Management of Acute Stress Reaction with Depressive and Anxiety Symptoms Following Domestic Violence
This patient requires immediate psychiatric referral for comprehensive mental health assessment and initiation of pharmacotherapy, given the presence of recent suicidal ideation, significant functional impairment (work resignation), acute stress reaction with breakdown, and multiple high-risk factors including domestic violence history and social isolation.
Immediate Safety Assessment and Risk Stratification
Conduct immediate suicide risk assessment using structured questioning about current suicidal thoughts, plans, means, and intent, as patients with depression and recent suicidal ideation during counseling represent an emergency requiring same-day psychiatric evaluation 1.
Assess for harm to self or others immediately - any endorsement of current suicidal thoughts, severe depression with agitation, psychosis, or confusion requires emergency psychiatric consultation or emergency department referral 1.
Document the recent suicidal ideation that occurred during the second counseling session, even though currently denied, as this represents a critical risk factor requiring ongoing monitoring 2.
Formal Screening and Diagnostic Assessment
Administer the PHQ-9 (Patient Health Questionnaire-9) to quantify depression severity, as this validated tool provides reportable scores with established clinical cutoffs and should be used at initial presentation 1, 3.
Administer the GAD-7 (Generalized Anxiety Disorder-7) to assess anxiety severity, as this is the recommended screening tool for anxiety disorders in primary care 1.
Screen for PTSD symptoms given the history of emotional domestic violence, recent triggering event (ex-partner visit), and return of traumatic memories, as trauma history significantly increases distress risk 1.
Recognize this patient has multiple high-risk factors for severe distress: younger age (35 years), female gender, having young children, prior emotional abuse, social isolation (no friends, limited support), and acute functional impairment 1.
Immediate Referral Requirements
Refer immediately to a psychiatrist or licensed mental health professional for comprehensive diagnostic assessment and treatment initiation, as the combination of recent suicidal ideation, acute breakdown, significant weight loss, sleep disturbance, and functional impairment (immediate work resignation) indicates moderate to severe distress requiring specialist care 1.
Do not attempt to manage this patient solely in primary care given the complexity of presentation including recent suicidal thoughts, trauma history, acute crisis, and lack of social support 1.
Facilitate urgent psychiatric appointment within 48-72 hours and provide crisis contact numbers (suicide hotline, emergency services) for interim safety 1.
Continue the existing EAP counseling while awaiting psychiatric evaluation, ensuring the counselor is aware of the current clinical status and safety concerns 1.
Pharmacotherapy Considerations for Psychiatric Referral
SSRI initiation should be considered by the psychiatrist as first-line pharmacotherapy for depression and anxiety, with sertraline or escitalopram being appropriate choices given their favorable side-effect profiles 3, 2.
Monitor closely for worsening depression, suicidal ideation, or unusual behavioral changes during the first few months of antidepressant treatment or with dose changes, as SSRIs carry a black box warning for increased suicidal thoughts in young adults 2.
Avoid benzodiazepines despite the acute anxiety and sleep disturbance, as these medications carry risks of dependence, cognitive impairment, and do not address the underlying depression 3.
Target therapeutic SSRI dosing (e.g., sertraline 50-200mg daily or escitalopram 10-20mg daily) rather than subtherapeutic doses, with reassessment at 6-8 weeks before declaring treatment failure 3, 2.
Concurrent Non-Pharmacologic Interventions
Implement trauma-focused cognitive behavioral therapy (CBT) through the psychiatric referral, as this addresses both the acute stress reaction and underlying trauma from domestic violence 1.
Provide structured problem-solving therapy to address the immediate stressors including unemployment, financial concerns, childcare arrangements, and social isolation 1, 3.
Establish behavioral activation strategies to counter depressive withdrawal, including structured daily activities, sleep hygiene protocols (consistent bedtime before midnight, sleep environment optimization), and gradual return to routine 1, 3.
Connect with domestic violence support services for specialized counseling, safety planning, legal advocacy, and peer support groups for survivors of emotional abuse 1.
Social Support and Safety Planning
Develop a crisis safety plan that includes warning signs of worsening symptoms, coping strategies, reasons for living, emergency contacts (including the one supportive relative), and crisis hotline numbers 1.
Address social isolation urgently by connecting with community resources, support groups for domestic violence survivors, single parent support networks, and exploring childcare assistance programs 1.
Assess housing stability and financial resources given the immediate work resignation, and provide referrals to social services for income support, housing assistance, and food security if needed 1.
Evaluate child safety and wellbeing, particularly regarding the children's contact with the ex-partner who triggered the recent crisis, and consider child protective services consultation if concerns arise 1.
Medical Certificate and Work Documentation
Provide a medical certificate for stress-related leave documenting acute stress reaction and recommending time off work (suggest 2-4 weeks initially with reassessment), as the patient is currently unable to function in a customer service role requiring emotional regulation 4.
Avoid premature return to work until psychiatric treatment is established, symptoms stabilize, and functional capacity improves, as returning too early risks worsening the crisis 4.
Document the work-related stress component while recognizing the underlying domestic violence trauma as the primary driver, to support any disability or employment protection claims 4.
Monitoring and Follow-Up Schedule
Schedule follow-up within 1 week to reassess safety, confirm psychiatric appointment attendance, review crisis plan effectiveness, and monitor for treatment-emergent suicidal ideation 1, 3.
Use the same screening tools (PHQ-9, GAD-7) at each visit to track symptom trajectory and treatment response consistently 1, 3.
Monitor weight weekly given the documented weight loss, as continued decline may indicate inadequate treatment response or need for nutritional intervention 3.
Assess sleep patterns at each visit using specific questions about sleep onset time, number of awakenings, total sleep duration, and daytime functioning 3.
Continue biweekly monitoring until symptoms remit to mild range, then transition to monthly follow-up for maintenance phase 3.
Critical Pitfalls to Avoid
Do not minimize the recent suicidal ideation simply because it is currently denied - this represents a significant risk factor requiring ongoing vigilance and specialist involvement 2.
Do not delay psychiatric referral by attempting prolonged primary care management alone, as the complexity and severity of this presentation exceed primary care scope 1.
Do not prescribe benzodiazepines for the acute anxiety and insomnia despite patient distress, as these create dependence risk and do not address the underlying mood disorder 3.
Do not overlook the trauma component - this is not simple adjustment disorder but rather acute stress reaction with depressive and anxiety features in the context of domestic violence trauma requiring specialized treatment 1.
Do not allow the patient to remain socially isolated - actively facilitate connections to support services and peer support, as isolation significantly worsens prognosis 1.
Do not restart work prematurely before psychiatric stabilization, as this risks acute decompensation and potential safety concerns in a customer-facing role 4.