In a 16-year-old male discontinuing atomoxetine (Strattera) who currently does not meet full DSM‑5 criteria for a major depressive episode or a primary anxiety disorder, and whose ADHD symptoms cannot be fully assessed while on medication, should the existing diagnoses of attention‑deficit hyperactivity disorder, unspecified anxiety disorder, major depressive disorder (single episode), and adolescent‑onset conduct disorder be retained?

Diagnostic Coding After Atomoxetine Discontinuation

You should discontinue the diagnoses of major depressive disorder (F32.9) and anxiety disorder (F41.9) immediately, as this patient does not currently meet DSM-5 criteria for either condition. The ADHD diagnosis (F90.9) should be retained provisionally but reassessed off medication within 4-8 weeks, as current functioning cannot confirm or exclude ADHD while on atomoxetine. The conduct disorder diagnosis (F91.2) requires additional clarification regarding current behavioral criteria.

Rationale for Each Diagnosis

Major Depressive Disorder (F32.9) - DISCONTINUE

This diagnosis should be removed because:

• Patient explicitly denies persistent depressed mood or anhedonia (the two cardinal symptoms required for MDD)
• Reports only occasional guilt/worthlessness (not persistent)
• Has intact energy, appetite, and sleep
• Denies current suicidal ideation or intent
• The past suicide attempt in 7th grade represents historical risk but does not justify a current MDD diagnosis without meeting current symptom criteria

DSM-5 requires at least 5 symptoms present during the same 2-week period, including either depressed mood or anhedonia—neither of which this patient endorses.

Anxiety Disorder (F41.9) - DISCONTINUE

Remove this diagnosis because:

• Patient denies excessive worry, restlessness, or autonomic symptoms
• No DSM-5 criteria for generalized anxiety disorder, social anxiety, panic disorder, or other primary anxiety disorders are met by current report
• While atomoxetine can improve comorbid anxiety symptoms 1, the absence of anxiety symptoms now does not justify maintaining this diagnosis

ADHD, Unspecified Type (F90.9) - RETAIN PROVISIONALLY WITH MANDATORY REASSESSMENT

This diagnosis requires careful handling:

Why you cannot definitively assess ADHD now:

• Patient reports subjectively controlled attention while taking atomoxetine
• Excellent academic functioning (straight A+ grades, finishes work early) on medication
• DSM-5 ADHD criteria off medication cannot be confirmed from this visit 2
• The 2019 AAP guideline emphasizes that adolescents must have documented manifestations before age 12, and clinicians must strongly consider whether mimicking conditions are present 2

Critical next steps:

1. Retain the diagnosis provisionally to maintain continuity of care and documentation
2. Schedule reassessment 4-8 weeks after atomoxetine discontinuation to observe functioning off medication
3. Obtain collateral information from at least 2 teachers or other observers (coaches, school counselors) as recommended for adolescent ADHD evaluation 2
4. Document historical symptoms before age 12 if not already established
5. Monitor for substance use given casual alcohol use reported—substances like marijuana can mimic ADHD 2

Research shows atomoxetine discontinuation does not cause symptom rebound 3, and symptoms may worsen after discontinuation but typically don't return to pretreatment levels 3. However, maintenance of response after atomoxetine discontinuation may persist longer than with stimulants 4, making immediate post-discontinuation assessment potentially misleading.

Conduct Disorder, Adolescent-Onset Type (F91.2) - REQUIRES CLARIFICATION

This diagnosis needs immediate review:

• Parent reports patient has remained "behaviorally stable without aggression or agitation" since discontinuing other psychotropics
• Patient denies current thoughts of harming others
• DSM-5 requires at least 3 criteria from specific categories (aggression to people/animals, property destruction, deceitfulness/theft, serious rule violations) within the past 12 months, with at least 1 criterion present in the past 6 months

Action required: Review the chart for documented behaviors meeting conduct disorder criteria within the past 6-12 months. If current behavioral stability means criteria are no longer met, consider:

• Changing to "Conduct disorder, in partial remission" if some but not all criteria are met
• Discontinuing the diagnosis if no criteria are currently met
• Documenting as "History of conduct disorder" if fully remitted

Common Pitfalls to Avoid

1. Maintaining diagnoses "just in case": This practice inflates psychiatric burden, affects insurance, and can influence future treatment decisions inappropriately. Diagnoses should reflect current clinical status.

2. Assessing ADHD while on medication: The 2019 AAP guideline explicitly addresses this—you cannot confirm ADHD criteria off medication during a visit when the patient is still taking atomoxetine 2.

3. Ignoring the need for collateral information in adolescents: Adolescents tend to minimize problematic behaviors 2. Multiple informant sources are essential.

4. Overlooking substance use as ADHD mimic: The patient reports casual alcohol use. The guideline strongly emphasizes that substances can mimic ADHD in adolescents 2.

5. Failing to document historical ADHD symptoms before age 12: This is a DSM-5 requirement that must be established 2.

Monitoring Plan Post-Discontinuation

Given the FDA black box warning about suicidal ideation risk with atomoxetine 5 and this patient's history of a suicide attempt, close monitoring is essential even during discontinuation:

• Weekly contact for first month after discontinuation
• Monitor for: clinical worsening, unusual behavioral changes, emergence of suicidality, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity 5
• Reassess ADHD symptoms at 4-8 weeks off medication with standardized rating scales from multiple informants
• Screen for substance use given reported alcohol use and adolescent risk factors 2

Research indicates atomoxetine discontinuation is generally well tolerated without acute discontinuation syndrome 3, but clinical vigilance remains essential given this patient's psychiatric history.