Night Consultation: Insomnia, Suicidal Ideation and a Vocational Licence
Mr Raj, 35, attends at 9pm. He is a taxi driver and asks for a repeat of "the sleeping pills" he received from another clinic three months ago. He has been taking zopiclone 7.5 mg nightly and sometimes two tablets, and admits to "a few beers" most nights to help him sleep. He works night shifts. Over the past two months he has lost interest in his hobbies, lost 5 kg, wakes at 4am, and his wife has recently left with their two children. When you ask directly about self-harm he says, "Sometimes I think everyone would be better off without me," but denies any plan and declines to see a psychiatrist. He asks you not to record the depression because he is renewing his vocational driving licence, and asks for three months of tablets so he does not have to come back.
1. How do you conduct and act on the risk assessment in this consultation?
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Structure the assessment. Move from open questions to direct ones: thoughts of being better off dead; thoughts of self-harm; any plan, means or preparation; any prior attempt; protective factors (children, faith, parents, a key worker); and the degree of current intent. Note that "everyone would be better off without me" is passive ideation that warrants explicit enquiry, not reassurance. Use a validated tool (PHQ-9 item 9) but treat the score as an adjunct - the clinical conversation decides.
What raises my concern here. Recent relationship breakdown, weight loss, early waking, alcohol use, access to a vehicle and to a stockpile of sedatives, sleep deprivation and night-shift work are all additive. Access to means matters: he can fill a prescription and he has a car.
Action. He is not acutely intent or planned, so detention is not the frame; a collaborative safety plan is. That means: an agreed crisis number (SOS 1767, or 995 if there is immediate danger), named people he can call tonight, removal of the means I can control - no large quantity of zopiclone, no more than a short bridging supply - and a clear follow-up appointment within 72 hours, ideally within the week. Ask about alcohol quantity and use an AUDIT-C; the drinking is both a maintaining factor for insomnia and a risk amplifier.
Refusal of psychiatry. Respect it, but make a concrete offer (a referral letter he can use, a phone number, an appointment he can cancel), and document that it was offered and declined. If risk escalates, that position changes.
Document the reasoning, not just the conclusion - what was asked, what he said, what the safety plan contains.
2. What is your approach to the zopiclone request and to his fitness to drive?
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The prescription. Cognitive behavioural therapy for insomnia is first-line and should be offered with a realistic explanation of why it beats a hypnotic. Zopiclone has genuine harms here: dependence with dose escalation, next-day impairment, interaction with alcohol, and possible contribution to early waking and low mood. A three-month supply to a distressed man who is doubling the dose and drinking is not safe. A short, tapering dispense - small quantity, with a written tapering plan and review - is defensible; a repeat of three months is not. Do not abruptly stop a nightly Z-drug in someone who may be dependent without a plan; taper and monitor.
Fitness to drive. Sedating medication, alcohol, and untreated moderate-to-severe depression each independently impair driving, and his livelihood depends on it. I would say plainly that he should not drive while sedated and should not drive after drinking, explain why, and record the advice. If I judged him currently unfit to drive, that would have to be reflected honestly in any licence medical - a vocational licence protects the public, not the driver's income. I would prefer to negotiate a short period of daytime-only work or leave, which is more acceptable than an outright "unfit". If he refuses and continues driving impaired, my duty to public safety can override confidentiality, and I would tell him that before taking that step.
Insomnia and shift work. Practical behavioural advice - a fixed sleep window, light exposure, no caffeine before the shift end - will achieve more than any tablet.
3. How do you respond to his request that the depression not appear in the record?
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The request. He is asking me to remove the very information that makes the prescribing safe and the risk management possible. I would separate the parts he is really worried about: the employer or licensing authority seeing a diagnosis, and being judged. If the concern is licence-related, the answer may partly reassure him - his medical record is confidential, and a licensing body receives only what he consents to disclose, usually a fitness opinion, not the full notes.
Why I cannot comply. Records must be complete, accurate and contemporaneous; a record that omits a diagnosis the doctor acted on is falsified, and the next clinician would prescribe without knowing the risk. An incomplete record also exposes him to harm: if a future doctor restarts a sedative not knowing about his low mood, the consequences fall on him.
What I can offer. Strictly controlled access to the notes; a summary letter he can read before it is sent anywhere; sharing only the minimum with any third party, with his written consent; and a clear statement that his consultations are not reported to his employer or the traffic authorities unless the public safety threshold is met. Being explicit about the exceptions builds more trust than a vague promise of secrecy.
If he insists. I would not accede, and I would explain that refusal is about his safety rather than about rules. Record his request and my response, and the discussion about confidentiality limits.
Close the loop. Confirm the follow-up date, the tapering plan, the crisis numbers and the safety plan in writing, and confirm he understands.