What is the diagnosis and recommended treatment for a patient with suicidal ideation, intimate partner violence, and a history of substance use, presenting with severe anxiety and a plan to overdose, who has a pending court date for a protection order and requires surgical repair for skull, nose, and jaw fractures?

Diagnosis and Treatment Approach

This patient meets criteria for Major Depressive Disorder with severe suicidal ideation, active substance use disorder, and acute trauma from intimate partner violence—requiring immediate psychiatric hospitalization with cognitive behavioral therapy focused on suicide prevention as the primary intervention. 1, 2

Primary Psychiatric Diagnoses

• Major Depressive Disorder with suicidal features: The patient demonstrates depressed mood, suicidal ideation with plan/method/intent, hopelessness ("spiraling"), and recognition of impending decompensation—all cardinal features of severe depression 1
• Substance Use Disorder: Active drug use pattern with recognition of relapse triggers and protective hospital-seeking behavior to avoid drug use 1
• Post-Traumatic Stress Disorder (likely): Three years of intimate partner violence including near-fatal assault, ongoing threats, and trauma-triggered decompensation after serving protection order paperwork 1, 3
• Acute stress reaction: Severe anxiety triggered by legal proceedings and contact with abuser 1

Immediate Management: Psychiatric Hospitalization Required

This patient requires inpatient psychiatric admission based on persistent wish to die, concrete suicide plan (overdose), and ongoing safety threats from intimate partner violence. 1, 4

Hospitalization Criteria Met:

• Active suicidal ideation with specific plan, method, and intent to die via overdose 1, 4
• Unstable mental state with severe anxiety and recognition of "spiraling" 1
• Unsafe living environment with active domestic violence threats and pending court proceedings 1, 5
• Substance use disorder with high relapse risk during crisis 1

Inpatient treatment should continue until suicidal ideation resolves, mental state stabilizes, and safety planning is established for the upcoming court date. 1, 4

Primary Treatment: Cognitive Behavioral Therapy for Suicide Prevention

Initiate CBT focused on suicide prevention immediately—this is the single most evidence-based intervention to reduce both suicidal ideation and suicide attempts, with 50% reduction in suicide attempts compared to treatment as usual. 1, 2

CBT Implementation:

• Begin during hospitalization with focus on identifying and changing suicidal thought patterns 1, 2
• Target hopelessness, catastrophic thinking about court proceedings, and trauma-related cognitions 1
• Most patients require fewer than 12 sessions to achieve benefit 1
• Continue outpatient after discharge with close follow-up 2

Adjunctive Pharmacologic Treatment

Consider ketamine infusion (0.5 mg/kg IV over 40 minutes) for rapid reduction of acute suicidal ideation, with antisuicidal effects beginning within 24 hours. 1, 2, 6

Ketamine Considerations:

• Specifically indicated for patients with major depressive disorder and active suicidal ideation 1, 2
• Provides rapid symptom relief while waiting for traditional antidepressants to take effect 2, 6
• Evidence supports short-term reduction in suicidal thoughts, not suicide attempts 1, 2
• Use as adjunctive treatment, not replacement for ongoing antidepressant therapy 2

Initiate or optimize antidepressant medication for underlying major depressive disorder during hospitalization. 1

Crisis Response Planning and Safety Planning

Develop a collaborative crisis response plan that includes specific warning signs, coping strategies, social supports, and crisis resources—this structured approach reduces suicide attempts. 1, 2

Essential Safety Plan Components:

• Identify behavioral, cognitive, and affective warning signs of crisis (e.g., seeing ex-partner, court-related triggers) 1
• List self-management skills and distraction techniques the patient can use independently 1
• Identify supportive friends/family members patient feels comfortable contacting 1
• Document crisis resources including emergency contacts, suicide lifeline, and follow-up appointments 1
• Critical: Remove access to lethal means including all medications that could be used for overdose 1, 4

Substance Use Disorder Treatment

Screen for opioid use disorder and consider office-based buprenorphine therapy if indicated—this is safe, effective, and reduces relapse risk. 1

Substance Use Management:

• Conduct comprehensive substance use assessment including type, frequency, and triggers 1
• The patient's protective choice to seek hospitalization rather than use drugs demonstrates insight and motivation 1
• Patients with substance use disorders have over 50% prevalence of intimate partner violence and require integrated treatment 1
• Consider residential treatment if outpatient setting cannot provide adequate structure and safety 1

Intimate Partner Violence Intervention

All patients with substance use disorders and suicidal ideation must be screened for intimate partner violence—this patient has severe IPV with life-threatening assault history requiring immediate safety planning. 1, 5

IPV-Specific Interventions:

• Document all injuries including skull, nose, and jaw fractures requiring surgical repair 1
• Coordinate with legal advocates regarding protection order court date on [DATE] 1
• IPV is associated with 43% of suicides where intimate partner problems are identified, and arguments immediately precede 30% of these deaths 7
• Treatment of substance use disorder may reduce both perpetration and victimization of IPV 1
• Ensure patient has safe discharge plan that does not involve contact with abuser 5

Comprehensive Risk Assessment Domains

Conduct full suicide risk assessment including all critical domains: self-directed violence history, psychiatric symptoms, social determinants, lethal means access, and trauma history. 1

Specific Assessment Elements:

• Current suicidal thoughts: frequency, intensity, duration, and specific plan details 1
• Prior suicide attempts and family history of suicide 1
• Access to firearms and medications for overdose 1, 4
• Psychosocial stressors: legal proceedings, housing instability, financial problems, lack of social support 1
• Trauma history: three years of IPV including near-fatal assault 1
• Substance use patterns and triggers for relapse 1

Use validated screening tools such as the Columbia Suicide Severity Rating Scale Screener to monitor suicidal ideation at each encounter. 1, 2

Post-Discharge Follow-Up

Schedule first outpatient appointment within 48-72 hours of discharge and implement periodic caring communications (text/mail) for 12 months to reduce suicide attempt risk. 1, 2

Follow-Up Structure:

• Continue CBT focused on suicide prevention with weekly sessions initially 1, 2
• Reassess suicidal ideation at every visit using validated measures 2
• Monitor for substance use relapse, especially around court date 1
• Coordinate with surgical team for facial fracture repair 1
• Greatest risk for new suicide attempt occurs in months following initial crisis—close monitoring is essential 2

Critical Pitfalls to Avoid

• Never discharge without confirming third-party supervision and removal of lethal means from home environment 1, 4
• Do not rely on "no-suicide contracts"—these have no proven efficacy and create false reassurance 4
• Avoid prescribing medications with high lethality in overdose; use benzodiazepines cautiously as they reduce self-control 6
• Do not minimize the mental health impact of IPV—patients consistently report psychological abuse as worse than physical violence 1
• Never overlook substance use as a disinhibiting factor that dramatically increases suicide risk 1, 4, 3