What is the diagnosis and treatment plan for a 44-year-old Caucasian female with a history of Crohn's disease, cannabis use disorder, and no prior psychiatric hospitalizations, presenting with new-onset psychosis, severe paranoia, delusions, hallucinations, suicidal ideation, and homicidal ideation?

Diagnosis and Treatment Plan

Primary Diagnosis

This patient presents with first-episode psychosis with severe depressive features, most consistent with Major Depressive Disorder with Psychotic Features, complicated by cannabis use disorder and acute high suicide risk. 1, 2

The presentation includes:

• Command auditory hallucinations instructing self-harm (significantly elevates short-term suicide risk) 1
• Visual hallucinations (figures, shadows, death-related imagery) 1
• Persecutory delusions and severe paranoia 1
• Depressive symptoms with suicidal ideation, intent, and multiple contemplated methods 1, 2
• New-onset psychosis without prior psychiatric history 3
• Cannabis use disorder (cannabis can trigger psychosis, particularly with high THC content) 3

Critical differential consideration: While delirium must be excluded given the acute presentation, the patient's intact orientation to person/place/situation, absence of fluctuating consciousness, and clear temporal progression over weeks favor primary psychiatric illness over delirium 3, 4. However, medical workup remains mandatory given Crohn's disease and elevated blood pressure 3.

Immediate Safety and Risk Stratification

This patient requires continued high-risk suicide precautions with 15-minute observations. 1 Multiple factors converge to create extreme risk:

• Command hallucinations to self-harm 1
• Multiple high-lethality suicide methods contemplated (running into traffic, drowning, cutting) 1
• C-SSRS score >16 with suicidal intent and plan 1
• Frequency 2-5 times weekly, duration 1-4 hours, difficulty controlling thoughts 1
• Recent unsafe wandering behavior (20 hours resulting in dehydration and injuries) 1
• Hopelessness and impaired judgment 2
• Social isolation and unemployment (lack of protective factors) 2

Environmental safety measures must include: personal belongings search, hospital attire, safe room without access to potential means, and continuous monitoring 1.

Required Medical Workup

Before finalizing psychiatric diagnosis, the following must be completed to exclude organic causes of new-onset psychosis: 3

• Complete metabolic panel, CBC, liver function tests (already ordered appropriately)
• Thyroid function (TSH, free T4) 3
• Urinalysis and urine drug screen (to assess cannabis use and exclude other substances) 3
• Vitamin B12 and folate levels 3
• Rapid plasma reagin (RPR) for syphilis 3
• HIV testing 3
• Pregnancy test (if applicable) 3
• Neuroimaging (MRI brain preferred over CT) is indicated given new-onset psychosis at age 44, atypical presentation with prominent visual hallucinations, and need to exclude structural lesions, particularly given Crohn's disease history (risk of CNS complications) 3

The elevated blood pressure (164/92 mmHg) requires monitoring as it may represent hypertensive emergency contributing to symptoms or may be secondary to acute psychiatric distress 3.

Pharmacological Treatment Plan

Antipsychotic Therapy

Initiate low-dose atypical antipsychotic immediately for first-episode psychosis. 3, 1 The current regimen appears appropriate but requires clarification:

Recommended approach:

• Start with risperidone 1-2 mg/day or olanzapine 5-10 mg/day (lower end of dosing for first episode) 3
• Avoid high doses in first-episode psychosis as they increase side effects without improving efficacy 3, 1
• Maximum doses should not exceed 4 mg/day risperidone or 20 mg/day olanzapine initially 3
• Therapeutic trial duration: 4-6 weeks minimum before assessing efficacy 1

Rationale for atypical antipsychotics: Lower risk of extrapyramidal symptoms, better tolerability in first episode, and efficacy for both psychotic and depressive symptoms 3.

Critical monitoring (given olanzapine FDA warnings): 5

• Metabolic parameters: fasting glucose, lipid panel, weight/BMI (patient already has BMI 34.2)
• Blood pressure monitoring (already elevated at baseline)
• Extrapyramidal symptoms
• Sedation and orthostatic hypotension

Adjunctive Medications

Hydroxyzine for acute anxiety and agitation is appropriate as it provides anxiolysis without worsening psychosis or adding extrapyramidal side effects, and does not interact adversely with antipsychotics 1.

Antidepressant therapy should be deferred until psychotic symptoms are controlled with antipsychotic medication, as treating depression with psychotic features requires antipsychotic coverage first 1.

Sleep restoration is critical: Consider adding trazodone 50-100 mg at bedtime or increasing hydroxyzine dosing at night, as the patient reports only 1-3 hours sleep nightly, which perpetuates psychosis and suicidality 3.

Psychosocial Interventions

The following non-pharmacological interventions are mandatory components of treatment: 3

• Daily suicide risk assessment including command hallucinations, intent, plan, and patient's intended course of action if symptoms worsen 1
• Supportive psychotherapy with active problem-solving orientation focused on developing coping skills for psychotic symptoms 3
• Family psychoeducation and engagement: Parents are identified as primary support; provide multi-family psychoeducation sessions explaining first-episode psychosis, treatment expectations, and early warning signs of relapse 3
• Recovery-focused work: Help patient find meaning in the psychotic experience and develop mastery over symptoms 3
• Address secondary comorbidities: Cannabis use disorder requires specific intervention; patient must understand the link between cannabis (especially high-THC products) and psychosis risk 3

Hospitalization Duration and Discharge Planning

Hospitalization must continue until: 3, 1

• Suicidal ideation resolves or becomes manageable
• Command hallucinations cease or patient demonstrates ability to resist them
• Psychotic symptoms show meaningful improvement
• Sleep pattern normalizes
• Patient demonstrates insight into illness and medication adherence

Premature discharge is contraindicated when: 1

• Patient endorses persistent wish to die
• Severe hopelessness remains
• Homelessness without adequate support system (patient living with mother, but relationship strained by paranoia)
• Lack of concrete follow-up plan

Discharge planning must include: 3, 1

• Transition to specialized early psychosis intervention program (patient should remain in comprehensive, multidisciplinary specialist care, not be discharged to primary care alone) 3
• Scheduled outpatient psychiatry appointment within 7 days of discharge
• Case management services to address unemployment and financial problems
• Substance use treatment for cannabis use disorder 3
• Family therapy to repair strained relationships and establish monitoring system 3
• Early warning signs plan: Develop written plan with patient and family identifying prodromal symptoms of relapse (increased paranoia, sleep disruption, social withdrawal) 3

Treatment Timeline and Monitoring

Acute phase (first 6-8 weeks): 3, 1

• Daily inpatient monitoring of suicidality, psychosis, and medication response
• Weekly assessment of metabolic parameters given olanzapine use and baseline obesity 5
• Target: resolution of acute suicidality and stabilization of psychotic symptoms

Critical period (first 18 months): 3

• Maintain continuity with same treating clinician throughout this period 3
• Continue antipsychotic medication for minimum 6 months to 2 years after symptom resolution 3
• After sustained remission, attempt slow dose reduction to determine minimal effective dose 3
• 80% of patients remain vulnerable to relapse during first few years; vigilance required 3

Long-term considerations: 3

• If patient experiences frequent relapses, long-term medication is advisable 3
• Ongoing specialist involvement required; early intervention services should not discharge to primary care without continuing specialist partnership 3

Critical Pitfalls to Avoid

Do not:

• Discharge while command hallucinations persist or patient lacks ability to resist them 1
• Use high-dose antipsychotics in first episode (increases side effects without benefit) 3, 1
• Treat depression with antidepressants alone before controlling psychosis 1
• Minimize the role of cannabis use disorder in triggering and perpetuating psychosis 3
• Fail to monitor metabolic parameters (patient has obesity, elevated BP, and is receiving olanzapine) 5
• Discharge without concrete follow-up in specialized early psychosis program 3
• Overlook Crohn's disease as potential contributor to psychiatric symptoms (though association is primarily with depression, not psychosis) 6
• Assume involuntary treatment will be needed long-term; it should be time-limited to allow engagement 3

Do:

• Maintain high index of suspicion for medical causes given age 44 presentation and Crohn's disease 3
• Engage family as partners in treatment despite current strain 3
• Address developmental disruption (unemployment, separation from children) as part of recovery 3
• Establish therapeutic alliance and emphasize that prognosis for first-episode psychosis can be good with appropriate treatment 3