What is the appropriate management for a 14-year-old patient with a history of anemia, recent onset of sexual activity, substance use, and past suicidal ideation, who presents with fatigue and a recent concern about potential pregnancy, following the loss of her father 7 months ago?

From the Guidelines

The patient requires immediate and comprehensive management, including a mental health risk assessment, crisis response planning, and establishment of a safety plan, to mitigate her risk of suicidal behavior and address her multiple vulnerabilities, including grief, potential pregnancy, substance use, and anemia. The patient's history of past suicidal ideation, recent onset of sexual activity, substance use, and past suicidal ideation, combined with her current presentation of fatigue and concern about potential pregnancy, following the loss of her father 7 months ago, represent significant risk factors for adolescent mental health issues 1.

Key Considerations

• The patient's risk factors, including her history of suicidal ideation, substance use, and risky behavior, necessitate a thorough mental health evaluation and the development of a crisis response plan 1.
• The establishment of a safety plan, including removing access to potential means of self-harm, providing crisis hotline numbers, and ensuring adult supervision, is crucial to preventing suicidal behavior 1.
• The patient would benefit from grief counseling to address the loss of her father and comprehensive mental health evaluation to assess for depression and other conditions that may be contributing to her symptoms and behaviors 1.
• Prompt follow-up within 24-48 hours is necessary to reassess her mental status, address the pregnancy concern with appropriate testing, and evaluate her anemia, which may contribute to her fatigue.

Management Recommendations

• Immediate follow-up with child protective services and mental health services is required due to the patient's vulnerability and risk factors.
• Crisis response planning, including a collaborative approach between patient and clinician, should be implemented to identify clear signs of crisis and develop self-management skills.
• Dialectical behavior therapy (DBT) may be beneficial in treating suicidal ideation and behavior, as it combines elements of cognitive-behavioral therapy, skills training, and mindfulness techniques to help patients develop skills in emotion regulation, interpersonal effectiveness, and distress tolerance 1.
• Grief counseling and comprehensive mental health evaluation should be provided to address the patient's underlying conditions and contributing factors.

From the Research

Patient Assessment and Management

The patient's presentation with fatigue, recent onset of sexual activity, substance use, and past suicidal ideation, along with a history of anemia and a recent concern about potential pregnancy, requires a comprehensive assessment and management plan. The following points should be considered:

• Ensuring the patient's safety and the safety of others is the first step in evaluation, as psychiatric emergencies can pose a risk to the patient and those around them 2.
• The patient's history of anemia is important, as maternal anemia during pregnancy has been associated with adverse gestational outcomes and neurodevelopmental disorders in the offspring 3.
• The patient's substance use and past suicidal ideation should be addressed, and treatment for co-occurring depression and substance use disorders should be considered 4.
• If the patient is pregnant or considering pregnancy, the risks and benefits of antidepressant use should be discussed, including the potential risks of selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine 5, 6.

Treatment Considerations

Treatment should focus on stabilization of the patient, followed by addressing specific symptoms and ultimately the cause of symptoms. The following points should be considered:

• Antidepressant treatment may be necessary, but the potential risks and benefits should be carefully weighed, particularly in the context of pregnancy 5, 3, 6.
• Substance use disorders should be treated simultaneously with depression, and the potential interactions between antidepressants and substances of abuse should be considered 4.
• The patient's history of anemia should be addressed, and iron deficiency during pregnancy should be prevented or treated to minimize the risk of adverse outcomes 3.