Case 36: A retired teacher who asks “why should I live?”

01The case

A 59-year-old retired teacher lives alone. Her husband died five years ago after a stroke and they had no children. Her only relative is her brother, whose family she visits once or twice a week. She has been treated several times for episodes of depression. Just after New Year she comes to a psychiatrist on her own and says she feels bad, lonely and without any future. A few weeks ago she stopped her maintenance medication. During the interview she says: "Why should I take the pills? I don't want to do anything, I ache all over, I can't even cry... Why should I live?"

02Summary

What the therapist should do

Explore the risk of suicide, now. She has almost raised it herself, which makes it easier: take up her question rather than steer away from it. Move step by step from feelings to thoughts, intentions, plans and preparations, asking directly, for example "Do you sometimes feel you would be better off dead?" and then "Have you thought of taking your own life?"

Why

• She is very likely in a new depressive episode, with loss of drive, bodily pains and an inability to cry, on a background of recurrent depression.
• She has many factors linked to suicide: depression, hopelessness, loneliness, living alone, widowhood, older age, physical complaints, and having just stopped her treatment. The holiday period, spent alone, adds to it.
• Asking directly does not put the idea in her head, and many patients are relieved to be asked.

Where the interview goes next

• If she has thought of suicide: how often and how strongly, whether she has a method in mind, what she has done to prepare (stored tablets, a note, putting her affairs in order), any past attempts, alcohol, and what stops her.
• Ask what she has at home. Stockpiled medicines are a ready means of overdose, and limiting access to them is part of keeping her safe.
• The depth of the depression: sleep, appetite, weight, guilt, and any psychotic features. Her aches need a physical examination too.
• Her support: whether her brother knows how she is, and whether she agrees to his being involved.
• Then decide together where care happens. Active intent or a plan calls for same-day help from a crisis team or admission. Otherwise, a written safety plan, restarting antidepressant treatment in limited supplies, and early follow-up within days.