What is the diagnosis for a 13-year-old mixed-race adopted girl with marked mood instability, recurrent self‑injurious behavior, a recent suicide attempt by pill ingestion, disordered eating patterns, and significant sleep disturbances?

Differential Diagnosis: Major Depressive Disorder with High Suicide Risk

This 13-year-old presents with major depressive disorder (MDD) requiring immediate psychiatric hospitalization given her recent suicide attempt, self-injurious behavior, mood instability, and multiple vegetative symptoms. 1

Primary Diagnosis: Major Depressive Disorder

The constellation of symptoms strongly indicates MDD based on the following criteria:

• Mood instability and dysphoria – Core depressive symptoms in adolescents often manifest as irritability rather than classic sadness 1
• Recent suicide attempt by pill ingestion – Indicates severe depression with suicidal behavior, a hallmark of MDD 1, 2
• Self-injurious behavior – Recurrent self-harm is strongly associated with depressive disorders and predicts suicide attempts 3, 4
• Disordered eating patterns – Significant weight changes or eating disturbances are vegetative symptoms of depression 1
• Sleep disturbances – Insomnia or hypersomnia are cardinal features of MDD; severe sleep complaints predict both suicide attempts and nonsuicidal self-injury 1, 3

Critical Risk Stratification

This patient meets criteria for HIGH RISK requiring immediate psychiatric hospitalization based on:

• Recent suicide attempt with pill ingestion (regardless of medical lethality, intent matters more) 1, 5
• Recurrent self-injurious behavior indicating poor impulse control 1
• Multiple high-risk features: mood instability, eating disturbances, and sleep problems occurring simultaneously 1, 3
• Adolescents with MDD are 8.62 times more likely to die by suicide compared to the general population 2

The American Academy of Pediatrics emphasizes that even low-lethality attempts (like taking pills) can represent serious suicidal intent, as adolescents systematically overestimate the lethality of methods. 5, 2

Important Differential Considerations

Bipolar Disorder vs. MDD

While mood instability is present, consider MDD first rather than immediately diagnosing bipolar disorder or borderline personality disorder in adolescents with rapid mood shifts. 2 However, if family history of bipolar disorder emerges or manic/hypomanic symptoms develop, reassessment is warranted. 1

Comorbid Conditions to Assess

• Anxiety disorders – Comorbid generalized anxiety significantly elevates suicide risk and predicts poorer treatment response 2
• PTSD/trauma history – Physical or emotional abuse contributes to MDD development and increases suicide risk; the adoption history warrants exploration of early adversity 2, 6
• Substance use – Must be screened as it markedly increases risk of suicidal acts during mood episodes 1, 6

Immediate Management Algorithm

Step 1: Ensure Immediate Safety (During Current Visit)

• Arrange immediate psychiatric hospitalization during this office visit – Do not delay or schedule for later 1, 5
• Maintain continuous 1:1 observation until transfer occurs 5
• Remove access to sharps, medications, and potential weapons from examination room 5
• Call 911 if patient has active intent, refuses voluntary transport, or shows severe agitation 5

Step 2: Mandatory Safety Interventions Before Transfer

• Explicitly instruct parents to remove ALL firearms from the home (adolescents can access locked guns) 1, 5
• Lock up all medications, both prescription and over-the-counter 1
• Secure knives and restrict access to alcohol/substances 5

Step 3: Avoid Common Pitfalls

• Do NOT rely on "no-suicide contracts" – These have not been proven effective and provide false reassurance 1, 7, 5
• Do NOT dismiss the suicide attempt based on low medical lethality – Intent matters more than actual lethality 5, 2
• Do NOT accept family reassurance alone when high-risk features are present 5
• Never dismiss suicidal statements as attention-seeking – This may be the only way she can signal distress 1, 2

Post-Hospitalization Treatment Plan

Pharmacologic Management

• Initiate SSRI (fluoxetine, sertraline, or paroxetine) as first-line treatment for MDD-related symptoms 7
• Weekly monitoring for first 1-2 weeks is mandatory in patients under 25 years due to increased suicide risk with SSRI initiation 7
• Minimum therapeutic trial of 6-8 weeks required before medication changes 7
• Continue SSRI for at least 4-9 months after achieving response 7

Psychotherapy

• Cognitive-behavioral therapy (CBT) focused on suicide prevention has the strongest evidence for reducing suicide attempts and ideation when combined with medication 7
• Initiate CBT within 1-2 weeks of starting medication 7
• Immediate referral to mental health specialist experienced in suicide risk management is mandatory 7

Ongoing Monitoring

• Weekly follow-up visits for the first month to assess suicidality, medication adherence, and treatment response 7
• Maintain contact even after psychiatric referral, as collaborative care results in greater symptom reduction 1, 5
• Regular brief supportive communications (texts/calls) lower suicide attempts by approximately 43% 7

Special Considerations for This Patient

The adoption history and mixed-race identity warrant exploration of:

• Identity-related stressors and sense of belonging 1
• Early childhood adversity or trauma (increases suicide risk) 2, 6
• Perceived social support, as poor support predicts suicidal acts 6
• Cultural factors affecting help-seeking and treatment engagement 1

Documentation Requirements

Document thoroughly:

• Specific suicidal ideation, plan, and intent 5
• Previous self-harm episodes and suicide attempt details 5
• Mental status examination findings 5
• Family support assessment 5
• Means restriction counseling provided 5
• Disposition decision rationale and follow-up arrangements 5

The first year after initial presentation carries the highest suicide risk, making aggressive treatment and close monitoring essential. 2