What adjustments can be made to the treatment plan for a 15-year-old female patient with intense sadness, mood swings, and suicidal thoughts, currently taking Prozac (fluoxetine) 10mg daily?

HPI Improvement Suggestions and Treatment Plan Adjustments

Critical Safety Assessment Required

This patient requires immediate dose optimization of fluoxetine and intensification of psychotherapy given daily suicidal ideation with a history of detailed plans, combined with high-risk behaviors (substance use, school suspension). 1

Immediate Monitoring Priorities

• Document specific details about the "detailed plans some months ago" - when exactly they occurred, what changed, and whether any means are accessible 2
• Quantify the daily suicidal thoughts more precisely - frequency per day, duration, intensity on a 0-10 scale, and specific triggers beyond just "being upset or angry" 2
• Assess for emerging agitation, irritability, or behavioral activation since starting Prozac, as these symptoms may represent precursors to worsening suicidality 1
• Clarify the alcohol use timeline - when it occurred relative to medication start, frequency, and whether it represents self-medication or impulsivity 2

Pharmacologic Treatment Adjustments

Fluoxetine Dose Optimization

Increase fluoxetine from 10mg to 20mg daily immediately. 1 The current dose is subtherapeutic for major depressive disorder with suicidal ideation. The FDA-approved starting dose for adolescents with depression is 10-20mg daily, with the target therapeutic dose being 20mg daily 1. After 2 weeks at 10mg showing only minimal improvement ("helping a little bit"), dose escalation is indicated 2.

• Monitor closely for increased suicidal thoughts within 1-2 weeks of this dose change, as risk is highest during medication adjustments 1
• The full therapeutic effect may require 4-6 weeks at the therapeutic dose 1
• If no adequate response after 6-8 weeks at 20mg, consider increasing to 40mg daily or switching agents 2

Alternative Considerations if Current Treatment Fails

If inadequate response persists after 6-8 weeks at 20mg fluoxetine, consider augmentation with lithium (starting at low dose 150mg daily, targeting levels 0.2-0.6 mEq/L), which has the strongest evidence for reducing suicidal behaviors in depressed adolescents 3. However, this requires careful monitoring given the patient's substance use and potential compliance issues 3.

Psychotherapy Intensification Required

Increase therapy frequency from weekly to twice-weekly sessions and ensure the therapist is using evidence-based CBT or DBT protocols specifically targeting suicidal ideation. 2

Specific Therapy Components Needed

• Implement structured CBT for suicidal adolescents using a manualized approach (12-16 weekly sessions) that addresses negative cognitions about self, environment, and future 2
• Focus on assertive communication skills and problem-solving alternatives rather than passive avoidant coping strategies, particularly around school stressors and family conflict 2
• Include parent sessions to address family dynamics, given the recent disciplinary issues and home restrictions 2
• The patient's vague response ("I guess it's going ok") suggests poor therapeutic engagement - document specific treatment goals and progress markers 2

HPI Documentation Improvements

Missing Critical Details

Psychiatric Review of Systems:

• Clarify mood pattern: Is this unipolar depression or are the rapid mood swings (anger to sadness within hours) suggesting bipolar spectrum or borderline personality features? 1
• Document presence/absence of: anhedonia severity, concentration problems affecting grades, psychomotor changes, guilt/worthlessness content 2
• Assess for impulsivity beyond substance use: spending, sexual behavior, reckless driving 2

Suicidality Assessment Gaps:

• Change from "thoughts of dying" to specific documentation: passive death wishes vs. active suicidal ideation vs. intent vs. plan 2
• Document protective factors: reasons for living, future orientation, relationship quality 2
• Clarify "most recent episode 1 hour prior to visit" - was this passive ideation or active planning? 2

Substance Use Details:

• Frequency and pattern of nicotine vaping (daily? multiple times daily?) 4
• Alcohol use: when did it start, how many episodes, any blackouts or risky behavior while intoxicated 2
• Screen for other substances beyond marijuana (stimulants, benzodiazepines, opioids) 4

Functional Impairment:

• Academic performance trajectory: current grades vs. baseline, missed assignments, ability to concentrate in class 2
• Social functioning: peer relationships, isolation, conflict patterns 2
• Family dynamics: quality of relationship with parent, communication patterns, parental mental health history 2

Reframed HPI Structure

Consider reorganizing as:

1. Chief concern (patient's words about what bothers her most)
2. Suicidality (detailed assessment as above)
3. Mood symptoms (with pattern, triggers, duration)
4. Substance use (timeline, frequency, consequences)
5. Functional impairment (school, family, peers)
6. Treatment response (medication effects, therapy engagement)
7. Safety factors (supervision, means restriction, support system)

Safety Planning Requirements

Document a specific safety plan beyond the "no-suicide contract" approach, which has no proven efficacy and may impair therapeutic alliance. 2

• Identify specific warning signs the patient recognizes before suicidal urges intensify 2
• List coping strategies: distraction techniques, people to contact, safe places to go 2
• Provide crisis numbers: 988 Suicide & Crisis Lifeline, local crisis services 2
• Ensure parent has removed/secured potential means: medications, firearms, sharp objects 2
• Schedule follow-up within 1 week, not longer, given current risk level 2

Disposition Decision

This patient does NOT currently require hospitalization given she denies current intent/plan, has adequate home supervision (parent present, restrictions in place), and can contract for safety in the immediate term 2. However, she requires intensive outpatient management with close follow-up 2.

Consider partial hospitalization if: suicidal ideation intensifies, substance use escalates, or family cannot provide adequate supervision 2.