Psychiatric Evaluation

Low mood, loss of interest in usual activities, passive suicidal ideation with specific plan. Symptoms worsening over past 3 weeks following job loss.

Patient reports progressive anhedonia over approximately 6 months, with marked worsening in the past 3 weeks coinciding with termination from employment. Describes pervasive sadness, tearfulness most mornings, and difficulty getting out of bed. Interest in previously enjoyed activities (painting, hiking) has diminished completely. Appetite decreased with 8-lb weight loss in one month. Sleep onset latency 2-3 hours, frequent middle-of-night awakenings, early morning awakening at 4 AM. Energy markedly low. Concentration impaired — unable to read more than a few pages. Feelings of worthlessness and excessive guilt about job loss.

Suicidal ideation: passive thoughts of not wanting to be alive transitioned to active ideation 2 weeks ago. Has a specific plan involving overdose on accumulated medication supply (has researched lethal doses online). Denies intent to act today but admits difficulty controlling urges when alone at night. Has not made any preparations or written notes. One prior attempt at age 19 (medication OD, medically cleared).

No manic or psychotic symptoms reported. No substance use currently.

MDD, recurrent, moderate severity — first episode at age 19, second episode at age 27 (postpartum). Prior trials: sertraline (partial response, discontinued due to sexual SE), bupropion (activated anxiety), escitalopram (good response previously, stopped 2 years ago feeling "well"). Prior hospitalization: 5-day voluntary admission at age 19 following suicide attempt.

Appearance: casually dressed, grooming fair, hygiene maintained.

Behavior: cooperative, appropriate eye contact, mild psychomotor retardation evident.

Speech: normal rate, tone, and volume. Spontaneous but somewhat effortful.

Mood: "empty," "numb." Affect: dysphoric, congruent, restricted range.

Thought process: linear, logical, goal-directed.

Thought content: preoccupation with death/dying, guilt cognitions. No delusions, no obsessions.

Perception: no hallucinations.

Cognition: alert and oriented x3. Memory intact. Concentration mildly impaired on serial-7s.

Insight: fair — recognizes depression but questions whether "deserves" help.

Judgment: compromised by active SI with plan.

Columbia-Suicide Severity Rating Scale (C-SSRS): SI present with method and plan. No recent preparatory behavior. Lifetime history of 1 attempt.

Protective factors: strong relationship with sister (patient agreed to stay with her tonight), beloved dog at home, previous positive response to treatment.

Risk factors: recent job loss (significant stressor), access to medications at home, social isolation (lives alone), prior attempt history, active plan with identified means.

Overall risk: MODERATE-HIGH. Requires urgent safety intervention.

34F with recurrent MDD presenting in moderate-severe depressive episode with active suicidal ideation and specific plan, precipitated by job loss 3 weeks ago. Patient has prior positive response to SSRI therapy (escitalopram) and prior benefit from CBT. Strong family support available. Risk is elevated due to plan + means access but mitigated by protective factors and treatment engagement.

DSM-5: Major Depressive Disorder, Recurrent, Moderate Severe, With Anxious Distress

Safety:

- Medication lockbox arranged — partner will secure all meds at home tonight

- Crisis line numbers provided (988, local crisis center)

- Sister will stay with patient overnight; patient agrees

- Return precaution: if urges intensify or plan forms, present to nearest ED

Pharmacotherapy:

- Restart escitalopram 10 mg daily (prior good response, well-tolerated)

- Consider adding low-dose quetiapine 25 mg at bedtime for sleep/suicidal ideation if needed at f/u

- No benzodiazepines given SI + access concern

Psychotherapy:

- Referral for CBT (urgent slot requested) — focus on cognitive restructuring, safety planning, behavioral activation

- Safety Planning Intervention completed in session today

Follow-up:

- Telehealth appointment in 48 hours (phone check-in)

- In-person session in 1 week

- Patient agreed: will not be alone overnight tonight