What is the diagnosis and treatment plan for a 42-year-old white female with a history of severe depression, anxiety, post-traumatic stress disorder (PTSD), psychotic symptoms, and substance use disorder, who presents with suicidal ideation, recent intimate partner violence, and a complex psychiatric history, currently taking Risperidone (risperidone), Duloxetine (duloxetine), Doxepin (doxepin), and Prazosin (prazosin)?

Primary Diagnosis and Treatment Plan

This patient meets criteria for Major Depressive Disorder, Recurrent, Severe with Psychotic Features; PTSD; and Severe Polysubstance Use Disorder (Methamphetamine, Opioid, Cannabis), with high acute suicide risk requiring immediate inpatient stabilization and comprehensive trauma-focused treatment.

Diagnostic Formulation

Primary Psychiatric Diagnoses

Major Depressive Disorder, Recurrent, Severe with Psychotic Features is the most appropriate primary diagnosis given:

• PHQ-9 score of 27 (severe depression) with anhedonia, hopelessness, fatigue, and passive suicidal ideation 1
• Auditory hallucinations ("group full of people talking") and visual hallucinations (shadows in peripheral vision) present during interview 1
• Blunted affect, poverty of thought, and psychomotor restlessness 1
• History of >20 suicide attempts in the past year, representing extremely high risk for completed suicide 1

PTSD is clearly established with:

• Extensive intimate partner violence including near-fatal assault resulting in skull, nose, and jaw fractures 2
• Full symptom cluster: nightmares, flashbacks, avoidance, hypervigilance, intrusive thoughts 2
• GAD-7 score of 21 (severe anxiety) with specific trauma-related triggers 2
• Prazosin already prescribed for nightmares, which is the only Level A recommendation for PTSD-associated nightmares 2

Severe Polysubstance Use Disorder with:

• Daily methamphetamine and fentanyl use for 5 years, last use within days of admission 1

• 20 lifetime opioid overdoses 1

• Currently in drug court program, recently released from incarceration 1
• Intimate partner violence rates exceed 50% in patients with substance use disorders, requiring routine screening 1

Critical Diagnostic Consideration: Rule Out Bipolar Disorder

The recent bipolar diagnosis and recent initiation of risperidone raise urgent concerns about potential misdiagnosis or undertreated bipolar disorder:

• Patient was "awake for 3 consecutive days" with "high energy, excessive pacing" after jail release, suggesting possible manic/hypomanic episode 3, 4, 5
• Current psychomotor restlessness and akathisia-like symptoms ("cannot sit still," "not comfortable in my own skin") could represent mixed features 1
• History of rapid mood shifts between depression, anxiety, rage, and euthymia with transient psychotic symptoms is strongly associated with bipolar disorder 1
• Recurring suicidal behavior is associated with hypomanic personality traits and rapid cycling 1
• Antidepressant monotherapy (duloxetine 20mg) without mood stabilizer is contraindicated if bipolar disorder is present, as it may precipitate manic episodes 3, 4, 5

Immediate Safety and Stabilization (Days 1-7)

Suicide Risk Management

This patient has extremely high acute suicide risk requiring maximum precautions:

• C-SSRS score of 17 indicates high risk with recent suicidal ideation, plan, method, and intent 1
• Multiple risk factors: female gender, living alone (recently housed but feels unsafe), >20 previous attempts, current abnormal mental state with psychotic symptoms 1
• Ambivalence about reasons for living ("I don't know yet") indicates persistent suicidal intent 1
• Maintain 1:1 observation, remove all means of self-harm, and continue inpatient hospitalization until suicidal ideation resolves and safety plan is established 1

Medication Optimization for Acute Phase

Immediate medication adjustments are required:

1. Address potential bipolar disorder FIRST before optimizing antidepressants:

   • If bipolar disorder is confirmed or strongly suspected, initiate lithium or valproate as mood stabilizer foundation 3
   • Continue duloxetine ONLY in combination with mood stabilizer, never as monotherapy in bipolar disorder 3, 5
   • If bipolar disorder is ruled out, increase duloxetine from 20mg to 40-60mg daily for adequate antidepressant effect 5

2. Optimize antipsychotic for psychotic depression:

   • Current risperidone 3mg total daily (1mg + 2mg QHS) is appropriate starting dose 6, 7, 8
   • Risperidone has empirical evidence (Level A) for PTSD with psychotic symptoms 8
   • Monitor for extrapyramidal symptoms given current akathisia-like presentation 1
   • Consider quetiapine as alternative if akathisia worsens, as it is effective for chronic insomnia, aggressiveness, and psychotic depression in PTSD 6

3. Continue prazosin 2mg QHS for PTSD nightmares:

   • This is the only Level A recommendation for PTSD-associated nightmares 2
   • May titrate up to 3-10mg if nightmares persist, monitoring for orthostatic hypotension 2

4. Continue naltrexone 50mg daily for opioid use disorder:

   • Appropriate for post-acute withdrawal phase (COWS=0) 1
   • Naltrexone has evidence for reducing substance use in PTSD patients with alcohol/opioid dependence 8

5. AVOID benzodiazepines completely:

   • Benzodiazepines are absolutely contraindicated given substance use history 9
   • Evidence shows 63% of patients receiving benzodiazepines developed PTSD at 6 months versus 23% with placebo 9
   • Replace hydroxyzine PRN with non-addictive alternatives for acute anxiety 9, 7

Substance Use Disorder Management

Comprehensive addiction treatment is essential:

• Patient strongly advocates for inpatient substance treatment after discharge, which should be prioritized 1
• Continue drug court program participation as it provides structure and accountability 1
• Address intimate partner violence as both victim and potential perpetrator risk, as treatment of substance use disorders decreases intimate partner violence rates 1
• Screen for hepatotoxicity given duloxetine use and history of substance use 5

Intermediate Treatment Phase (Weeks 2-12)

Trauma-Focused Psychotherapy as First-Line Treatment

Initiate trauma-focused cognitive behavioral therapy IMMEDIATELY without waiting for "stabilization":

• Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), or EMDR should begin now, showing 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions 9
• Delaying trauma-focused treatment is demoralizing and iatrogenic, potentially reducing self-confidence and treatment motivation 2, 9
• Trauma-focused therapy is safe even with comorbid substance abuse, severe mental illness, and suicidal ideation 2, 9
• These therapies have substantially lower relapse rates than medication alone (26-52% relapse with sertraline discontinuation versus lower rates post-CBT) 2, 9

Pharmacotherapy Monitoring and Adjustment

After 8 weeks of optimized medication:

• Reassess depression severity with PHQ-9 and psychotic symptoms 9, 7
• If inadequate response with good compliance, consider switching SSRIs (sertraline or paroxetine are FDA-approved for PTSD with 53-85% response rates) 2, 9, 7
• If partial response, augment with trauma-focused therapy rather than adding medications 9
• Continue SSRI treatment for at least 9-12 months after symptom remission to prevent relapse 2, 7

Address Comorbid Conditions

Depression and suicide risk require active ongoing treatment:

• Multi-family psychoeducation groups should be provided to address family dynamics and separation/individuation issues 1
• Depression, suicide risk, substance misuse, and social anxiety must be identified and actively treated throughout recovery 1
• Monitor for early warning signs of relapse with patient and family 1

Substance use disorder treatment:

• Transition to residential treatment program after acute psychiatric stabilization 1
• Continue naltrexone long-term for opioid use disorder 1
• Consider disulfiram if alcohol use emerges as problem 8

Long-Term Maintenance (Months 3-24+)

Continuation and Relapse Prevention

Maintain comprehensive specialist care throughout early recovery:

• Patients should remain in comprehensive, multidisciplinary, specialist mental healthcare throughout the early years and not be discharged to primary care without continuing specialist involvement 1
• Relapses are common during first few years, with vulnerability persisting in 80% of patients 1
• Establish partnerships between specialist center, primary care, and drug court program 1

Medication maintenance:

• Continue antidepressant for minimum 12 months after remission 2, 7
• If bipolar disorder confirmed, continue mood stabilizer for at least 2 years after last episode 3
• Once psychosis achieves sustained remission, attempt slow reduction of antipsychotic to determine minimal effective dose 1
• Long-term medication is advisable for individuals who experience frequent relapses 1

Recovery-Oriented Care

Emphasize meaning-making and mastery:

• Recovery work should emphasize finding meaning and developing mastery in relation to psychotic experience 1
• Negotiate occupational pursuits including employment and/or education 1
• Address impact of trauma on developmental and vocational tasks 1
• Monitor medication side effects (weight gain, sexual dysfunction, sedation) that can retard recovery 1

Safety Planning for Intimate Partner Violence

Ensure protection order is finalized and safety measures maintained:

• Court date for protection order must be attended 1
• Continue monitoring for intimate partner violence as both victim and potential perpetrator 1
• Substance abuse treatment appears to decrease both victimization and perpetration of intimate partner violence 1

Critical Pitfalls to Avoid

1. Never use antidepressant monotherapy if bipolar disorder is suspected - always combine with mood stabilizer 3, 4, 5
2. Never prescribe benzodiazepines in patients with substance use history - they worsen PTSD outcomes and have high abuse potential 9, 7
3. Never delay trauma-focused therapy waiting for "stabilization" - this is not evidence-based and delays effective treatment 2, 9
4. Never discharge to primary care alone during first 18 months - maintain specialist involvement throughout early recovery 1
5. Never stop antidepressants prematurely - continue for minimum 9-12 months after remission to prevent relapse 2, 7
6. Never ignore screening for bipolar disorder in patients presenting with depression - detailed psychiatric history including family history of suicide, bipolar disorder, and depression is essential 4, 5