What is the best course of treatment for a 28-year-old female with a history of Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), Attention Deficit Hyperactivity Disorder (ADHD), and bipolar disorder, who recently engaged in self-harm and is experiencing suicidal ideation, shame, hopelessness, and feelings of worthlessness?

Immediate Risk Assessment and Disposition

This patient requires immediate mental health professional evaluation during this visit, with strong consideration for hospitalization given her active suicidal ideation with intent ("feeling her kids would be better without her"), recent self-harm behavior, and multiple high-risk features including hopelessness, shame, and bipolar disorder with impulsivity. 1, 2

High-Risk Features Present

This patient demonstrates multiple indicators of high acute suicide risk:

• Recent self-harm with a knife indicates both intent and access to lethal means 1
• Active suicidal ideation with specific content ("kids would be better without her") represents more than passive death wishes 1, 2
• Severe hopelessness and worthlessness are critical risk factors that increase lethality 1
• Bipolar disorder with impulsivity creates profound risk, as impulsivity combined with dysphoric mood significantly elevates suicide risk 1, 3
• Recent interpersonal crisis (strained relationship, triggering text) represents an acute psychosocial stressor 1

Immediate Disposition Decision

Do not allow this patient to leave without arranging immediate mental health evaluation. Options include: 1, 2

• Hospitalization (preferred given multiple high-risk features and recent self-harm)
• Emergency department transfer with direct handoff
• Same-day mental health professional evaluation only if you can guarantee immediate availability

Outpatient management alone is inappropriate for this patient. While the American Academy of Pediatrics notes that patients with responsive families and little likelihood of acting on impulses may require only outpatient treatment, this patient has demonstrated recent action (self-harm), has access to means (knife), and exhibits severe hopelessness—all contraindications to outpatient-only care. 1

Safety Measures During This Visit

While arranging disposition:

• Remove access to all lethal means immediately—have family remove medications, firearms, sharp objects from the home 2, 4
• Do not leave patient alone—maintain continuous observation until transfer is complete 5
• Avoid "no-suicide contracts"—these have no empirical evidence of efficacy and create false reassurance 2, 6
• Activate support networks—contact family members or supportive individuals who can provide supervision 7

Comprehensive Risk Assessment Documentation

Document the following specific elements: 1, 6

• Intent and plan details: What method is she considering? How lethal? What preparations has she made? 1
• Frequency and intensity of suicidal thoughts: How often? How long do they last? What triggers them? 2, 6
• Access to means: Does she still have access to knives or other lethal methods? 1, 2
• Protective factors: What are her reasons for living? Quality of therapeutic alliance? 1
• Substance use: Clarify alcohol or drug use timeline, as this increases impulsivity 6
• Mental status: Assess for psychosis, command hallucinations, agitation, or severe anxiety 1

Treatment Plan Upon Stabilization

Once the patient is in an appropriate level of care (likely inpatient), the following evidence-based interventions should be initiated:

Psychotherapy (Primary Intervention)

Cognitive Behavioral Therapy (CBT) focused on suicide prevention is the first-line psychotherapy, as it reduces suicidal ideation and cuts suicide attempt risk by half compared to treatment as usual. 1, 2

• Dialectical Behavior Therapy (DBT) is particularly indicated given her likely borderline features (self-harm, interpersonal crisis reactivity, shame, impulsivity), as DBT specifically targets emotion regulation, distress tolerance, and interpersonal effectiveness 1, 2
• Therapy should be intensive (twice weekly initially) using manualized, evidence-based protocols 6

Pharmacological Management

Lithium should be strongly considered given her bipolar disorder and suicidal ideation, as lithium has the strongest evidence for reducing suicidal behaviors and deaths in patients with mood disorders. 1, 2

• Avoid tricyclic antidepressants due to high lethality in overdose 2
• Use benzodiazepines cautiously as they may increase disinhibition or impulsivity 2
• Ketamine infusion may be considered for rapid short-term reduction in suicidal ideation if symptoms are severe, with benefits beginning within 24 hours and lasting up to 6 weeks 1, 2
• If she's currently on antidepressants, assess for behavioral activation (agitation, irritability) which may represent precursors to worsening suicidality 6

Collaborative Safety Planning

Develop a structured crisis response plan (not a no-suicide contract): 2, 6

• Identify specific warning signs she recognizes before suicidal urges intensify 6
• List concrete coping strategies: distraction techniques, people to contact, safe places to go 6
• Include crisis resources: suicide hotline (988), emergency contacts, nearest emergency department 2
• Ensure a third party monitors medications and reports mood changes 2

Follow-Up After Acute Stabilization

• Schedule closely spaced follow-up appointments and contact the patient if appointments are missed 2
• Send periodic caring communications (postal mail or text messages) for 12 months following any hospitalization 2
• Consider self-guided digital interventions with CBT-based content for additional support 2

Critical Pitfall to Avoid

Do not be reassured by absence of current suicidal ideation if none of the factors that led to the self-harm have changed. This patient's recent self-harm, combined with ongoing hopelessness and unchanged psychosocial stressors, means she remains at high risk even if she denies current intent during this visit. 1