Does a client experiencing suicidal ideation, intense anxiety, and feelings of worthlessness due to perceived mistakes at work, warrant a diagnosis of major depressive disorder (MDD) with impaired coping mechanisms?

From the Guidelines

The client requires immediate intervention with a comprehensive treatment approach combining cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT) skills training, and psychiatric evaluation for possible medication to address suicidal ideation and underlying depression. The client's narrative of being a "bad person" for making mistakes indicates severe cognitive distortions that escalate to suicidal ideation, suggesting severe depression with possible borderline personality features 1. For immediate intervention, the client should learn distress tolerance techniques such as the TIPP skill (Temperature change, Intense exercise, Paced breathing, Progressive muscle relaxation) to interrupt acute distress episodes.

A safety plan should be established immediately, including crisis hotline numbers (988 Suicide & Crisis Lifeline) and identified support persons, as supported by a meta-analysis of safety planning-type interventions for suicide prevention, which found a significant reduction in suicidal behavior 1. The safety plan should involve a collaborative approach between the client and clinician, including identification of clear signs of crisis, self-management skills, and social support, as outlined in the study by Bryan and colleagues 1.

For medication, an SSRI such as sertraline (starting at 50mg daily, potentially increasing to 100-200mg) or escitalopram (10-20mg daily) could address underlying depression, while low-dose quetiapine (25-50mg) might help manage acute anxiety episodes. Therapy should focus on challenging the core belief of being "bad" through cognitive restructuring, developing self-compassion practices, and building distress tolerance. Regular therapy sessions (weekly for at least 3-6 months) combined with medication management appointments every 2-4 weeks initially would provide the structure needed. This approach addresses both immediate safety concerns and long-term cognitive patterns that maintain the client's distress cycle.

Key components of the treatment plan include:

• Immediate establishment of a safety plan with crisis hotline numbers and identified support persons
• Distress tolerance techniques such as TIPP skills
• Cognitive-behavioral therapy (CBT) to challenge core beliefs and cognitive distortions
• Dialectical behavior therapy (DBT) skills training for emotion regulation and distress tolerance
• Psychiatric evaluation for possible medication, including SSRIs and low-dose quetiapine
• Regular therapy sessions and medication management appointments to provide structure and support.

From the FDA Drug Label

Suicide is a known risk of depression and certain other psychiatric disorders, and these disorders themselves are the strongest predictors of suicide. The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have been reported in adult and pediatric patients being treated with antidepressants for major depressive disorder as well as for other indications, both psychiatric and nonpsychiatric Although a causal link between the emergence of such symptoms and either the worsening of depression and/or the emergence of suicidal impulses has not been established, there is concern that such symptoms may represent precursors to emerging suicidality Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse, or who are experiencing emergent suicidality or symptoms that might be precursors to worsening depression or suicidality, especially if these symptoms are severe, abrupt in onset, or were not part of the patient’s presenting symptoms.

The client is experiencing suicidal thoughts and severe emotional distress. The FDA drug label for fluoxetine 2 indicates that suicidality is a known risk of depression and certain other psychiatric disorders. The label also notes that antidepressants may increase the risk of suicidal thinking and behavior in certain patients, especially during the early phases of treatment.

• The client's symptoms, including anxiety, fear, and worthlessness, may be precursors to emerging suicidality.
• The client's lack of coping skills and severe emotional distress may increase the risk of suicidality.
• Close monitoring of the client's symptoms and adjustment of the therapeutic regimen may be necessary to prevent worsening depression or suicidality.

From the Research

Client's Thoughts and Behaviors

• The client experiences thoughts of being worthless and disliked when making mistakes at work, which can spiral into believing death is the only way out of emotional pain 3.
• The client freezes with fear and anxiety in these moments and lacks good coping skills to manage distress.
• The client's narrative is that she is a "bad person" for making mistakes.

Potential Interventions

• Individual cognitive behavioral therapy (CBT)-based psychotherapy may reduce repetition of self-harm as compared to treatment-as-usual (TAU) or another comparator 3.
• Dialectical behavior therapy (DBT) may lead to a reduction in frequency of self-harm, although the evidence remains uncertain 3.
• Mentalisation-based therapy (MBT) reduces repetition of self-harm and frequency of self-harm by the post-intervention assessment 3.
• Group-based emotion-regulation psychotherapy may also reduce repetition of self-harm by the post-intervention assessment 3.
• Combining selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy (CBT) consistently produces greater improvement than either treatment alone for youth with depression and anxiety 4, 5, 6.

Considerations for Treatment

• The combination of fluoxetine with CBT offered the most favorable tradeoff between benefit and risk for adolescents with major depressive disorder 5.
• The additive benefit of CBT over SSRI monotherapy was not statistically significant until week 12 of treatment 6.
• Response to combined treatment varies across disorders (anxiety versus depression) and by specific patient characteristics, such as age, baseline symptoms, and depressive disorders 6.