What is the most appropriate step to decrease a 15-year-old girl's immediate risk for suicide, given her diagnosis of major depressive disorder, current treatment with fluoxetine (selective serotonin reuptake inhibitor), and access to a gun at home?

Immediate Removal of Firearms is Critical to Reduce Suicide Risk in Adolescents

Instructing the father to remove the gun from the home is the most appropriate step to decrease this patient's immediate risk for suicide. 1

Assessment of Current Risk Factors

This 15-year-old patient presents with several critical risk factors for suicide:

• Major depressive disorder diagnosis
• Current treatment with fluoxetine (SSRI)
• Worsening symptoms (isolation, decreased eating and sleeping)
• Access to a lethal means (father's gun in the home)

Why Firearm Removal is the Priority Intervention

The presence of firearms in the home significantly increases suicide risk in adolescents:

• Firearms are the most common method used by adolescents to commit suicide in the United States 1
• Access to guns in the home is associated with a 4.4-fold increase in suicide risk for adolescents, even after adjusting for psychiatric disorders 2
• Adolescents with handgun access have a 9.4-fold increased risk of suicide 2
• The AAP explicitly recommends that "the safest home for a child or adolescent is one without firearms" 1

Management Algorithm for Adolescent Suicide Risk

1. Immediate safety measures:

   • Remove firearms from the home 1
   • Secure medications (both prescription and over-the-counter) 1
   • Provide close supervision

2. Evaluate severity of depression and suicidality:

   • Assess for suicidal ideation, intent, and plan
   • Determine if hospitalization is needed based on risk level
   • Monitor for clinical worsening, especially since patient is on fluoxetine

3. Medication management:

   • Continue monitoring fluoxetine effects closely
   • Be vigilant for increased suicidality, especially during initial treatment or dose changes 3
   • Watch for warning signs: anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity 3

4. Follow-up care:

   • Arrange immediate mental health evaluation if moderate to high risk 1
   • Consider psychotherapy options (CBT, IPT-A, family therapy) 1
   • Maintain close follow-up with collaborative care approach 1

Why Other Options Are Less Appropriate

• Cognitive-behavioral therapy: While beneficial for depression treatment, it does not address the immediate suicide risk posed by firearm access 1
• Discontinuing fluoxetine: Abrupt discontinuation could worsen depression and increase suicide risk 3
• Encouraging socialization: Social support is important but insufficient to address immediate access to lethal means 1
• Listing positive things: This cognitive technique may be helpful eventually but doesn't address immediate safety concerns 1

Important Considerations

• Means restriction is one of the few empirically-based strategies shown to reduce suicide deaths by 30-50% 4
• Even with locked storage, adolescents may still find access to guns in the home 1
• The risk of suicide with firearms is particularly high in adolescents with no apparent psychiatric disorder (OR = 12.9) 2
• Loaded guns in the home represent an extremely high risk factor (OR = 32.3) 2

Implementation Approach

When discussing firearm removal with the father:

• Emphasize that this is a temporary safety measure
• Explain that suicide attempts with guns rarely afford second chances 5
• Suggest options for safe storage outside the home (with trusted family member, at a gun shop, or with law enforcement) 4
• Document the conversation and follow up to confirm removal has occurred 6

The evidence is clear that removing access to lethal means, particularly firearms, is the most effective immediate intervention to reduce suicide risk in this adolescent patient.