What is the most likely diagnosis for an adult female with chronic major depressive disorder, generalized anxiety disorder, attention‑deficit/hyperactivity disorder, and a trauma history who now experiences daily intrusive, unwanted passive suicidal thoughts of death without a plan or intent?

Major Depressive Disorder with Passive Suicidal Ideation

This patient has Major Depressive Disorder (MDD) with passive suicidal ideation (PSI), characterized by daily intrusive thoughts of dying without current intent or plan. 1

Diagnostic Criteria and Clinical Features

The patient meets diagnostic criteria for MDD based on:

• Persistent depressed mood and loss of interest lasting more than 2 weeks with significant functional impairment 1
• Recurrent thoughts of death (passive suicidal ideation) occurring daily since the specified date 1
• Additional depressive symptoms including fatigue/low energy, difficulty concentrating (executive dysfunction), and distress causing occupational impairment (currently on disability) 1

Passive suicidal ideation is defined as the desire to die without any intent to act and represents a distinct clinical phenomenon within the spectrum of suicidality. 2 The patient explicitly denies current suicidal intent or plan, attributing safety to responsibility to her son and low energy to act, which is consistent with PSI rather than active suicidal ideation. 2

Comorbid Diagnoses

This patient has multiple comorbid conditions that significantly impact prognosis:

• Generalized Anxiety Disorder (GAD): Longstanding anxiety with excessive worry, restlessness, and difficulty concentrating 1
• Attention-Deficit/Hyperactivity Disorder (ADHD): Diagnosed at age 5 with persistent inattention and executive dysfunction, worsened after methylphenidate discontinuation 1
• Post-Traumatic Stress Symptoms: History of childhood emotional neglect, dissociation, and sexually coercive relationship requiring trauma-focused therapy including EMDR 1
• Possible Borderline Personality Features: History of impulsive high-risk behaviors, dissociation, maladaptive coping strategies, and recurrent suicidal thoughts since adolescence warrant consideration 3

Risk Stratification and Prognostic Factors

This patient is at substantially elevated suicide risk. The likelihood of dying by suicide in MDD is 8.62 times higher than the general population, with women facing 9.40 times higher odds. 1, 4

High-Risk Features Present:

• Comorbid anxiety disorder: Anxiety is more prevalent and strongly linked to suicidality in MDD 1
• History of suicide attempts: Prior suicide attempt during college following fluoxetine-induced manic episode 1
• Childhood trauma: Physical and emotional abuse/neglect are established risk factors 1, 5
• Treatment resistance: Multiple failed medication trials indicate more severe illness 1
• Recent major life stressors: Death of relative, return to work, cessation of breastfeeding 1, 5
• Younger age at onset: First significant episode in high school 1

Passive suicidal ideation itself is prognostically significant. PSI is common in MDD (59% prevalence) and is associated with more severe depressive symptoms, higher rates of comorbid anxiety disorders, and more childhood traumas. 2 While PSI shows modest overall accuracy (37-46%) in predicting suicidal behavior, its sensitivity (66-85%) and negative predictive value (78-89%) are good, meaning its absence is reassuring but its presence warrants serious attention. 2

Consideration of Bipolar Spectrum Disorder

The history of a fluoxetine-induced manic episode and suicide attempt raises concern for bipolar disorder. 6 The patient's description of the "happiest time of life" during maternity leave and breastfeeding, followed by worsening depression after returning to work, could represent mood cycling. 6 Family history is significant for mood disorders, and the patient has tried multiple antipsychotics (quetiapane, aripiprazole, brexpiprazole, cariprazine), which are typically used for bipolar depression or treatment-resistant unipolar depression. 6

If bipolar disorder is confirmed or strongly suspected, lithium should be strongly considered as it reduces suicide attempts 8.6-fold and is the only medication with strong evidence for reducing suicide risk. 7, 4 Lithium is effective in decreasing aggression and impulsivity independent of its mood-stabilizing effects. 7

Borderline Personality Features Assessment

The severity of borderline personality features associates with suicide risk in a dose-dependent manner among all mood disorder patients. 3 This patient's history includes:

• Recurrent suicidal thoughts since adolescence
• Impulsive high-risk behaviors (standing on parking decks, wandering at night hoping for accidental harm)
• Dissociation and maladaptive coping strategies
• Emotional dysregulation
• History of DBT participation (which was helpful)

Patients with comorbid MDD and borderline personality features have remarkably high risk of suicide attempts (60% lifetime prevalence), and those with both bipolar disorder and borderline features exceed 90% lifetime prevalence. 3 Reliable assessment of borderline features may advance the evaluation of suicide risk. 3

Treatment-Resistant Depression

The patient has failed multiple antidepressant trials including fluoxetine, escitalopram, vilazodone, and augmentation strategies with quetiapine, aripiprazole, brexpiprazole, and cariprazine. 1 Inadequate trial duration is a modifiable risk factor for persistent suicidality, and a minimum therapeutic trial of 6-8 weeks is required before considering medication changes. 8, 7

The recent addition of Avalezi (bupropion/naltrexone) with no significant improvement after several months suggests continued treatment resistance. 1

Common Pitfalls to Avoid

• Do not dismiss passive suicidal ideation as unimportant or attention-seeking behavior; it may be the only way the patient signals distress and is associated with worse prognosis. 8, 2
• Do not overlook the possibility of bipolar disorder given the history of antidepressant-induced mania; this fundamentally changes treatment approach and suicide risk management. 6
• Do not underestimate the role of comorbid anxiety and ADHD in treatment resistance and suicide risk; these require concurrent management. 1
• Do not prescribe benzodiazepines despite anxiety symptoms, as they can impair self-control and increase impulsivity in suicidal patients. 8, 7
• Do not delay mental health specialist involvement; immediate referral is mandatory when passive suicidal ideation is identified. 8
• Recognize that insomnia and anhedonia are associated with poorer outcomes and may act as barriers to PSI remission during treatment. 2

Monitoring Requirements

The first year following diagnosis or treatment changes carries the greatest suicide risk, requiring vigilant monitoring. 4 The patient should have:

• Weekly monitoring within 1-2 weeks of any medication changes 4
• Assessment for worsening depression, emergence of suicidality, and unusual behavioral changes 6
• Specific monitoring for anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, and mania 6
• Extended monitoring throughout the first year when risk is highest 7, 4