What is the appropriate management plan for a patient with bipolar disorder (F31.2), generalized anxiety disorder (F41.1), and suicidal ideation, currently on Buspar (buspirone) 10 mg TID, Lithium (lithium carbonate) 150 mg BID, Benztropine (benztropine mesylate) 1 mg BID, and MacroBid (nitrofurantoin)?

From the Guidelines

The patient requires continued inpatient psychiatric hospitalization with a focus on stabilizing her bipolar disorder, addressing her suicidal ideation, and potentially reconsidering hormone replacement therapy, as supported by the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines 1.

Current Situation

The patient is a woman with bipolar disorder who was hospitalized following a suicide attempt by self-strangulation. She has a history of multiple psychiatric hospitalizations and expresses wanting to "be done with life." Her current medication regimen includes Buspar 10 mg three times daily, Lithium 150 mg twice daily (recently started), Benztropine 1 mg twice daily, and MacroBid twice daily.

Key Considerations

• The patient's history of multiple psychiatric hospitalizations and recent suicide attempt indicate a high risk for future suicidal behavior.
• The patient's bipolar disorder, generalized anxiety, and PTSD require comprehensive management to reduce her risk of suicide.
• The use of lithium may reduce the risk for suicide in patients with unipolar depression or bipolar disorder, as supported by several cohort studies and systematic reviews 1.
• Cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) have been shown to be effective in reducing suicidal ideation and behavior in patients with a history of self-directed violence 1.

Treatment Plan

• Continue inpatient psychiatric hospitalization for at least 72 hours to ensure the patient's safety and stabilize her condition.
• Implement suicide watch protocol and daily assessment of suicidal ideation to closely monitor the patient's risk.
• Review and optimize the patient's current medication regimen, considering the potential benefits of lithium in reducing suicidal risk.
• Provide CBT or DBT to address the patient's suicidal ideation and behavior, as well as her underlying psychiatric conditions.
• Consider reconsidering hormone replacement therapy in consultation with specialists, given the patient's history of hormone replacement therapy and potential impact on her mood and suicidal risk.
• A probiotic supplement has also been recommended to support the patient's overall health and well-being.

From the Research

Assessment and Recommendations

The patient's current condition and history of bipolar disorder, suicidal ideation, and previous suicide attempts require careful consideration and management. Based on the provided evidence, the following points are relevant:

• The patient's risk of suicide is high, and inpatient psychiatric hospitalization is necessary to ensure her safety 2, 3.
• Lithium has been shown to be effective in reducing suicide risk in patients with bipolar disorder, and its use is recommended as a first-line treatment 3, 4, 5.
• The patient's medication regimen should be reviewed and optimized, and lithium should be considered as a potential addition to her treatment plan 3, 4, 5.
• Close monitoring and daily assessment of suicidal ideation are crucial to prevent future suicide attempts 2, 3.
• The patient's history of trauma or abuse should be further explored, and appropriate interventions should be provided to address any underlying factors contributing to her suicidal thoughts 2, 3.
• Cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT) may be beneficial in reducing suicide risk and improving the patient's mental health outcomes 2, 6.

Treatment Plan

The patient's treatment plan should include:

• Continued inpatient psychiatric hospitalization for at least 72 hours to ensure her safety and stabilize her condition.
• Implementation of suicide watch protocol and daily assessment of suicidal ideation.
• Review and optimization of her medication regimen, including consideration of lithium as a potential addition to her treatment plan.
• Provision of psychoeducation on bipolar disorder and medication adherence.
• Exploration of underlying factors contributing to her suicidal thoughts and provision of appropriate interventions.
• Consideration of CBT or DBT as adjunctive therapies to reduce suicide risk and improve mental health outcomes.

Medications

The patient is currently taking:

• Buspar 10 mg TID
• Lithium 150 mg BID (started 5/16)
• Benztropine 1 mg BID
• MacroBid BID The patient's medication regimen should be reviewed and optimized, and lithium should be considered as a potential addition to her treatment plan 3, 4, 5.