What is the best course of treatment for a 17-year-old male with a history of Major Depressive Disorder (MDD), suicidal ideation, and multiple Traumatic Brain Injuries (TBIs), who is currently experiencing depression symptoms and substance use, and has been admitted to the Emergency Department (ED) on a 5585 hold due to imminent danger to self?

Assessment and Differential Diagnosis

Primary Assessment: High-Risk Suicidal Crisis with Major Depressive Disorder

This 17-year-old male requires immediate psychiatric hospitalization due to active suicidal ideation with specific plan (jumping in front of train), recent elopement behavior, daily suicidal thoughts, and inadequate response to current treatment. 1

Differential Diagnosis (Ranked by Priority)

1. Major Depressive Disorder with High Suicide Risk (Primary Diagnosis)

• Supporting evidence:
  • Daily suicidal ideation with fluctuating intensity ("vague idea" to "I need to kill myself") 1
  • Persistent sad mood most of day, every day 1
  • Recent treatment failure (residential treatment "didn't help," sertraline ineffective after 3 weeks) 1, 2
  • Impulsive dangerous behavior (running away, "crazy things") 1
  • Recent high-risk suicidal plan with lethal means (train) 1
  • History of psychiatric hospitalization for SI 1

2. Bipolar Disorder Type I or II (Must Rule Out)

• Supporting evidence:
  • Prolonged period of decreased sleep need during residential treatment (whole nights without sleep or only 2 hours) with high energy 1
  • Only felt tired "some of the time" despite severe sleep deprivation 1
  • Year-long sleep disturbance pattern 1
  • Impulsive behaviors (fights at school, skipping school, running away) 1
  • Critical concern: Antidepressant monotherapy in unrecognized bipolar disorder significantly increases suicide risk 1, 3
  • Patient started on sertraline without mood stabilizer 2, 3

3. Post-Concussion Syndrome with Mood Disorder

• Supporting evidence:
  • Two severe TBIs (2-week hospitalization requiring relearning to walk/talk; months-long recovery from second) 1
  • Patient attributes all depression symptoms to first TBI 1
  • TBI is independent risk factor for suicide and mood disorders 1
  • Impulsivity and emotional dysregulation ("difficult to control and express emotions") may reflect frontal lobe injury 1

4. Cannabis Use Disorder (Severe) with Substance-Induced Mood Disorder

• Supporting evidence:
  • Self-described "addiction" with daily use, "high all the time" 1
  • Started using marijuana for sleep (self-medication) 1
  • Expressed desire to quit but continues daily use 1
  • Last use 2 days ago (Sunday morning) - potential withdrawal contributing to current crisis 1
  • Cannabis use disorder dramatically increases suicide risk in adolescents 1

5. Alcohol Use Disorder (Moderate)

• Supporting evidence:
  • 5-year history starting age 11-12 1
  • Pattern of drinking to blackout 1
  • Uses alcohol as "escape" 1
  • Last use 2 months ago (pre-residential treatment) 1

6. Adjustment Disorder with Depressed Mood (Less Likely)

• Against this diagnosis:
  • Symptoms too severe and persistent 1
  • Multiple treatment failures 1
  • Daily suicidal ideation 1

Critical Risk Factors Present

Immediate High-Risk Features Requiring Hospitalization:

• Active suicidal ideation with specific lethal plan (jumping in front of train) 1, 4
• Recent impulsive elopement behavior indicating poor impulse control 1
• Daily suicidal thoughts with variable intensity suggesting unstable mental state 1
• Treatment resistance (residential treatment failure, medication ineffective) 1
• Substance use disorder with daily cannabis use 1
• Multiple severe TBIs with persistent cognitive/emotional sequelae 1
• Possible undiagnosed bipolar disorder being treated with antidepressant monotherapy 1, 3

Additional Risk Factors:

• Male gender (higher lethality) 1
• Adolescent age (vulnerable period) 1, 2, 5
• History of fights/aggression (impulsivity) 1
• Recent residential treatment discharge (high-risk transition period) 1

Reasoning and Clinical Concerns

Why Bipolar Disorder Must Be Urgently Evaluated:

The sleep pattern described during residential treatment is highly concerning for hypomania or mania - going entire nights without sleep while maintaining high energy and only occasionally feeling tired is not consistent with insomnia from depression or anxiety. 1 This represents a critical diagnostic emergency because:

1. Antidepressants can precipitate mixed states or rapid cycling in bipolar disorder, dramatically increasing suicide risk 1, 3
2. The patient has been on sertraline for 3 weeks without mood stabilizer coverage 2, 3
3. His impulsive "crazy things" and running away may represent mixed features 1, 3
4. Noradrenergic effects of SSRIs can worsen suicidal ideation in bipolar patients 3

Why Immediate Hospitalization is Non-Negotiable:

This patient meets multiple criteria that make outpatient management unsafe: 1, 4

• Cannot engage meaningfully in safety planning (doesn't know why he ran away, can't articulate what "crazy things" means) 1, 4
• Active intent with specific lethal means 1, 4
• High impulsivity demonstrated by elopement 1
• Substance use disorder compromising judgment 1
• Treatment-resistant depression requiring medication changes that increase short-term risk 1
• Possible bipolar disorder requiring complex medication adjustments 1

Substance Use Complicating Factor:

Daily cannabis use "to help sleep" that evolved into self-described addiction represents both a risk factor and a diagnostic confound. 1 The patient's depression and sleep disturbance may be partially substance-induced, but cannabis use disorder in adolescents with mood disorders creates a dangerous synergy that substantially elevates suicide risk. 1 Acute cannabis withdrawal (last use 2 days ago) may be contributing to current crisis. 1

TBI as Underlying Vulnerability:

Two severe TBIs requiring prolonged rehabilitation create permanent vulnerability to mood disorders, impulsivity, and suicide risk. 1 The patient's attribution of all symptoms to TBI may be partially accurate - frontal lobe injury can cause emotional dysregulation, impulsivity, and mood instability that mimics or predisposes to psychiatric illness. 1 This organic component makes treatment more complex and increases risk.

Treatment Failure Pattern:

Recent residential treatment discharge followed by continued daily suicidal ideation and treatment-seeking behavior indicates the current treatment plan is inadequate. 1 The patient reports residential treatment "didn't help" and sertraline after 3 weeks shows no benefit. 1, 2 While SSRIs typically require 4-8 weeks for full effect, the combination of treatment resistance, possible bipolar disorder, and active suicidal crisis means waiting for sertraline to work is not safe. 1, 2

Recommended Immediate Actions

Disposition:

Psychiatric hospitalization is mandatory - this patient cannot be safely managed in any outpatient setting, including intensive outpatient or partial hospitalization programs. 1, 4

During ED Stay:

• Maintain continuous 1:1 observation 4
• Remove all potential means of self-harm from environment 1, 4
• Do NOT rely on "no-suicide contract" - these are ineffective and provide false reassurance 1, 4
• Conduct comprehensive substance use screening (urine drug screen) 1
• Assess for acute intoxication or withdrawal 1

Urgent Psychiatric Consultation Should Address:

1. Bipolar disorder evaluation - detailed history of mood episodes, sleep patterns, energy levels, impulsivity 1
2. Medication review - sertraline may need discontinuation if bipolar disorder confirmed 1, 3
3. Substance use disorder treatment planning - cannabis and alcohol use require integrated treatment 1
4. TBI sequelae assessment - neuropsychological testing may be indicated 1
5. Family assessment - evaluate home safety, parental monitoring capacity, family psychiatric history 1

Safety Planning for Family:

• Remove all firearms from home immediately - even if locked, adolescents find access 1
• Lock up all medications (prescription and over-the-counter) 1
• Remove or secure knives and other sharp objects 1
• Eliminate access to car keys given elopement risk 1
• Address cannabis access - patient reports it's "very easy" to obtain from friends 1

Common Pitfalls to Avoid

• Do not discharge based on patient's statement that he "didn't do it because of family" - this represents minimal protective factor that can change rapidly 1
• Do not underestimate risk because he sought help - treatment-seeking with active SI indicates high distress and risk 1
• Do not continue sertraline without ruling out bipolar disorder - antidepressant monotherapy in bipolar disorder increases suicide risk 1, 3
• Do not accept family reassurance alone - families consistently underestimate risk and overestimate their supervision capacity 4
• Do not focus solely on depression while ignoring substance use - cannabis use disorder requires concurrent treatment 1
• Do not dismiss TBI history as irrelevant - organic brain injury creates permanent vulnerability requiring specialized approach 1