What is the best course of action for a female patient with bipolar affective disorder presenting with suicidal ideation, increased depression, poor self-care, poor hygiene, and intermittent psychosis, currently taking Lithium (lithium) 900mg, Wellbutrin (bupropion), Remeron (mirtazapine), Klonopin (clonazepam), Propranolol (propranolol), and Rexulti (brexpiprazole)?

Management of Bipolar Disorder with Suicidal Ideation and Breakthrough Depression

This patient requires immediate hospitalization for safety given active suicidal ideation, and her current regimen needs urgent optimization—specifically, her lithium level should be verified as truly therapeutic (0.8-1.2 mEq/L), the antidepressant combination (Wellbutrin + Remeron) should be carefully evaluated for potential mood destabilization, and Klonopin should be tapered given its disinhibiting risk in suicidal patients. 1, 2, 3

Immediate Safety Interventions

Hospitalization is indicated for this patient presenting with active suicidal ideation, worsening depression, and functional decline (poor self-care/hygiene). 4, 3

• Remove access to lethal means including all medications from the home, with explicit instructions to family members about firearm removal and securing all potentially lethal substances. 4
• Avoid "no-suicide contracts" as they have no empirical evidence supporting efficacy and may create false reassurance—vigilance must remain high regardless of any verbal agreements. 4, 3
• Establish third-party medication monitoring where a responsible family member or caretaker controls and dispenses all medications, reporting any behavioral changes, increased agitation, or side effects immediately. 4, 2, 3

Critical Medication Review and Optimization

Lithium Assessment

• Verify the actual serum lithium level is truly therapeutic (0.8-1.2 mEq/L for acute treatment). Lithium at 900 mg may not achieve adequate levels depending on renal function, body weight, and individual pharmacokinetics. 1
• Lithium remains the cornerstone of treatment given its specific anti-suicidal properties that reduce both suicide attempts and completed suicides in bipolar disorder—this should be maintained and optimized. 4, 1, 2

Antidepressant Concerns

• The combination of two antidepressants (Wellbutrin + Remeron) without adequate mood stabilization is problematic and may be contributing to mood instability, rapid cycling, or the intermittent psychotic episodes. 1, 2, 5
• Antidepressants should never be used as monotherapy or in excessive combinations in bipolar disorder as they can trigger manic/mixed episodes or worsen rapid cycling. 1, 5, 6
• Consider tapering one antidepressant (likely Remeron first) while ensuring lithium is optimized, as bupropion (Wellbutrin) is generally preferred when an antidepressant is needed in bipolar depression. 7, 5

Benzodiazepine Risk

• Klonopin (clonazepam) should be tapered and discontinued as benzodiazepines may reduce self-control and potentially disinhibit individuals, leading to increased aggression or suicide attempts in vulnerable patients. 4, 1, 2, 3
• Propranolol can be maintained for anxiety/akathisia management as it lacks the disinhibiting properties of benzodiazepines. 4

Antipsychotic Optimization

• Rexulti (brexpiprazole) is appropriate for the intermittent psychotic symptoms, though the dose should be reviewed to ensure adequacy. 1
• Consider switching to or augmenting with olanzapine (7.5-10 mg/day) if psychotic symptoms or mood instability persist, as it has stronger evidence for bipolar depression with psychotic features. 1, 8, 5

Recommended Treatment Algorithm

Phase 1: Acute Stabilization (Hospital Setting)

1. Optimize lithium to therapeutic levels (0.8-1.2 mEq/L), increasing dose as needed with monitoring every 3-5 days. 1, 2
2. Begin tapering Klonopin using a gradual schedule to avoid withdrawal. 4, 2
3. Reduce antidepressant burden by tapering Remeron while maintaining Wellbutrin if depression remains severe. 7, 5
4. Consider adjunctive olanzapine (7.5-10 mg/day) if Rexulti is insufficient for psychotic symptoms or mood stabilization. 1, 8

Phase 2: If Inadequate Response After 2-3 Weeks

• Add divalproex (valproate) to lithium, creating the lithium-divalproex combination that serves as the foundation for treatment-resistant bipolar depression. 1, 8, 7
• Consider lamotrigine as an alternative or additional mood stabilizer, particularly given its specific efficacy in bipolar depression (titrate slowly to avoid rash). 7, 5, 6

Phase 3: Rapid Intervention Options for Persistent Suicidality

• Ketamine infusion (0.5 mg/kg IV over 40 minutes) can provide rapid reduction in suicidal ideation within 24 hours if symptoms remain severe despite medication optimization. 1, 3
• Electroconvulsive therapy (ECT) should be considered for severe, treatment-refractory depression with acute suicidal risk, though effects may take 1-2 weeks. 1

Essential Psychosocial Interventions

• Cognitive-behavioral therapy (CBT) focused on suicide prevention should be initiated immediately and has been shown to reduce suicidal ideation and cut suicide attempt risk by half. 4, 2, 3
• Dialectical behavior therapy (DBT) is an alternative evidence-based option combining CBT with skills training in emotion regulation and distress tolerance. 4, 2, 3
• Family psychoeducation through multi-family groups should be provided to enhance support systems and improve treatment adherence. 4
• Develop a collaborative crisis response plan identifying warning signs, coping skills, social support contacts, and crisis resources. 3

Monitoring and Follow-Up

• Schedule closely-spaced follow-up appointments (at least weekly initially) with the treating clinician remaining constant for at least 18 months to ensure continuity of care. 4, 2
• The clinician must be available outside regular hours or ensure adequate coverage for crisis situations. 4, 2
• Monitor systematically for suicidal ideation at every visit, particularly during medication changes or dose adjustments. 1, 2
• Watch for early warning signs of relapse including sleep changes, increased irritability, or emerging psychotic symptoms, as relapses are common in the first few years. 4
• Send periodic caring communications (postal mail or text messages) for 12 months following hospitalization to maintain therapeutic connection. 3

Critical Pitfalls to Avoid

• Never rely on verbal agreements about safety as a substitute for clinical vigilance and environmental safety measures. 4, 3
• Avoid prescribing medications with high lethality in overdose (tricyclic antidepressants) given active suicidal ideation. 4, 2, 3
• Do not discharge to primary care without continuing specialist involvement during the critical early years of treatment. 4
• Recognize that insight improvement can paradoxically increase suicide risk as patients become more aware of their illness burden—enhance coping strategies proactively. 9