How should I assess and manage a 52‑year‑old female presenting for psychiatric follow‑up after an Emergency Department overdose of sleeping pills, who has severe Major Depressive Disorder (MDD) with a Patient Health Questionnaire‑9 (PHQ‑9) score of 15, 20‑lb weight loss (Body Mass Index 17.5), insomnia, psychomotor retardation, impaired concentration, and a recent suicide attempt?

Assessment and Management of Severe MDD with Recent Suicide Attempt

This patient requires immediate psychiatric hospitalization given her persistent high-risk features: recent high-lethality suicide attempt (overdose), severe depression with PHQ-9 of 15, inability to maintain safety (as evidenced by the attempt), severe malnutrition (BMI 17.5), and multiple indicators of acute suicide risk. 1, 2

Immediate Risk Stratification and Disposition

Admit to inpatient psychiatric facility immediately based on the following high-risk criteria that mandate hospitalization 1, 2, 3:

• Recent suicide attempt with sleeping pills (high-lethality method with clear intent) 1
• Severe functional impairment (20-lb weight loss, BMI 17.5, psychomotor retardation) 1
• Multiple acute risk factors (insomnia, impaired concentration, anhedonia, early morning awakening) 1
• Need to rule out bipolar disorder before initiating antidepressant monotherapy (critical to prevent manic switch and worsening suicidality) 2

The 2016 Pediatrics guidelines (applicable to adults) specify that patients with recent suicide attempts, continued distress, or inability to engage in safety planning require inpatient admission once medically cleared 1. This patient's recent ED overdose qualifies as a high-lethality attempt requiring the highest level of care 1.

Critical Pre-Treatment Assessment

Essential Information to Obtain Before Treatment Decisions 1, 2:

• Exact number and type of pills ingested (determines lethality and intent) 1
• Suicidal intent at time of overdose (expectation of death vs. impulsive act) 1
• Current suicidal ideation using C-SSRS (structured assessment of current risk) 1
• Access to remaining medications, firearms, and other lethal means 1, 3
• Whether patient sought help or was found (indicates ambivalence vs. clear intent) 1
• Lifetime history of hypomania or mania (rule out bipolar II disorder—critical before antidepressant initiation) 2
• Substance use history (alcohol, illicit drugs—increases impulsivity and risk) 1
• Duration of depressive symptoms prior to bereavement (distinguishes MDD from bereavement-related depression) 1
• Family history of bipolar disorder or suicide 2

Mental Status Examination Components 1:

• Appearance and psychomotor activity (document retardation severity) 1
• Thought process (linear vs. tangential, racing thoughts suggesting hypomania) 1
• Thought content (active suicidal ideation, plan, intent, hallucinations, delusions) 1
• Mood and affect (severity of hopelessness—strongest predictor of imminent risk) 1
• Insight and judgment (ability to engage in safety planning) 1
• Screen for delirium (medical causes of psychiatric symptoms) 1

Mandatory Laboratory and Diagnostic Testing 1:

The 2006 Annals of Emergency Medicine guidelines recommend focused testing based on clinical presentation rather than routine screening 1. However, given this patient's severe malnutrition (BMI 17.5), overdose history, and need to rule out medical causes:

• Urine drug screen (detect substances contributing to overdose or ongoing use) 1
• Comprehensive metabolic panel (electrolyte abnormalities from malnutrition, renal function before lithium) 1
• Complete blood count (anemia from malnutrition) 1
• Thyroid-stimulating hormone (hypothyroidism mimics depression) 1
• Vitamin B12 and folate (deficiency causes depression and cognitive impairment) 1
• Vitamin D (deficiency associated with depression) 1
• Pregnancy test if applicable (alters medication choices) 1

Immediate Safety Interventions During Hospitalization

Lethal Means Restriction (Implement Before Any Discharge Consideration) 1, 2, 3:

• Remove all firearms from home and any locations patient frequents (firearms have 85% case-fatality rate vs. 2% for medication overdose) 1, 3
• Lock all medications with third-party control (family member, not patient) 1, 3
• Secure knives and sharp objects 1, 3
• Assess access to means at friends' or relatives' homes 1, 3
• Do not rely on patient's assurances about secured weapons—family often underestimates patient's ability to access supposedly locked items 1, 3

Structured Safety Planning (Collaborative Development) 1, 2, 3:

Do not use "no-suicide contracts"—these have no proven efficacy and may impair therapeutic engagement by encouraging deceit 3. Instead, develop a comprehensive safety plan including 1, 2, 3:

1. Warning signs and triggers (specific situations, thoughts, or feelings that precede suicidal urges) 1, 2
2. Internal coping strategies (activities patient can do independently without contacting others) 1, 2
3. Social supports (specific people to contact, with phone numbers) 1, 2
4. Professional contacts (crisis line, therapist, psychiatrist with 24-hour access instructions) 1, 2
5. Instructions for reaccessing emergency services (when to call 911 or go to ED) 1, 2
6. Means restriction verification (documented removal of lethal means) 1, 2, 3

Pharmacological Management Algorithm

Step 1: Rule Out Bipolar Disorder BEFORE Initiating Antidepressants 2

Critical pitfall to avoid: Antidepressant monotherapy in undiagnosed bipolar II disorder increases suicide risk 7-fold and can precipitate rapid cycling or mixed states 2. The differential diagnosis appropriately includes bipolar II disorder, which must be systematically ruled out through 2:

• Lifetime history of hypomanic episodes (4+ days of elevated/irritable mood with increased energy) 2
• Family history of bipolar disorder 2
• History of antidepressant-induced activation, agitation, or mood switching 2
• Early age of depression onset (before age 25 suggests bipolar) 2
• Recurrent depressive episodes (≥3 episodes suggests bipolar) 2

Step 2: First-Line Pharmacotherapy Based on Diagnosis 2, 4, 5

If Bipolar II Disorder is Confirmed or Strongly Suspected 2:

• Initiate lithium immediately as the only medication with strong evidence for reducing suicide risk in bipolar disorder (reduces suicide attempts 8.6-fold and completions 9-fold) 2
• Lithium requires careful third-party supervision given overdose lethality 2
• Monitor lithium levels, renal function, and thyroid function 2
• Do not discontinue lithium abruptly (increases suicide attempt rate 7-fold and completion rate 9-fold) 2
• Add antidepressant only after mood stabilization with lithium or other mood stabilizer 2

If Major Depressive Disorder is Confirmed (Bipolar Ruled Out) 4, 5:

• Initiate SSRI (sertraline 50 mg daily) or SNRI (venlafaxine 37.5-75 mg daily) as first-line agents for severe MDD 4, 5
• Sertraline is FDA-approved for major depressive disorder and has established efficacy in 6-8 week trials 4
• Venlafaxine is FDA-approved for major depressive disorder with demonstrated efficacy in maintaining antidepressant response up to 26 weeks 5
• Titrate to therapeutic doses over 1-2 weeks based on tolerability 4, 5
• Monitor closely for activation, agitation, or emergence of suicidal ideation (particularly in first 4 weeks) 4, 5

Step 3: Adjunctive Pharmacotherapy for Acute Suicidal Ideation 1

Consider ketamine infusion (0.5 mg/kg IV over 40 minutes) as adjunctive treatment for short-term reduction in suicidal ideation in patients with MDD and active suicidal ideation 1. The 2025 VA/DoD guidelines provide a weak recommendation for ketamine based on evidence showing rapid (within 24 hours) reduction in suicidal ideation 1. However, there is insufficient evidence that ketamine reduces suicide attempts or deaths 1.

Critical Medication Pitfalls to Avoid 2:

• Do not prescribe benzodiazepines or phenobarbital to suicidal patients (reduce self-control and increase impulsivity) 2
• Do not continue antidepressant monotherapy without ruling out bipolar disorder 2
• Do not abruptly discontinue any psychotropic medications (increases risk) 2

Psychotherapeutic Interventions

Evidence-Based Psychotherapy (Initiate During Hospitalization) 1, 2:

Cognitive behavioral therapy focused on suicide prevention is the psychotherapy of choice for patients with recent suicidal behavior 1, 2. The 2025 VA/DoD guidelines and American Psychological Association recommend CBT-based approaches as they reduce both suicide attempts and suicidal ideation in patients with self-directed violence history 1, 2.

Specific CBT components to include 1, 2:

• Problem-solving therapy (addressing precipitants like bereavement, weight loss, insomnia) 1, 2
• Cognitive restructuring (challenging hopelessness and worthlessness cognitions) 1, 2
• Behavioral activation (addressing anhedonia and psychomotor retardation) 1, 2
• Sleep hygiene and insomnia treatment (insomnia is a warning sign for imminent suicidal behavior) 1

Insufficient evidence exists for dialectical behavior therapy specifically for suicide reduction in MDD (evidence is stronger for borderline personality disorder) 1.

Discharge Planning and Follow-Up Structure

Criteria for Discharge Consideration 1, 2, 3:

Do not discharge until ALL of the following are met 1, 2, 3:

• No active suicidal ideation with intent or plan 1, 3
• Able to engage meaningfully in safety planning discussions 1, 3
• Documented removal of lethal means from all accessible locations 1, 3
• Adequate support system with responsible adult supervision confirmed 1, 3
• Scheduled psychiatric follow-up within 7 days (ideally within 48-72 hours) 1, 6
• Initiated evidence-based psychotherapy (CBT for suicide prevention) 1, 2
• Stabilized on appropriate pharmacotherapy (with bipolar disorder ruled out if on antidepressants) 2, 4, 5
• Nutritional stabilization plan (BMI 17.5 requires medical nutrition intervention) 7

Post-Discharge Follow-Up Protocol 1, 6:

Send periodic caring communications (postal mail or text messages) for 12 months following hospitalization to reduce suicide attempt risk 1. The 2025 VA/DoD guidelines provide a weak recommendation for this intervention based on evidence showing reduced reattempt rates 1.

Schedule intensive outpatient follow-up 1, 6:

• Psychiatric appointment within 48-72 hours (not 14 days—40% of patients fail to follow up within 14 days) 6
• Weekly psychiatric visits for first month 1
• Weekly psychotherapy sessions (CBT for suicide prevention) 1, 2
• Greatest risk of reattempt is in first months after discharge 1

Special Considerations for This Patient

Severe Malnutrition (BMI 17.5) and Treatment Response 7:

Underweight patients (BMI <18.5) show the best improvement to antidepressant treatment compared to normal weight or overweight patients 7. A 2021 study found that underweight MDD patients had greater HAMD-17 reduction and were 2 times more likely to achieve remission than overweight patients 7. However, severe malnutrition requires concurrent medical management:

• Nutritional consultation and refeeding protocol (prevent refeeding syndrome) 7
• Monitor electrolytes closely (hypokalemia, hypophosphatemia, hypomagnesemia) 7
• Address medical complications of malnutrition (cardiac, endocrine, bone health) 7

Insomnia as Warning Sign for Imminent Risk 1:

Sleep disturbance is a precipitant for suicidal behavior and requires aggressive treatment 1. A 2020 meta-analysis found that sleep disturbance predicts suicide attempts with medium-to-large effect sizes at short follow-up intervals 1. Address insomnia through:

• CBT for insomnia (first-line, non-pharmacological) 1
• Sleep hygiene education 1
• Consider trazodone or mirtazapine (dual benefit for depression and sleep) 1
• Avoid benzodiazepines (increase impulsivity and suicide risk) 2

PHQ-9 Score of 15 Interpretation 8, 9, 10:

PHQ-9 score of 15 indicates moderately severe depression (scores 15-19 = moderately severe; ≥20 = severe) 8. The PHQ-9 has 88% sensitivity and 88% specificity for major depression at cut-off ≥10 8, 9. However, PHQ-9 should not be used in isolation for suicide risk assessment—it includes only one suicide item and does not assess intent, plan, or access to means 8, 9, 10. Use C-SSRS for comprehensive suicide risk assessment 1.

Summary of Critical Pitfalls to Avoid

1. Do not discharge from ED without psychiatric admission given recent high-lethality attempt and persistent risk factors 1, 2, 3
2. Do not initiate antidepressant monotherapy without ruling out bipolar II disorder (increases suicide risk 7-fold) 2
3. Do not rely on "no-suicide contracts" (no proven efficacy) 3
4. Do not underestimate access to locked firearms or medications (patients frequently find ways to access secured items) 1, 3
5. Do not prescribe benzodiazepines (reduce self-control and increase impulsivity) 2
6. Do not schedule follow-up beyond 72 hours post-discharge (40% fail to follow up within 14 days) 6
7. Do not ignore severe malnutrition (BMI 17.5 requires concurrent medical management) 7
8. Do not treat insomnia inadequately (sleep disturbance is a warning sign for imminent suicidal behavior) 1