What is the next best step in managing a 19-year-old patient with a history of anorexia, depression, and manic episodes, currently on aripiprazole (Abilify) 10mg, who reports improvement in psychotic symptoms but persistent depressive symptoms and suicidal ideation?

Management of Persistent Depression and Suicidal Ideation in a 19-Year-Old on Aripiprazole

This patient requires immediate addition of an SSRI (preferably fluoxetine) to the current aripiprazole regimen, with close monitoring for increased suicidality, agitation, or manic conversion, and consideration of adding a mood stabilizer given the history of manic episodes. 1, 2

Immediate Pharmacological Intervention

Add an SSRI for Persistent Depression

• SSRIs are the first-line pharmacological treatment for adolescent depression with suicidal ideation, with fluoxetine being specifically preferred due to superior efficacy in treating adolescent depression compared to tricyclic antidepressants 1
• Fluoxetine has the advantage of low lethal potential in overdose, which is critical in a suicidal patient 1
• The aripiprazole should be continued at the current dose since psychotic symptoms have improved 2, 3

Critical Monitoring Requirements

Patients must be assessed within 1 week of starting the SSRI and monitored systematically for emergence of suicidal ideation, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, or mania 1, 2

• The FDA label for aripiprazole specifically warns that families and caregivers should monitor for these symptoms on a day-to-day basis, as changes may be abrupt 2
• Be especially alert to akathisia, as fluoxetine-induced akathisia has been associated with increased suicidality 1
• If akathisia develops, consider dose reduction or adding anticholinergic medication 3

Addressing the Bipolar Spectrum Concern

Consider Adding a Mood Stabilizer

Given this patient's history of manic episodes, the clinical picture suggests possible bipolar disorder or schizoaffective disorder rather than unipolar depression:

• Lithium or a mood stabilizer should be the first-line pharmacological treatment for patients with bipolar disorder and suicidal ideation, prescribed before an antidepressant 1
• Antidepressants administered as monotherapy in bipolar patients are associated with both suicidality and manic conversion 4
• However, antidepressants in combination with mood stabilizers may reduce depressive symptoms safely in bipolar depression 4
• Lithium has specific anti-suicidal properties and may prevent antidepressant-induced suicidality 4

Practical Algorithm

1. If bipolar disorder is confirmed: Add lithium or valproate first, then add fluoxetine once mood stabilization is achieved 1, 4
2. If diagnosis remains unclear but manic history is documented: Consider starting both a mood stabilizer and SSRI simultaneously, with the mood stabilizer taking priority 1, 4
3. Continue aripiprazole as it has proven efficacy for acute mania and may provide additional mood stabilization 3, 5

Safety Considerations in This High-Risk Patient

Medication Access Control

• All medications should have dosage regulated and monitored by a third party (family member or caregiver) who can report unexpected mood changes, increased agitation, or unwanted side effects 1
• Avoid prescribing large quantities that could be lethal in overdose 1
• Never prescribe tricyclic antidepressants due to high lethality in overdose 1

Avoid Certain Medications

• Do not prescribe benzodiazepines or phenobarbital, as these may reduce self-control and disinhibit some individuals, leading to increased aggression and suicide attempts 1
• If stimulants are needed for comorbid ADHD, they should only be prescribed after mood symptoms are stabilized 1

Follow-Up Schedule

Intensive Early Monitoring

• Assess in person within 1 week of initiating SSRI treatment 1
• At every assessment, systematically inquire about: (1) ongoing depressive symptoms, (2) risk of suicide, (3) adverse effects from treatment, (4) adherence to treatment, and (5) new or ongoing environmental stressors 1
• Continue monthly monitoring for 6-12 months after full resolution of symptoms 1
• The greatest risk of relapse occurs in the first 8-12 weeks after medication changes 1

When to Reassess Treatment

• If no improvement is noted after 6-8 weeks of treatment, diagnosis and treatment should be reassessed 1
• Mental health consultation should be obtained if the patient develops worsening psychosis, increased suicidal ideation, or new comorbid conditions 1

Adjunctive Psychotherapy

Evidence-based psychotherapy (CBT or IPT-A) should be added if not already initiated, as combination treatment is more effective than medication alone for adolescent depression 1

• Psychotherapy is particularly important given the persistent suicidal ideation 1
• Family therapy may be indicated given the patient's age and living situation 1

Common Pitfalls to Avoid

• Do not increase aripiprazole dose to address depression, as aripiprazole monotherapy has not shown efficacy for acute bipolar depression at the primary endpoint 6
• Do not discontinue aripiprazole since psychotic symptoms have improved; abrupt discontinuation could lead to relapse of psychosis 3
• Do not prescribe antidepressants without considering mood stabilization in a patient with documented manic episodes, as this increases risk of manic conversion 4
• Do not assume improvement in psychotic symptoms means the patient is safe—suicidal ideation requires separate, aggressive treatment 1, 2