What is the best course of treatment for a 29-year-old female patient with borderline personality disorder (BPD), presenting with ongoing suicidal ideation, depressive symptoms, and a history of self-harm, who has previously been treated with Sertraline (selective serotonin reuptake inhibitor (SSRI)) and Wellbutrin (bupropion)?

Treatment Approach for BPD with Suicidal Ideation and Depressive Symptoms

Dialectical Behavior Therapy (DBT) is the only evidence-based psychotherapy proven to reduce suicidality and self-harm in borderline personality disorder and should be initiated immediately as the cornerstone of treatment, combined with careful medication management targeting comorbid depression while avoiding pharmacological approaches that may worsen impulsivity. 1

Immediate Safety Assessment and Crisis Planning

• Remove all lethal means from the environment, including securing or disposing of medications, and explicitly instruct family/support persons to remove firearms if present, as this is a critical first step in suicide prevention. 2, 3

• Establish a crisis response plan through collaborative discussion with the patient that includes identification of warning signs, coping strategies, reasons for living, and emergency contacts—this intervention significantly reduces suicide attempts compared to treatment as usual. 1

• Avoid "no-suicide contracts" as they have no empirical evidence supporting efficacy and may create false reassurance; instead, focus on concrete safety planning and environmental interventions. 2, 3

• Assess for hospitalization indicators including persistent wish to die, clearly abnormal mental state, irritability, agitation, threatening violence, delusional thinking, hallucinations, or inability to commit to safety—any of these warrant inpatient psychiatric admission. 1, 3

Evidence-Based Psychotherapy (Primary Treatment)

• DBT is the only psychotherapy with randomized controlled trial evidence demonstrating reduction in suicidality specifically in adults with borderline personality disorder, making it the first-line psychotherapeutic intervention. 1

• DBT combines individual therapy, group skills training, phone coaching, and therapist consultation teams to address emotion regulation, distress tolerance, interpersonal effectiveness, and mindfulness—targeting the core deficits in BPD that drive suicidal behavior. 1

• Cognitive-behavioral therapy (CBT) focused on suicide prevention is an alternative evidence-based option that reduces suicidal ideation and behavior by more than 50% and cuts the risk for post-treatment suicide attempts in half compared to treatment as usual. 1

• Most effective CBT protocols involve fewer than 12 sessions, making this a practical option if DBT is not available, though DBT remains superior for BPD specifically. 1

• Interpersonal psychotherapy (IPT) can address the interpersonal conflicts and relationship distress (such as her pattern of destroying boyfriend's property during fights) that trigger depressive episodes and suicidal ideation, though it was developed for non-suicidal depressed patients. 1

Pharmacological Management

Antidepressant Considerations

• Sertraline (SSRI) can be restarted cautiously given her previous response at age 16-18, but SSRIs have only modest evidence for reducing suicidal ideation in depression and no specific anti-suicidal properties in BPD. 4, 5

• All patients starting or restarting antidepressants must be monitored closely for clinical worsening, suicidality, agitation, irritability, hostility, impulsivity, and akathisia—symptoms that may represent precursors to emerging suicidality—especially during the first few months and after dose changes. 4

• Bupropion (Wellbutrin) has noradrenergic and dopaminergic activity that may have activating effects and could potentially worsen suicidal ideation in certain phases of illness, requiring careful monitoring if restarted. 5

• Screen carefully for bipolar disorder before initiating any antidepressant, as treating a depressive episode with an antidepressant alone may precipitate mixed/manic episodes in patients at risk for bipolar disorder, and her family history of suspected bipolar disorder raises this concern. 4

• The FDA warns that antidepressants increase suicidal thinking and behavior in patients under age 25, though at age 29 this patient falls into the age range where antidepressants show neutral to mildly protective effects. 4

Adjunctive Pharmacotherapy

• Consider low-dose atypical antipsychotics (olanzapine 5-10 mg daily or quetiapine) as adjunctive treatment, as these have evidence for reducing aggression, impulsivity, and affective instability in BPD, though they are not specifically anti-suicidal. 6

• Lithium may reduce suicide risk and has the strongest evidence for anti-suicidal effects across mood disorders, though its role in BPD without clear bipolar features is less established. 1

• Avoid benzodiazepines as they may reduce self-control and potentially disinhibit individuals, leading to increased impulsivity or suicide attempts in patients with BPD. 2

• Do not prescribe medications with high lethality in overdose (tricyclic antidepressants) given active suicidal ideation. 2, 3

Emerging Treatments for Acute Suicidal Ideation

• Ketamine infusion (0.5 mg/kg single dose) results in rapid improvement of suicidal ideation within 24 hours that persists for at least 1 week, with 55-60% of patients reporting no suicidal ideation after treatment. 1

• Ketamine is reserved for patients with major depression and acute suicidal ideation who have not responded to multiple adequate antidepressant trials, and lacks long-term efficacy and safety data. 1

Monitoring and Follow-Up Protocol

• Schedule closely-spaced follow-up appointments (at least weekly initially) with the same clinician to ensure continuity of care, as frequent contact is associated with better outcomes. 2, 3

• The treating clinician must be available outside regular hours or ensure adequate coverage for crisis situations, as availability of support is critical during high-risk periods. 2, 3

• Monitor systematically for suicidal ideation at every visit, particularly during medication changes, dose adjustments, or psychosocial stressors. 2, 4

• Continue the same clinician for at least 18 months to maintain therapeutic continuity and alliance, which is protective against suicide attempts. 2

Addressing Interpersonal and Environmental Triggers

• Target the pattern of anger dysregulation and property destruction during relationship conflicts through DBT skills training in emotion regulation and distress tolerance, as these behaviors represent maladaptive affect regulation strategies. 1

• Involve the boyfriend or family members in psychoeducation about BPD, suicide risk factors, and how to respond to crises without reinforcing maladaptive behaviors. 3

• Address substance use explicitly, as alcohol and drugs have dangerous disinhibiting effects that dramatically increase suicide risk in patients with BPD. 3

Critical Pitfalls to Avoid

• Never rely on verbal safety agreements as a substitute for clinical vigilance and concrete environmental safety measures—these contracts provide false reassurance without reducing risk. 2, 3

• Do not treat with antidepressants alone without concurrent evidence-based psychotherapy, as medication alone is insufficient for suicide prevention in BPD and may worsen outcomes without addressing core personality pathology. 1, 3

• Avoid polypharmacy without clear indication, as patients with BPD are often prescribed multiple medications without evidence of benefit, increasing side effect burden and overdose risk. 5

• Do not discharge from acute care without third-party verification of adequate supervision and support systems, as patients may minimize risk to avoid hospitalization. 3

• Recognize that her previous medication discontinuations at ages 18 and 25 suggest a pattern of premature treatment termination when feeling better, requiring explicit discussion about maintenance treatment and relapse prevention. 4