What is the best course of treatment for a patient with a history of mood instability, major depressive disorder (MDD), anxiety, and agitation, who recently attempted suicide with an overdose of duloxetine (Cymbalta) and glibenclamide (Glyburide), and is experiencing family issues?

Immediate Psychiatric Hospitalization Required

This patient requires immediate psychiatric hospitalization given her recent suicide attempt with duloxetine and glibenclamide overdose, continued presence of high-risk factors including mood instability, agitation, and ongoing psychosocial stressors. 1

Acute Risk Assessment and Immediate Management

High-Risk Indicators Present

• Recent suicide attempt with medication overdose indicates serious intent and access to lethal means 1
• Mood instability with agitation represents a particularly dangerous combination that increases short-term suicide risk 1
• Major depressive disorder with anxiety and ongoing family crisis (perceived loss of son) provide persistent motivating factors 1
• Previous attempt increases risk of repetition, particularly in the months immediately following the initial attempt 1

Hospitalization Decision

Admit to inpatient psychiatric facility immediately because this patient exhibits persistent high-risk features: recent high-lethality attempt, mood instability with agitation, ongoing psychosocial crisis, and continued access to medications that were used in the overdose attempt 1. Inpatient treatment should continue until mental state and suicidality have stabilized 1.

Medication Management During Hospitalization

Immediate Medication Changes

• Consider switching from duloxetine to an SSRI (such as fluoxetine or escitalopram), which has better evidence for treating depression with suicidal features 2
• Remove all medications from patient's direct access and implement third-party monitoring for any prescribed medications 2
• Avoid tricyclic antidepressants due to their high lethality in overdose 2
• Use benzodiazepines cautiously for agitation, as they may increase disinhibition or impulsivity in some individuals 2

Mood Stabilization Considerations

• Lithium should be considered for patients with mood instability and suicidal ideation, as it has been associated with reduced suicidal behaviors and deaths 2
• Anticonvulsant mood stabilizers (carbamazepine, lamotrigine, or valproate) may be beneficial as adjuncts, particularly for treating irritability and agitation in MDD 3
• Screen for bipolar disorder given the mood instability, as treating an unrecognized manic/hypomanic episode with antidepressants alone may worsen the clinical picture 4, 5

Monitoring During Medication Adjustment

• Close observation for worsening depression, agitation, panic attacks, insomnia, irritability, hostility, or impulsivity is essential during the initial weeks of any antidepressant therapy or dose changes 4, 5
• Daily monitoring by psychiatric staff for emergence of suicidal ideation or behavioral changes 6, 4

Psychotherapeutic Interventions

Evidence-Based Therapy Initiation

• Initiate cognitive-behavioral therapy (CBT) focused on suicide prevention during hospitalization, as this has been shown to reduce suicidal ideation and cut the risk of suicide attempts by half compared to treatment as usual 2, 1
• Dialectical behavior therapy (DBT) should be considered given the mood instability, as it combines CBT with skills training in emotion regulation, interpersonal effectiveness, and distress tolerance 2, 1
• Address the specific psychosocial stressor (perceived loss of son to girlfriend) through problem-solving therapy to improve coping with this life stressor 2

Therapeutic Approach

• Work with a clinician who is available, skilled in managing suicidal crises, relates honestly and consistently, and conveys optimism 1
• Avoid implicit coercions such as telling the patient she will not be discharged until she states she is not suicidal 1
• Evaluate family dynamics and consider family therapy to address the mother-son relationship concerns and improve the home environment 1

Safety Planning and Means Restriction

Lethal Means Removal

• Remove all medications from the home, including both prescription and over-the-counter drugs, with a responsible third party controlling access 1, 2
• Remove any firearms from the home immediately, as access to firearms doubles suicide risk 7
• Counsel family about means restriction as a key component of discharge planning, emphasizing that most suicide attempts are impulsive and reducing access to lethal means increases time for reconsideration or intervention 1

Collaborative Safety Plan Development

• Create a structured safety plan including: (1) identification of warning signs and triggers for suicidal ideation, (2) coping strategies to use if suicidal thoughts return, (3) healthy distraction activities, (4) responsible social supports to contact, (5) professional support contact information including emergency services access, and (6) means restriction verification 1, 2
• Avoid relying on no-suicide contracts, as there is no empirical evidence supporting their efficacy in preventing suicidal behavior 1, 2

Discharge Planning and Follow-Up

Criteria for Discharge Readiness

• Stabilization of mental state with reduction in agitation and mood instability 1
• Absence of persistent wish to die or clearly abnormal mental state 1
• Adequate support system with family members who understand the safety plan and means restriction 1
• Confirmed outpatient psychiatric follow-up arranged before discharge 1

Post-Discharge Monitoring Structure

• Schedule closely-spaced follow-up appointments with flexibility for crisis visits 1, 2
• Contact the patient if appointments are missed to maintain engagement in care 1
• Send periodic caring communications (postal mail or text messages) for 12 months following hospitalization 2
• Continue third-party medication monitoring with family member reporting any changes in mood, increases in agitation, or side effects 2

Family Education and Support

• Educate family about suicide risk factors and the importance of ongoing monitoring 1
• Alert family to monitor for emergence of agitation, irritability, unusual behavioral changes, and suicidal ideation, with instructions to report immediately 4, 5
• Address the mother-son relationship dynamics through family therapy to reduce the psychosocial stressor driving suicidal ideation 1

Critical Pitfalls to Avoid

• Do not discharge without psychiatric evaluation and stabilization of the abnormal mental state 1
• Do not assume low risk based on method lethality alone; intent and psychiatric factors are more important than the actual danger of the method used 7
• Do not rely on patient's denial of current suicidal ideation if the factors that led to the attempt have not changed or are not understood 1
• Do not prescribe medications with high lethality in overdose (such as tricyclic antidepressants) given the recent overdose attempt 2
• Do not underestimate the patient's ability to access locked medications; ensure a responsible third party has complete control 7