What is the best course of treatment for a 17-year-old male with Major Depressive Disorder (MDD), a history of traumatic brain injuries (TBI), and suicidal ideation, currently taking 10mg of Lexapro (escitalopram) daily?

Immediate Psychiatric Hospitalization with Comprehensive Safety Planning and Evidence-Based Psychotherapy

This 17-year-old male with MDD, history of TBI, active suicidal ideation with specific plan (train tracks), and recent elopement requires immediate psychiatric hospitalization for safety stabilization, followed by intensive evidence-based psychotherapy—specifically cognitive behavioral therapy (CBT) and problem-solving therapy tailored for TBI patients—while continuing his current escitalopram 10mg daily. 1

Acute Safety Management

Hospitalization Criteria Met

• Active suicidal ideation with specific method (train tracks), recent preparatory acts (eloping to areas with train access), daily thoughts lasting 4-8 hours, and inability to control thoughts all mandate immediate psychiatric hospitalization 1
• The patient endorsed suicidal ideation to law enforcement, mentioned train tracks as a method, and has a pattern of elopement when triggered—these are high-risk features requiring inpatient stabilization 1
• His BSSA reveals daily suicidal thoughts lasting most of the day with preparatory behaviors (running to locations with train access), which represents imminent danger 1

Lethal Means Safety

• All medications must be removed from the home environment and secured by family members, with particular attention to restricting access to transportation that could facilitate access to train tracks 1
• Firearms (if present in home), sharp objects, and any means of accessing train tracks must be addressed through family collaboration 1
• The family should be counseled that access to lethal means is a critical risk factor, and approximately 90% of suicide attempts involving trains result in death 1

Pharmacotherapy Considerations

Continue Current Escitalopram

• The patient should continue escitalopram 10mg daily, as it is FDA-approved for adolescent MDD and has demonstrated efficacy in this age group 2
• Escitalopram showed statistically significant improvement on the Children's Depression Rating Scale-Revised (CDRS-R) in adolescents aged 12-17 with MDD 2
• Close monitoring for worsening suicidal ideation is mandatory within 1-2 weeks of any medication changes, as suicide risk is highest during the first 1-2 months of antidepressant treatment 1

Special Considerations for TBI Population

• The patient's history of two TBIs (one severe requiring relearning to walk/talk, one recent) significantly complicates his depression, as 53.1% of TBI patients develop MDD within the first year post-injury 3
• Depression following TBI is associated with executive dysfunction, which this patient demonstrates through poor impulse control (elopement) and difficulty with problem-solving 4
• Studies show citalopram (escitalopram's parent compound) has modest efficacy in TBI-related depression, with only 27.7% response at 6 weeks and 46.2% at 10 weeks—substantially lower than non-TBI populations 5
• The combination of TBI and MDD creates a particularly high-risk scenario, as TBI patients with depression show reduced left prefrontal gray matter volumes and greater executive dysfunction 4

Avoid Medication Changes During Acute Crisis

• Do not add lithium at this time despite its anti-suicidal properties, as this patient has unipolar depression (MDD), not bipolar disorder—lithium's evidence base is specific to bipolar patients 6
• Ketamine infusion could provide rapid relief of suicidal ideation within 24 hours (55% of patients report no suicidal ideation after 24 hours), but this should only be considered as adjunctive treatment if the patient fails to respond to standard interventions after adequate trials 1
• If no adequate response occurs within 6-8 weeks of escitalopram at therapeutic dose, consider dose optimization to 20mg daily before switching agents 1, 2

Evidence-Based Psychotherapy (Primary Treatment)

Cognitive Behavioral Therapy for Suicide Prevention

• CBT focused on suicide prevention is the cornerstone of treatment and reduces suicide attempts by 50% compared to treatment as usual 1, 7
• CBT should begin immediately upon psychiatric stabilization, with most patients requiring fewer than 12 sessions to achieve benefit 1
• CBT teaches identification and modification of problematic thinking patterns (e.g., "life hasn't been worth it since my brain injuries," "I'm not the same") and develops alternative coping strategies 1

Problem-Solving Therapy for TBI Patients

• Given his TBI history, the Window to Hope (WtoH) problem-solving treatment is specifically indicated, as it improved hopelessness in veterans with moderate-to-severe TBI who were at suicide risk 1
• WtoH includes behavioral activation, cognitive restructuring, problem-solving skills, compensatory techniques for TBI-related challenges, relapse prevention, and posttraumatic growth 1
• This intervention is delivered in 8-10 sessions (16-20 hours total) and directly addresses his stated triggers: feeling "not the same" since TBI and inability to cope with stressors 1

Crisis Response Plan Development

• A collaborative crisis response plan must be created with the patient and family, which has been shown to significantly reduce suicide attempts compared to treatment as usual 1
• The plan must include:
  • Warning signs specific to this patient: running away, isolating in room, vaping (which triggered recent episode), statements about life not being worth it 1
  • Self-management skills: physical activity (which he identifies as a coping skill), distraction techniques, grounding exercises 1
  • Social support contacts: mother, therapist, pastor, psychiatrist—all identified by family as support system 1
  • Crisis resources: 988 Suicide & Crisis Lifeline, local mobile crisis team, emergency department contact information 1
  • Specific plan for elopement risk: what family should do if he leaves home, when to call law enforcement 1

Substance Use Intervention

Address Cannabis Use

• The patient's cannabis use (flower and wax for 4 months) must be addressed, as substance use worsens depression outcomes and increases suicide risk 6
• Cannabis use may be self-medication for depression or TBI-related symptoms, but it impairs executive function already compromised by TBI 4
• Family should be educated about monitoring for cannabis use and its removal from the home environment 1

Post-Discharge Planning

Intensive Outpatient Follow-Up

• Schedule first outpatient appointment within 1 week of discharge, as the period immediately following psychiatric hospitalization carries heightened suicide risk 1, 6
• Periodic caring communications (postcards, letters, phone calls) should be implemented for at least 12 months post-discharge, as this intervention reduces suicide deaths, attempts, and ideation 1
• Single communications are ineffective; repeated contact over 12+ months is necessary 1

School Reintegration Support

• The patient is returning to campus after 50 days in residential treatment where he reports symptoms worsened and he felt unsafe [@case presentation]
• Coordinate with school counselors to ensure academic accommodations for TBI-related executive dysfunction and depression, and establish a safety plan for school hours [@11@, @13@]
• His mother reports he was doing "home and hospital" schooling—gradual reintegration with support is critical [@case presentation]

Family Psychoeducation

• Family members must receive education about recognizing early warning signs of suicidal crisis: increased isolation, statements about death, giving away possessions, sudden calmness after depression, increased elopement attempts 6
• The mother's emotional reaction to finding the vape triggered the recent crisis—family therapy should address communication patterns and de-escalation strategies [@case presentation]
• Family should understand that his statement "I could have run to the train tracks but I didn't" represents ongoing suicidal ideation with partial deterrents, not safety [@1@]

Treatment Duration and Monitoring

Continuation Phase

• Continue escitalopram for minimum 4-9 months after achieving satisfactory response, given this is not his first depressive episode (he reports depression since first TBI in middle school) [@5@]
• Given his history of multiple depressive episodes and chronic course since TBI, longer-term maintenance treatment (years) may be beneficial 1
• Regular monitoring every 1-2 weeks initially, then monthly once stabilized, assessing for suicidal ideation, medication adherence, and treatment response 1

Avoid Common Pitfalls

• Never use "no-suicide contracts"—they have no empirical evidence supporting efficacy and create false reassurance [@9@]
• Do not rely exclusively on any single suicide risk assessment tool; the C-SSRS and other instruments cannot sufficiently determine risk level [@1@]
• Do not discharge from inpatient care until: suicidal ideation has significantly decreased, he can identify and commit to using coping skills, family safety plan is in place, and outpatient follow-up is secured within 1 week [@3@, 1, @8@]
• His recent residential treatment discharge (just days ago) followed by immediate crisis suggests inadequate discharge planning—do not repeat this error [@case presentation]

Red Flags Requiring Immediate Intervention

• Increased elopement attempts, acquisition of means to access train tracks, giving away possessions, sudden improvement in mood (may indicate decision to attempt), increased substance use, or statements of hopelessness 1
• His pattern of running away "to escape from what was triggering me" represents maladaptive coping that must be replaced with healthier alternatives through CBT and problem-solving therapy 1