Does a client experiencing suicidal ideation, intense anxiety, and feelings of worthlessness due to perceived mistakes at work, indicating possible major depressive disorder (MDD) with inadequate coping mechanisms, require immediate psychiatric evaluation?

From the Guidelines

The client requires immediate intervention through cognitive behavioral therapy (CBT) combined with possible medication management to address the suicidal ideation and cognitive distortions. I recommend a dual approach of weekly CBT sessions for 12-16 weeks to address the catastrophic thinking patterns and negative self-schema, alongside an evaluation for antidepressant medication such as sertraline (starting at 50mg daily, potentially increasing to 100-200mg as tolerated) or escitalopram (10mg daily) 1. For immediate coping skills, the client should implement a distress tolerance plan including grounding techniques (5-4-3-2-1 sensory awareness exercise), deep breathing (4-7-8 method), and thought challenging worksheets to interrupt the spiral of negative thoughts. The client should also establish a safety plan with identified support persons to contact when experiencing suicidal thoughts, and keep crisis resources readily available (National Suicide Prevention Lifeline: 988) 1. Given the client's risk of harm to themselves, it is essential to facilitate a safe environment, provide one-to-one observation, and initiate interventions to reduce the risk of harm to themselves, as outlined in the American Society of Clinical Oncology guideline adaptation 1. The catastrophic thinking pattern where mistakes escalate to thoughts of worthlessness and suicidality suggests deeply ingrained negative core beliefs that are activated by perceived failures, and responds well to cognitive restructuring techniques that help separate performance from self-worth and develop more balanced self-evaluation skills. Some key points to consider in the management of this client include:

• The use of dialectical behavior therapy (DBT) to reduce suicidal ideation and behavior, particularly in patients with borderline personality disorder 1
• The implementation of a crisis response plan, which involves a collaborative approach between the patient and clinician to identify clear signs of crisis, self-management skills, and social support 1
• The potential benefits of problem-solving therapy in improving one's ability to cope with stressful life experiences through active problem solving 1
• The importance of screening for suicide risk using tools such as the Patient Health Questionnaire-9 (PHQ-9) item 9 and the Columbia-Suicide Severity Rating Scale (C-SSRS) 1

From the FDA Drug Label

Patients with major depressive disorder (MDD), both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior, whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs A major depressive episode (DSM–IV) implies a prominent and relatively persistent (nearly every day for at least 2 weeks) depressed or dysphoric mood that usually interferes with daily functioning, and includes at least 5 of the following 9 symptoms: depressed mood, loss of interest in usual activities, significant change in weight and/or appetite, insomnia or hypersomnia, psychomotor agitation or retardation, increased fatigue, feelings of guilt or worthlessness, slowed thinking or impaired concentration, a suicide attempt or suicidal ideation.

The client's symptoms, including thoughts of being worthless and disliked, and suicidal ideation, are consistent with a major depressive episode. The FDA drug label for fluoxetine 2 indicates that patients with major depressive disorder may experience worsening of their depression and/or the emergence of suicidal ideation and behavior. The client's narrative of being a "bad person" for making mistakes and her thoughts spiraling into believing death is the only way out of her emotional pain suggest a high risk of suicidality.

• The client's symptoms meet the criteria for a major depressive episode, including feelings of guilt or worthlessness and suicidal ideation.
• The FDA drug label for fluoxetine 2 warns of the risk of worsening depression and suicidality in patients with major depressive disorder.
• The client's lack of good coping skills to manage her distress and her freezing with fear and anxiety in these moments suggest a need for close monitoring and observation for clinical worsening, suicidality, and unusual changes in behavior.

From the Research

Client's Thoughts and Emotions

• 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, 4.
• These thoughts are accompanied by feelings of fear and anxiety, and the client freezes in these moments, lacking good coping skills to manage distress.
• The client's narrative is that she is a "bad person" for making mistakes, indicating a negative self-image and self-criticism.

Treatment Options

• Cognitive Behavioral Therapy (CBT) and Selective Serotonin Reuptake Inhibitors (SSRIs) are considered effective treatments for anxiety and depression in children and adolescents 3, 4, 5.
• Combining CBT and SSRIs may produce greater improvement than either treatment alone, especially for patients with mild baseline symptoms and depressive disorders 3, 5.
• CBT is associated with lower attrition rates and may be a preferred treatment option for some patients 4.

Management of Agitation and Distress

• Early recognition and treatment of underlying etiology, rapid control of behavior, and prevention of harm to the patient and personnel are crucial in managing agitation 6.
• Validated techniques such as frequent reality orientation, validation therapy, and strategies to improve quality of life can be effective in calming agitated patients 6.

Considerations for Treatment

• Patient characteristics, such as age, sex, and baseline symptom severity, can influence treatment response and should be considered when devising a treatment plan 3, 4, 5.
• The presence of psychiatric comorbidities can affect treatment outcomes, and patients with multiple comorbidities may require more tailored treatment approaches 7.