent with shifting thought content.
• Thought Process: Flight of ideas with frequent tangentiality; requires redirection.
• Thought Content: Active suicidal ideation with plan and intent; grandiose delusions regarding financial markets; profound guilt; no homicidal ideation.
• Perceptions: Auditory hallucinations (whispers calling his name); no visual hallucinations.
• Cognition: Oriented to person, place, and time; attention and concentration impaired by distractibility; memory grossly intact.
• Insight: Partial; recognizes he is unwell and needs help to stay safe, but minimizes the role of medication non-adherence.
• Judgment: Impaired, evidenced by recent reckless spending, medication discontinuation, and acute suicidal intent.

Impression

Primary Diagnosis

Bipolar I Disorder, current episode mixed, severe, with psychotic features. The patient presents with a classic relapse of mania with mixed depressive features precipitated by medication non-adherence. This is supported by his 2-week history of insomnia, pressured speech, flight of ideas, reckless spending, auditory hallucinations, and acute shift into severe dysphoria with active suicidal intent. Differentials include substance-induced mood disorder (secondary to alcohol and cannabis use), though symptoms preceded the escalation in alcohol intake and align closely with his index manic episode in 2019.

Secondary Diagnoses

• Alcohol Use Disorder, moderate (escalated use in context of mania).
• Cannabis Use Disorder, mild.
• History of Bipolar I Disorder.

Plan

1. Safety: The patient exhibits acute suicidality with a lethal plan and impaired judgment secondary to a mixed affective state with psychosis. Inpatient psychiatric admission is warranted. He is unwilling to stay voluntarily; therefore, he has been placed on a Form 1 and will be assessed for a Form 3 (Certificate of Involuntary Admission) upon transfer to the inpatient unit. Place on constant 1:1 observation in the ED until bed transfer.

2. Biological:

• Order STAT bloodwork: CBC, electrolytes, creatinine, eGFR, liver enzymes, TSH, serum lithium level, serum ethanol level, and urine drug screen.
• Order ECG to assess QTc interval.
• Restart lithium carbonate 600 mg PO QHS tonight (to titrate back to 900 mg PO QHS pending renal function and baseline levels).
• Restart quetiapine (Seroquel®) 200 mg PO QHS tonight, increasing to 300 mg PO QHS tomorrow.
• Continue levothyroxine 50 mcg PO daily.
• Order lorazepam (Ativan®) 1 to 2 mg PO/IM Q4H PRN for acute agitation or severe anxiety (maximum 6 mg/24 hours).
• Initiate CIWA-Ar protocol to monitor and manage potential alcohol withdrawal.

3. Psychosocial:

• Consult inpatient social work once admitted to assist with short-term disability documentation and financial trusteeship exploration.
• Notify outpatient psychiatrist Dr. E. Vance of admission.
• Provide psychoeducation to the patient regarding the necessity of admission, medication adherence, and safety protocols; the patient was instructed to notify nursing staff immediately if suicidal impulses worsen while awaiting bed transfer.

“It was a pleasure to participate in this patient’s care. Please contact me with any questions.

Sincerely, Dr. A. Sterling, MD, FRCPC”