What is the appropriate management for an 18-year-old female with a history of substance abuse, recent onset of auditory hallucinations and delusions, and a background of trauma and significant behavioral changes, who is at risk of harming herself or others?

Kailangan ng Agarang Psychiatric Hospitalization

Ang 18-anyos na babaeng ito ay may malubhang panganib sa sarili at sa iba dahil sa active auditory hallucinations, delusions, at kasaysayan ng substance abuse at trauma—kailangan ng immediate involuntary psychiatric hospitalization kahit na tumanggi siya. 1

Immediate Risk Assessment

Ang pasyenteng ito ay nasa maximum risk category dahil sa:

• Active psychotic symptoms: Naririnig ang mga boses at may delusion na "baka mamatay ako sa hangin kapag lumabas ako" 2
• Severe behavioral deterioration: Hindi nakakatulog ng 2 araw, tumatawa mag-isa, self-harm behavior (nilagay ang lighter sa tenga para sirain ang eardrums) 3
• Substance abuse: Regular alcohol intake hanggang pass out, smoker 3
• History of sexual assault: Hinawakan ang 14-year-old cousin habang intoxicated, indicating severe impulsivity and risk to others 3
• Severe depression with psychotic features: 1 month ng sobrang lungkot kasama ng auditory hallucinations 2
• Social withdrawal and self-neglect: Hindi naliligo ng 5 days, nakakatulog sa tabi ng aso 3

Tawagan ang 911 o Dalhin sa Emergency Department Ngayon

Kailangan ng immediate transport via emergency services dahil ang pasyente ay may: 1

• Active suicidal/self-harm behavior (sinira ang sariling eardrums)
• Psychotic symptoms na may severe agitation
• Inability to care for self (hindi natutulog, hindi naliligo)
• Risk to others (sexual assault history habang intoxicated)
• Severe substance abuse complicating mental status

Habang naghihintay ng transport: 1

• Continuous 1:1 observation—hindi pwedeng iwanan mag-isa kahit sandali
• Alisin lahat ng potential weapons, medications, sharps sa paligid
• Search patient at belongings para sa anumang means of harm
• Keep in safe environment without access to windows, equipment, o anumang pwedeng gamitin para makasakit

Mandatory Safety Interventions Bago Umalis ng Bahay

Explicit instructions sa pamilya (kahit papunta na sa hospital, applicable ito pagbalik): 1

• Remove ALL firearms mula sa bahay—kahit naka-lock, makikita pa rin ng adolescent 3
• Lock up ALL medications—prescription at over-the-counter 3
• Restrict access to alcohol—kailangan ng complete removal dahil sa substance abuse history 3
• Secure knives and other sharp objects 1

Diagnosis at Underlying Conditions

Ang combination ng symptoms ay strongly suggestive ng: 2

Primary concern: Major Depressive Disorder with Psychotic Features

• Severe depression (1 month ng sobrang lungkot) 2
• Auditory hallucinations ("boses ng tao naririnig ko") 2
• Delusions (takot mamatay sa hangin) 2
• Severe hopelessness at agitation 3

Comorbid conditions na kailangan i-address: 2

• Substance Use Disorder: Regular alcohol abuse, smoking 3
• Post-Traumatic Stress Disorder: History ng trauma (death ng relative, sexual assault perpetration habang intoxicated) 2
• Possible emerging personality disorder: Severe impulsivity, unstable mood, self-harm behavior 2

Critical distinction: Ang auditory hallucinations sa context ng severe depression with trauma history ay maaaring dissociative voices (trauma-driven) kaysa purely psychotic 4. However, ang presence ng delusions at severe functional impairment indicates psychotic features requiring antipsychotic treatment 3.

Hospital Treatment Plan

First-line pharmacologic treatment sa emergency setting: 3

• Atypical antipsychotics para sa psychotic features (hallucinations, delusions causing distress) 3
• Benzodiazepines para sa acute agitation kung kinakailangan 3
• Avoid typical antipsychotics (haloperidol) as first-line dahil mas mataas ang side effects 3

Inpatient psychiatric hospitalization goals: 3

• Safe, protected environment para sa complete evaluation 3
• Medical workup para sa organic causes (infection, delirium, substance withdrawal) 3
• Initiation ng appropriate psychotropic medications 3
• Substance abuse detoxification at stabilization 3
• Trauma-focused assessment 2
• Family education at engagement 3

Common Pitfalls na Iwasan

HUWAG gumamit ng "no-suicide contract"—proven ineffective at nagbibigay ng false reassurance 1, 3. Instead, develop collaborative safety plan with specific coping strategies pagdating ng follow-up 1.

HUWAG mag-rely sa family reassurance alone—families often underestimate risk at overestimate supervision ability 1. Ang severity ng symptoms (psychosis, self-harm, substance abuse) requires professional psychiatric care 3.

HUWAG i-underestimate ang risk based sa previous low-lethality behaviors—ang intent matters more than actual lethality 3. Ang self-harm behavior (sinira ang eardrums) indicates escalating severity 2.

HUWAG maghintay ng "voluntary" agreement—ang presence ng psychotic symptoms with inability to care for self meets criteria for involuntary hold 1.

Post-Discharge Planning (Para sa Future)

Pagkatapos ng psychiatric stabilization, kailangan ng: 3

• Long-term psychiatric follow-up within days, hindi weeks 1
• Substance abuse treatment program—simultaneous treatment ng psychiatric at substance use disorders 2
• Trauma-focused psychotherapy (Cognitive-Behavioral Therapy o Dialectical Behavior Therapy) 5
• Family therapy para sa support system development 3
• Close monitoring ng medication compliance at symptom recurrence 3
• Collaborative care between psychiatry at primary care 1

Ang greatest risk for reattempt occurs in the months immediately following initial presentation—kaya critical ang close follow-up 5.