What treatment plan is most appropriate for managing situational depression, anxiety, and suicidal ideation in a patient with a complex psychiatric history?

Treatment Plan for Situational Depression, Anxiety, and Suicidal Ideation

Immediate Safety Assessment and Crisis Management

This patient requires immediate implementation of a collaborative crisis response plan and close monitoring given her active suicidal ideation, even without intent. 1

• Conduct a thorough suicide risk assessment focusing on frequency and intensity of suicidal thoughts (currently present as "thoughts in the back of her mind"), access to lethal means, social support quality, and her history of suicide attempt at age 12. 1
• Remove access to lethal means immediately: All medications should be removed from her direct access, including the St. John's wort, NiteLean, and any other supplements that could be used in overdose. 2 Given her history of overdose attempt, this is non-negotiable.
• Establish third-party medication monitoring: A responsible family member must control and dispense all medications, reporting any behavioral changes, increased agitation, or worsening mood immediately. 1, 2
• Develop a written crisis response plan that includes: identification of warning signs (increased rumination, alcohol use, isolation), self-management coping skills she's already using (journaling, podcasts), social support contacts (family, ex-husband, crisis hotline), and emergency resources including the 988 Suicide & Crisis Lifeline. 1

Critical pitfall to avoid: Do not use "no-suicide contracts" or verbal agreements about safety—these have no empirical evidence supporting efficacy and create false reassurance. 2, 3

Pharmacological Intervention

Initiate an SSRI immediately as first-line pharmacological treatment for her depression with suicidal ideation. 1, 3

• Start sertraline 50 mg daily or escitalopram 10 mg daily, as SSRIs have the best evidence for treating depression with suicidal features and have low lethality in overdose. 1, 3, 4
• Discontinue St. John's wort immediately due to potential serotonin syndrome risk when combined with SSRIs and lack of evidence for efficacy in her case. 4
• Avoid benzodiazepines entirely—do not prescribe any anxiolytics from this class as they may increase disinhibition or impulsivity and could worsen suicidal behavior. 1, 3
• Prescribe only small quantities (7-14 days maximum) of medication at a time to reduce overdose risk, with the third-party monitor controlling dispensing. 4

Monitor closely for activation symptoms during the first 4-8 weeks: anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, or mania. These may represent precursors to emerging suicidality. 4

Psychotherapy: The Primary Treatment Modality

Initiate cognitive behavioral therapy (CBT) focused on suicide prevention immediately—this is the most critical intervention. 5, 1

• CBT focused on suicide prevention has been shown to reduce suicidal ideation and cut the risk of suicide attempts by half compared to treatment as usual. 1 This should begin within the next week, not "in a couple of weeks."
• Sessions should occur weekly initially, addressing her ruminative thoughts about the breakup, cognitive distortions about relationships, and developing healthier coping strategies beyond alcohol use and past promiscuous behavior. 5, 1
• Problem-solving therapy should be integrated to help her cope with the acute stressor (breakup) and improve her ability to manage life stressors without catastrophizing. 1
• Dialectical behavior therapy (DBT) is an alternative evidence-based option that combines CBT with skills training in emotion regulation, interpersonal effectiveness, and distress tolerance—particularly relevant given her pattern of relationship difficulties and emotional dysregulation. 1, 2

The evidence shows that trauma-focused treatments (addressing her childhood trauma, turbulent relationship with mother, father's death) can be safely implemented without a prolonged stabilization phase, contrary to older recommendations. 5 However, given her acute crisis, initial focus should be on suicide prevention and current stressors before addressing historical trauma.

Substance Use Intervention

Address her problematic alcohol use pattern immediately as it significantly increases suicide risk. 6

• Her pattern of "going hard" 2-3 times monthly with mixed alcohol (beer, whiskey, vodka, rum) that makes her "sad or angry" is dangerous in the context of suicidal ideation. 6
• Recommend complete alcohol abstinence during this acute crisis period (minimum 3 months) as alcohol is a depressant that worsens mood and increases impulsivity. 6
• Her nicotine vaping and occasional Delta-8/CBD use are less concerning but should be monitored; consider these as harm reduction compared to her previous cigarette smoking. 6

Follow-Up and Monitoring Schedule

Schedule weekly appointments for the first month, then bi-weekly for the next two months. 1, 3

• You must be available outside regular hours or ensure adequate coverage for crisis situations—provide her with your emergency contact protocol. 3
• If she misses an appointment, contact her immediately by phone to assess safety. 1
• Send periodic caring communications (text messages or brief emails) between appointments for the next 12 months, as this intervention reduces suicide attempt risk following crisis. 5, 1
• Monitor systematically for suicidal ideation at every visit, particularly during the first 8 weeks of SSRI treatment when activation symptoms may emerge. 4

Addressing Her Support System Limitations

Strengthen her social support network actively rather than passively recommending it. 6

• Her reliance on her ex-husband for counsel, while her family finds it "strange," may actually be protective if he provides genuine support. Don't discourage this unless it becomes problematic. 6
• Connect her with structured support: Facilitate referral to a depression support group or grief support group (given she's comparing this breakup to her father's death). 6
• Her decision toward celibacy to avoid past maladaptive coping patterns shows insight—support this boundary-setting. 7
• The church connection you mentioned could provide community support; encourage regular attendance if she's receptive. 6

Lifestyle Modifications with Specific Targets

Her current sleep (5-6 hours vs. usual 7-8 hours) and appetite disturbance (10-pound loss in 3 days) require immediate attention. 6

• Sleep hygiene protocol: Continue her sleep meditation/hypnosis audio, but add: fixed wake time (even weekends), no screens 1 hour before bed, limit caffeine after 2 PM. Target return to 7-8 hours within 2 weeks. 6
• Nutritional support: Given her poor appetite and significant weight loss, recommend small frequent meals (5-6 times daily) focusing on protein and complex carbohydrates. Consider nutritional supplement drinks if solid food intake remains poor. 6
• Exercise prescription: Start with 10-minute daily walks, increasing by 5 minutes weekly to reach 30 minutes daily by week 4. Exercise has antidepressant effects and improves sleep. 6

What NOT to Do

• Do not wait "a couple of weeks" to consider medication—start SSRI now given the severity of her symptoms and suicidal ideation. 1, 3
• Do not prescribe tricyclic antidepressants (like amitriptyline) due to their high lethality in overdose. 1, 3
• Do not assume her suicidal ideation will resolve simply because she states she won't act on it—her history of attempt at age 12 and current severe distress require active intervention. 2
• Do not allow her to continue managing her own medications given active suicidal ideation and overdose history. 1, 2

Re-evaluation Timeline

• Week 2: Assess medication tolerability, side effects, and any activation symptoms. Confirm third-party medication monitoring is functioning. 4
• Week 4-6: Expect initial SSRI response; if no improvement in mood or suicidal ideation, consider dose increase or medication change. 4
• Week 8-12: If inadequate response to adequate SSRI trial, consider augmentation strategies or referral to psychiatry. 1

If at any point she develops a specific suicide plan, intent to act, or acute worsening of symptoms, immediate psychiatric hospitalization is indicated. 5, 2