Self-inflicted burns with depression and evolving PTSD risk (MEQ)

(i) Assessment domains. Mechanism and intent; current and lifetime psychiatric history; substance use; pain and sleep; trauma symptoms (intrusions, avoidance, hyperarousal); mood and anhedonia; suicide risk; body-image concerns emerging; social support and discharge environment; MSE with attention testing; collateral from family and burn team; capacity for the specific graft procedure after disclosure.[1][3][5]

(ii) Suicide and intentional injury. Clarify planning, intent at injury vs now, residual access to means, protective factors, command hallucinations, prior attempts, and impulsivity/substance facilitation. Self-inflicted burns are enriched for major psychiatric illness and can carry larger TBSA — treat as high-stakes risk work, not a moral label. Observation level and legal options follow local criteria without inventing statute numbers.[1][2]

(iii) Differential tracks. Delirium: acute fluctuating inattention, often pain/infection/drug driven — screen systematically. Trauma symptoms: nightmares of fire may be early ASD pathway after major burns. Depression: anhedonia and SI as treatable morbidity, not 'understandable so ignore.' These can coexist; do not collapse into one label.[3][4]

(iv) Management and capacity. Optimise analgesia overnight (pain is psychiatric care); treat depression; trauma-informed explanation of procedures; 1:1 or appropriate observation if risk high; involve psychology. Capacity is decision-specific (understand, appreciate, reason, communicate) after material disclosure of grafting risks/benefits; support decision-making; emergency necessity only if incapacity and serious harm under local law. Document residual risk and ongoing C-L plan — not a one-off 'cleared' stamp.[3][5]

(v) Evidence anchors. Examples: Atwell self-inflicted burns in major psychiatric illness; Smith suicide by burning series; McKibben prospective ASD/PTSD after major burns; Thombs depression systematic review; Appelbaum capacity framework; PADIS/CAM-ICU for ICU interface if ventilated.[1][2][3][4][5]