What is the diagnosis and recommended level of care for a 30-year-old married female patient with a history of anxiety, depression, ADHD, and possible bipolar disorder, presenting with chronic anxiety, major depressive disorder, panic attacks, and suicidal ideation, exacerbated by recent psychosocial stressors and substance use disorder?

Diagnosis and Level of Care Recommendation

This patient meets diagnostic criteria for Major Depressive Disorder with comorbid Generalized Anxiety Disorder, Panic Disorder, and Substance Use Disorder (cannabis and alcohol), and requires immediate referral to a higher level of care—specifically Intensive Outpatient Program (IOP) or Partial Hospitalization Program (PHP)—given the severity of symptoms, weekly passive suicidal ideation, treatment resistance, and substance use complicating the clinical picture. 1, 2

Primary Diagnoses

Major Depressive Disorder (Moderate to Severe)

• The patient exhibits persistent depressed mood for five years with significant functional impairment, meeting DSM-5 criteria including depressed mood, feelings of guilt, impaired concentration, and passive suicidal ideation 3
• Weekly passive suicidal ideation with fleeting impulsive thoughts (e.g., swerving car off road) without intent or plan represents significant risk requiring intensive monitoring 1, 2
• Multiple failed medication trials (Lexapro, Cymbalta, Avelity) with only transient benefit indicates treatment-resistant depression requiring specialist evaluation 1, 2

Generalized Anxiety Disorder

• Excessive anxiety and worry persisting for five years, difficult to control, with associated symptoms including restlessness, easy fatigue, difficulty concentrating, irritability, and sleep disturbance meets DSM-5 criteria for GAD 3
• Panic attacks lasting up to two hours with dyspnea, uncontrollable crying, and emesis represent severe autonomic arousal 4, 1

Panic Disorder

• Recurrent unexpected panic attacks with intense physical symptoms (dyspnea, emesis) lasting up to two hours with prolonged recovery periods (up to two hours) meet criteria for panic disorder 4, 1
• These episodes are precipitated by acute stressors but demonstrate severity beyond typical situational anxiety 1

Substance Use Disorder (Cannabis and Alcohol)

• Daily cannabis use (edibles and flower) for sleep and symptom management represents maladaptive coping and likely cannabis use disorder 1, 5
• Recent pattern of weekend binge drinking with impaired control and negative consequences (prolonged hangovers) indicates alcohol use disorder, though patient recently achieved two weeks of sobriety 1, 5
• Substance use significantly complicates anxiety and depression treatment and must be addressed concurrently 1, 5

Differential Diagnostic Considerations

Rule Out Bipolar Disorder (Critical Priority)

• History of impulsive behaviors during college (meeting strangers online, traveling without informing others) and impulsive polyamory shortly after marriage raises concern for possible hypomanic or manic episodes 6, 7
• Multiple failed SSRI trials with only transient benefit is characteristic of bipolar depression rather than unipolar depression 6, 7
• Prior trials of Abilify (an antipsychotic/mood stabilizer) suggest previous clinicians may have considered bipolar spectrum disorder 6
• Antidepressant monotherapy in undiagnosed bipolar disorder can precipitate mania and increase suicidality, making this differential diagnosis critical before resuming antidepressant treatment 8, 7
• Comprehensive psychiatric evaluation must include structured assessment for lifetime history of hypomanic/manic symptoms 6, 7

Rule Out Medical Causes

• Thyroid dysfunction must be excluded given the high comorbidity between thyroid disorders and anxiety, particularly in women with panic disorder (9% prevalence in one study) 4, 5
• TSH testing is indicated as routine screening since thyroid dysfunction commonly presents with anxiety symptoms 4, 5

Rule Out ADHD Contribution

• History of ADHD with prior trials of Focalin and Adderall suggests attention difficulties may contribute to functional impairment 4
• Untreated ADHD can exacerbate anxiety and depression and complicate treatment response 4

Rationale for Higher Level of Care

Severity Indicators Requiring Intensive Treatment

• Weekly passive suicidal ideation with impulsive thoughts of self-harm (swerving car) represents significant risk requiring more intensive monitoring than weekly outpatient therapy 1, 2, 9
• Panic attacks lasting up to two hours with severe physical symptoms (emesis) and prolonged recovery indicate severe anxiety requiring intensive intervention 1, 2
• Treatment resistance after five years and multiple medication trials indicates need for comprehensive psychiatric reassessment beyond primary care optimization 1, 2
• Active substance use disorder (daily cannabis, recent alcohol cessation) requires concurrent addiction treatment that is best addressed in intensive programming 1, 2

Anxiety Disorders Independently Increase Suicide Risk

• Each anxiety disorder (GAD, panic disorder) is independently associated with increased odds of lifetime suicide attempts (odds ratios 3.03-7.00) and suicidal ideation (odds ratios 2.62-10.57) even after controlling for depression and other comorbidities 9
• The combination of depression, anxiety disorders, and substance use creates multiplicative risk requiring intensive intervention 9

IOP/PHP Advantages Over Standard Outpatient Care

• Provides daily or near-daily contact for safety monitoring during acute exacerbation 1, 2
• Allows for rapid medication adjustments under close observation, particularly important given concern for bipolar disorder 1, 2
• Offers structured substance use treatment concurrent with psychiatric care 1, 2
• Provides intensive evidence-based psychotherapy (CBT) which has large effect sizes for GAD (Hedges g = 1.01) 1, 5
• Patient's employment flexibility as patient services representative allows for accommodation of higher level of care 2

Immediate Safety and Treatment Plan

Safety Assessment and Planning

• Complete formal suicide risk assessment including Columbia Suicide Severity Rating Scale (C-SSRS) to quantify ideation severity, intent, and plan 1, 2
• Implement safety plan with crisis resources (988 suicide and crisis prevention line) and emergency contact information 1, 2
• Ensure no access to lethal means (confirmed no firearms in home, but assess for medications, other means) 1, 2
• Establish regular contact schedule with supportive persons (mother, best friend) during referral process 2

Substance Use Intervention

• Immediate cessation of all substances (cannabis and alcohol) is essential as they worsen anxiety, depression, and interfere with medication efficacy 1, 5
• Cannabis use for sleep perpetuates anxiety and depression through disruption of natural sleep architecture 1
• Recent alcohol cessation should be supported and monitored for withdrawal symptoms 1

Medication Management Pending Psychiatric Evaluation

• Do not initiate or resume antidepressant monotherapy until bipolar disorder is definitively ruled out, as antidepressants can precipitate mania and increase suicidality in undiagnosed bipolar disorder 8, 7
• If bipolar disorder is confirmed, mood stabilizers (e.g., lithium) should be initiated before considering antidepressant augmentation 8
• If unipolar depression is confirmed, SSRI (escitalopram or sertraline) or SNRI (duloxetine) can be initiated with close monitoring 1, 3, 10

Psychotherapy Initiation

• Cognitive Behavioral Therapy (CBT) is the psychotherapy with strongest evidence for both GAD and depression and should be initiated immediately in IOP/PHP setting 1, 5
• Couples counseling should be considered given marital stressor (puppy acquisition) and husband's minimization of patient's distress 1

Common Pitfalls to Avoid

Critical Diagnostic Errors

• Do not assume unipolar depression without comprehensive evaluation for bipolar disorder given history of impulsive behaviors and multiple failed SSRI trials 6, 7
• Do not overlook thyroid dysfunction as a contributing factor—obtain TSH before attributing all symptoms to psychiatric causes 4, 5
• Do not underestimate suicide risk in anxiety disorders—each anxiety disorder independently increases suicide risk even after controlling for depression 9

Treatment Errors

• Do not restart antidepressant monotherapy without ruling out bipolar disorder—this can precipitate mania and worsen suicidality 8, 7
• Do not manage severe symptoms (weekly suicidal ideation, severe panic attacks, substance use) in standard outpatient setting—this requires intensive programming 1, 2
• Do not ignore substance use as "self-medication"—daily cannabis and alcohol use disorder require concurrent treatment and worsen psychiatric outcomes 1, 5

Family Planning Considerations

• Defer pregnancy planning until psychiatric stabilization is achieved, as recommended by patient's gynecologist 1
• Many psychiatric medications have teratogenic risks requiring careful planning before conception 1
• Untreated psychiatric illness during pregnancy carries significant risks to both mother and fetus 1

Monitoring During Referral Process

Symptom Tracking

• Administer GAD-7 and PHQ-9 at each contact to quantify symptom severity and track trajectory 1, 2, 5
• Document functional impairment across work, social, and family domains using Sheehan Disability Scale 1
• Reassess suicidal ideation at every contact using standardized questions 1, 2

Coordination of Care

• Ensure rapid referral to IOP/PHP program with psychiatric evaluation scheduled within one week 1, 2
• Provide comprehensive documentation including medication trial history, substance use patterns, and family psychiatric history to receiving program 1, 2
• Maintain regular contact with patient during transition to higher level of care to ensure safety 2