What is the plan of care for a patient with major depressive disorder, post-traumatic stress disorder, and borderline personality disorder, who recently attempted suicide and is currently being treated with Pristiq (desvenlafaxine)?

From the Guidelines

The client should remain at the higher level of care (HP LOC) with 15-minute safety checks due to the inability to assess suicide risk, and the treatment team should prioritize a comprehensive care plan focused on safety and stabilization. This approach is supported by the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines, which emphasize the importance of accurate risk stratification and appropriate level of care for patients at risk for suicide 1. The client's history of depression, PTSD, and borderline personality disorder, as well as recent suicidal ideation and self-harm behavior, necessitate a cautious and thorough approach to treatment.

Key components of the care plan should include:

• Continuing the current medication regimen (Pristiq) with close monitoring for effectiveness and side effects
• Conducting daily assessments of mental status, particularly for suicidal ideation, with documentation of any changes in behavior or communication
• Gentle attempts to engage the client using trauma-informed approaches, offering alternative communication methods like writing or drawing if verbal communication remains difficult
• Addressing the client's vegetarian dietary needs and exploring the possibility of autism spectrum disorder through formal assessment when the client is more stable
• Considering alternative approaches, such as cognitive behavioral therapy (CBT) or dialectical behavior therapy (DBT), which have been shown to reduce suicidal ideation and behavior in patients with similar diagnoses 1.

The treatment team should prioritize the client's safety and well-being, while also working to re-establish communication and address the underlying mental health conditions. By taking a comprehensive and cautious approach, the team can help reduce the client's risk for suicide and improve their overall quality of life.

From the FDA Drug Label

The pooled analyses of placebo-controlled studies in adults with MDD or other psychiatric disorders included a total of 295 short-term studies (median duration of 2 months) of 11 antidepressant drugs in over 77,000 patients. All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases

The client's plan of care should include:

• Close monitoring of the client's mental status, behavior, and suicidal ideation
• Regular assessment of the client's response to medication, including Pristiq
• Collaboration with the treatment team to adjust the treatment plan as needed
• Education of the client and their family members about the importance of monitoring for suicidal ideation and unusual changes in behavior
• Consideration of the client's history of self-harming behavior and recent overdose, and the potential risks associated with antidepressant therapy 2
• Monitoring for potential side effects of desvenlafaxine, including serotonin syndrome, elevated blood pressure, and hyponatremia 2

From the Research

Plan of Care

• The client has been diagnosed with major depressive disorder, generalized anxiety disorder, borderline personality disorder, and post-traumatic stress disorder (PTSD) 3, 4.
• The client is currently being treated with Pristiq, which targets serotonin, norepinephrine, and dopamine, and has shown no significant effects or adverse reactions yet.
• The plan includes continuing Pristiq, monitoring its efficacy, and considering combination treatment with TMS and Spravato.
• The client's possible autism spectrum disorder (ASD) has been noted, and studies have shown that medications such as venlafaxine can be effective in treating symptoms of ASD, including self-injurious behaviors and aggression 5, 4.
• The client's history of self-harming behavior and recent suicide attempt by overdose have been taken into account, and the plan includes ongoing monitoring of suicidal ideation and behavior.
• The client's vegetarian diet and possible ASD have been noted, and studies have shown that medications such as desvenlafaxine can be effective in treating major depressive disorder, with a similar rate of response and remission to other SNRIs 6.

Medication Management

• The client is currently being treated with Pristiq, and the plan includes monitoring its efficacy and considering combination treatment with TMS and Spravato.
• Studies have shown that esketamine can be effective in treating treatment-resistant depression, with a significant reduction in depression symptoms, although with tolerability issues 7.
• The client's possible ASD has been noted, and studies have shown that medications such as venlafaxine can be effective in treating symptoms of ASD, including self-injurious behaviors and aggression 5, 4.

Safety Precautions

• The client's history of self-harming behavior and recent suicide attempt by overdose have been taken into account, and the plan includes ongoing monitoring of suicidal ideation and behavior.
• The client will be closely monitored for any changes in mood or behavior, and the treatment plan will be adjusted as needed to ensure the client's safety.