What is the recommended treatment plan for a adult female with a long-standing history of mood instability, anxiety, emotional dysregulation, and interpersonal difficulties, who has experienced an acute worsening of symptoms after a recent family conflict, with a history of trauma exposure, daily cannabis use, impulsivity, obsessive traits, passive death wishes without intent or plan, and a family history positive for bipolar disorder?

Treatment Plan for Adult Female with Mood Instability, Trauma History, and Cannabis Use

Immediate Priority: Cannabis Cessation

Cannabis use must be discontinued immediately, as it significantly worsens mood instability, increases risk of manic episodes in bipolar disorder, and interferes with treatment response. 1, 2

• Daily cannabis use is associated with more severe bipolar symptoms, higher rates of comorbid substance use disorders, worse psychosocial functioning, and increased affective symptoms at both baseline and long-term follow-up 2
• Cannabis use doubles the risk for psychotic symptoms and induces manic symptoms in bipolar patients, while disrupting endogenous cannabinoid signaling 3
• Individuals with bipolar disorder who use cannabis report more frequent use and higher daily doses compared to those with major depression, and are more likely to use in physically hazardous situations with unsuccessful efforts to control use 4

Diagnostic Clarification Required Before Treatment

The family history of bipolar disorder, episodic increased energy lasting several days, and current mood instability require ruling out bipolar disorder before initiating any treatment, as antidepressant monotherapy is contraindicated in bipolar disorder. 5, 6

Key Diagnostic Features to Assess:

• Duration and quality of "episodic increased energy" episodes: Do these represent hypomanic/manic episodes (≥4 days with decreased need for sleep, grandiosity, increased goal-directed activity) versus anxiety-driven agitation? 5
• Pattern of mood episodes: Are mood shifts reactive to stressors (suggesting personality pathology) versus autonomous episodes with neurovegetative changes (suggesting bipolar disorder)? 5
• Sleep patterns during high-energy periods: Decreased need for sleep (bipolar) versus insomnia with fatigue (anxiety/depression)? 5
• Functional impairment pattern: Does it occur across multiple settings or only in interpersonal contexts? 5

If Bipolar Disorder is Confirmed or Strongly Suspected

First-Line Pharmacotherapy:

Initiate a mood stabilizer (lithium, lamotrigine, or valproate) or quetiapine monotherapy as first-line treatment, avoiding antidepressant monotherapy which is contraindicated due to risk of mood destabilization. 7, 6, 8

Lithium as Preferred Option:

• Lithium is FDA-approved for bipolar disorder in adults and shows superior evidence for long-term efficacy in preventing both manic and depressive episodes 6
• Lithium has specific anti-suicide effects independent of mood-stabilizing properties, reducing suicide attempts 8.6-fold and completed suicides 9-fold, making it particularly appropriate given passive death wishes 7, 6
• Target therapeutic level: 0.8-1.2 mEq/L for acute treatment 6
• Baseline monitoring: Complete blood count, thyroid function tests, urinalysis, BUN, creatinine, serum calcium, pregnancy test 6
• Ongoing monitoring: Lithium levels, renal and thyroid function every 3-6 months 6

Alternative: Quetiapine Monotherapy:

• Quetiapine is FDA-approved for acute treatment of both manic and depressive episodes in bipolar disorder 8
• Quetiapine (with or without mood stabilizer) is recommended as first-line for bipolar depression with strong efficacy evidence 7
• Addresses anxiety symptoms, intrusive thoughts, and sleep disturbance simultaneously 8

Maintenance Therapy:

• Continue effective regimen for minimum 12-24 months after stabilization; some patients require lifelong treatment 6
• Withdrawal of lithium dramatically increases relapse risk, especially within 6 months, with >90% of noncompliant patients relapsing versus 37.5% of compliant patients 6

If Bipolar Disorder is Ruled Out

For Major Depressive Disorder with Anxiety:

Initiate SSRI (sertraline or escitalopram preferred) combined with cognitive-behavioral therapy, as combination treatment is superior to either alone. 5

• Antidepressants should not be used for initial treatment of mild depressive episodes 5
• For moderate-to-severe depression, tricyclic antidepressants or fluoxetine should be considered 5
• Antidepressant treatment should continue for 9-12 months after recovery 5

For Anxiety and Intrusive Thoughts:

• Cognitive-behavioral therapy based on CBT principles is first-line for anxiety symptoms and should be considered for all patients 5
• SSRIs or SNRIs are suggested for pharmacological treatment of anxiety disorders 5
• Benzodiazepines should not be used for initial treatment of individuals with depressive symptoms in absence of current depressive episode 5

Essential Psychosocial Interventions (Regardless of Diagnosis)

Psychoeducation and evidence-based psychotherapy must accompany any pharmacotherapy to improve outcomes. 5, 6

Cognitive-Behavioral Therapy:

• CBT has strong evidence for emotional dysregulation, anxiety, and depression components 6
• Problem-solving treatment should be considered for individuals in distress with impaired functioning 5
• If face-to-face CBT is not desired, self-help with support based on CBT principles is suggested 5

Trauma-Focused Treatment:

• Direct trauma-focused treatment should be initiated without delay, as phase-based stabilization approaches lack empirical support and unnecessarily delay effective treatment 9
• Comorbidity does not negatively affect trauma-focused treatment efficacy 9
• Grief-focused CBT (if trauma involves loss) consists of 20-25 sessions incorporating exposure to grief memories, cognitive restructuring, and behavioral activation 9

Family Intervention:

• Family-focused therapy helps with medication supervision, early warning sign identification, and reducing access to lethal means (important given passive death wishes) 6
• Psychoeducation about symptoms, course of illness, treatment options, and critical importance of medication adherence 6

Addressing Specific Symptoms

Sleep Disturbance:

• Quetiapine addresses sleep disturbance as part of its therapeutic profile 8
• Relaxation training and advice on physical activity may be considered as adjunct treatment 5

Binge Eating:

• CBT principles should address eating patterns and emotional regulation 5
• Bupropion (if depression confirmed and bipolar ruled out) may help with impulse control, though must be combined with mood stabilizer if any bipolar risk 6

Obsessive Traits:

• CBT-based psychological treatment should be considered for obsessive symptoms 5
• SSRIs (if bipolar ruled out) have efficacy for obsessive-compulsive symptoms 5

Critical Safety Considerations

Suicide Risk Management:

• Close monitoring required given passive death wishes, particularly during first few months of treatment and at dose changes 8
• Lithium's anti-suicide effects make it preferred if bipolar disorder confirmed 7, 6
• Prescribe smallest quantity of medication consistent with good management to reduce overdose risk 8
• Family members should be engaged to restrict access to lethal means 6

Cannabis Use Monitoring:

• Assess cannabis use at every visit, as continued use will undermine treatment response 1, 2
• Consider referral to substance use treatment if patient unable to discontinue independently 2

Common Pitfalls to Avoid

• Never initiate antidepressant monotherapy without ruling out bipolar disorder, as this can trigger manic episodes or rapid cycling 7, 6
• Do not use benzodiazepines as primary treatment for anxiety in context of mood instability 5
• Avoid premature discontinuation of effective medications—maintenance therapy requires 12-24 months minimum 6
• Do not delay trauma-focused treatment with prolonged stabilization phases 9
• Never ignore ongoing cannabis use, as it significantly worsens prognosis in mood disorders 1, 2, 3

Follow-Up Schedule

• Weekly visits initially to assess medication response, suicidal ideation, cannabis use, and medication adherence 6
• Monthly visits once stable 6
• Reassess diagnosis if treatment response is poor or if manic symptoms emerge 5, 8