What is the best treatment approach for an 18-year-old female patient with a history of depression, anxiety, self-harm thoughts, and suicidal ideation, who has previously responded partially to [MEDICATION] (Generic Name) 20 mg daily, and also has severe acid reflux, a history of substance use (vaping nicotine), and past psychiatric hospitalizations?

Treatment Approach for 18-Year-Old Female with Depression, Anxiety, Self-Harm Thoughts, and Suicidal Ideation

This patient requires immediate implementation of Dialectical Behavior Therapy for Adolescents (DBT-A) as the primary intervention, combined with continuation of her current antidepressant regimen, comprehensive safety planning, and close monitoring—pharmacotherapy alone is insufficient for preventing self-harm and suicide in young people. 1

Immediate Safety Management

Comprehensive therapeutic assessment must be completed now, not just risk stratification. 1 This assessment should:

• Develop a collaborative crisis response plan identifying specific warning signs (e.g., when her intent reaches 7-8/10), concrete coping strategies she can use, social support contacts including her boyfriend, and crisis resources with 24/7 availability 1, 2
• Restrict access to lethal means by working with her adoptive mother to remove or secure medications (especially given multiple psychiatric medications in the home), ensure no firearm access (already confirmed), and address any other potential means 1, 3
• Establish that a responsible adult (her mother) will monitor medication administration and report mood changes, increased agitation, or concerning behaviors 2

Critical pitfall to avoid: Do not use "no-suicide contracts"—there is zero empirical evidence supporting their efficacy, and they provide false reassurance while potentially damaging the therapeutic relationship. 1, 2, 4

Primary Treatment: Psychotherapy

DBT-A is the evidence-based first-line treatment showing the most promise for reducing both absolute repetition of self-harm and frequency of repeated self-harm in young people. 1 While DBT-A is intensive (typically 6-12 months with weekly individual therapy, weekly skills group, phone coaching, and therapist consultation team), this patient's clinical picture—fluctuating high intent (8/10), active and passive SI, history of multiple hospitalizations, and treatment-resistant depression—justifies this level of intervention. 1

DBT-A specifically addresses:

• Emotion regulation skills for her irritable mood and anxiety
• Distress tolerance for managing urges to self-harm
• Interpersonal effectiveness for relationship functioning
• Mindfulness to reduce dissociation and increase present-moment awareness 2, 3, 5

If DBT-A is not immediately accessible, initiate cognitive-behavioral therapy specifically adapted for adolescent suicide prevention, which has been shown to reduce suicide attempts by 50% compared to treatment as usual. 2, 4 The CBT must include specific self-harm and suicidal-related content, not just depression treatment, as self-harm ideation can persist even when depression improves. 1

Family Involvement

Greater family involvement reduces non-adherence and improves outcomes. 1 Her adoptive mother should be:

• Included in treatment planning and psychoeducation sessions
• Taught to recognize warning signs and activate the crisis plan
• Supported in maintaining appropriate boundaries while providing monitoring
• Educated about the chronic nature of her daughter's conditions and realistic treatment timelines 1

The extent of involvement should respect the patient's autonomy as an 18-year-old while recognizing her continued dependence and safety needs. 1

Pharmacotherapy Management

Pharmacotherapy is NOT recommended solely for prevention of self-harm or suicide in young people—there are no published trials demonstrating efficacy for these endpoints. 1 However, treating underlying psychiatric disorders is essential. 1

Current Medication Review:

Her current regimen includes medications that require evaluation:

• Continue the current antidepressant (appears to be venlafaxine 150mg + 37.5mg based on dosing), as she has partial response history to this class and switching during acute crisis increases risk 2, 6
• The 300mg daily medication (likely gabapentin or another adjunct) should be continued if providing benefit
• The 25mg PRN medication (likely hydroxyzine or similar) is appropriate for acute anxiety

Medication Considerations:

If medication changes are needed after acute stabilization: Consider switching to an SSRI (sertraline or fluoxetine) which have better evidence for treating depression with suicidal features and safer overdose profiles. 2, 4 However, any antidepressant change requires intensive monitoring during the first 10-14 days due to increased suicide risk during this period. 5, 6

Avoid entirely:

• Tricyclic antidepressants due to high lethality in overdose 2, 4
• Benzodiazepines for regular use, as they may increase disinhibition and impulsivity in patients with suicidal ideation 2, 4

For treatment-resistant cases: If she fails to respond adequately to psychotherapy plus optimized antidepressant treatment, consider lithium augmentation, which has specific anti-suicide effects independent of mood stabilization. 1, 5, 6

Addressing Comorbid Conditions

Her severe acid reflux can exacerbate anxiety and must be managed concurrently with her PCP. [@Clinical context from case] Ensure she understands the bidirectional relationship between physical symptoms and anxiety.

Nicotine vaping cessation should be addressed but not as an immediate priority during acute suicidal crisis. [@2@] Once stabilized, incorporate smoking cessation into her treatment plan, as substance use (including nicotine) complicates mood disorder treatment. [@3@]

Follow-Up Protocol

Schedule definite, closely-spaced appointments:

• Weekly therapy sessions initially
• Psychiatric follow-up every 1-2 weeks during acute phase
• Contact her immediately if she misses any appointment—the highest risk period is in the months following crisis [@7@, 2, @10@]

Implement caring contact interventions: Send periodic caring communications (text messages given her age) for 12 months, which may reduce suicide attempts. [@8@, @10@] These should be brief, non-demanding messages expressing care and providing crisis resources.

Therapeutic Relationship

Establish an empathic, honest, and consistent therapeutic relationship using approaches like Collaborative Assessment and Management of Suicidality, which improve engagement between therapists and young people. 1 Given her history of "everything was going fine" while actually experiencing self-harm thoughts, she needs a therapeutic environment where she feels safe disclosing distress without fear of coercive hospitalization. [1, @7@]

Hospitalization Decision-Making

Current presentation does not mandate immediate psychiatric hospitalization given: no imminent plan, no active intent at this moment, confirmed absence of firearm access, and presence of supportive adoptive mother who can provide monitoring. [@2@, @7@]

However, hospitalization becomes necessary if:

• She develops a specific plan with intent and means
• Her intent remains consistently 8/10 or higher
• She cannot contract for safety in a meaningful way (different from no-suicide contracts)
• Her mother cannot provide adequate supervision
• She experiences acute psychotic symptoms or severe agitation [@2@, 1, @13@]

Treatment Duration

Antidepressant treatment should continue for at least 4-9 months after achieving remission for a first episode. [@9@] Given her multiple hospitalizations and chronic course, she likely requires indefinite maintenance treatment. [@9@] DBT-A typically runs 6-12 months but may need extension given severity. [@1@]

Monitoring for Treatment Response

If no adequate response within 6-8 weeks of optimized treatment, modify the approach by intensifying psychotherapy frequency, considering medication adjustment, or adding lithium augmentation. [@9@] For severe, persistent suicidal ideation despite optimal treatment, ketamine infusion (0.5 mg/kg IV over 40 minutes) can provide rapid reduction beginning within 24 hours, though effects last only up to one week. [@8@, 4, @10