What is the best treatment approach for a 13-year-old female with major depressive disorder, history of seizures, and recent suicide attempt?

Treatment Approach for Adolescent with Major Depressive Disorder, Seizure History, and Recent Suicide Attempt

This patient requires immediate psychiatric hospitalization given her recent suicide attempt, ongoing suicidal ideation with intent, history of self-harm, multiple psychosocial stressors including sexual abuse and domestic violence, and inability to contract for safety. 1, 2

Immediate Safety and Hospitalization

Hospitalization is mandatory based on multiple high-risk features 1, 2:

• Recent suicide attempt with ingestion
• Current suicidal ideation with stated intent ("if I were to go home she would find a way to end her life")
• History of self-injurious behaviors (cutting, burning)
• Severe depression with anhedonia and hopelessness
• Multiple environmental stressors (domestic violence, sexual abuse, bullying)
• Previous emergency department presentations for suicidality

During hospitalization, implement the following 2, 3:

• Remove all personal belongings and provide hospital attire only to prevent self-harm
• Daily assessment of suicidal ideation, mental status, and intended course of action
• Coordinate multidisciplinary care including psychiatry, social work, and child protective services given disclosed abuse

Pharmacotherapy Considerations

SSRI Treatment Despite Seizure History

Fluoxetine should be initiated at 10 mg daily given her lower weight as an adolescent, with increase to 20 mg after one week if tolerated. 4 The mother's concern about restarting an SSRI after the seizure episode with sertraline requires careful discussion:

• SSRIs, including fluoxetine, are not more epileptogenic than placebo and are the preferred antidepressants in patients with epilepsy 5, 6
• The temporal relationship between sertraline initiation and seizure onset may have been coincidental rather than causal 5
• Tricyclic antidepressants are epileptogenic and should be avoided, but SSRIs do not carry this risk 6
• Depression itself is common in epilepsy patients and requires treatment 5, 7

Close monitoring during the first weeks of treatment is essential 4:

• Weekly follow-up initially to monitor for worsening suicidality, agitation, or behavioral activation
• Full antidepressant effect may require 4 weeks or longer 4
• Families must be educated to monitor for emergence of agitation, irritability, unusual behavior changes, or worsening suicidality 4

Seizure Management Coordination

Continue levetiracetam 300 mg as prescribed 5. Coordinate care with neurology to ensure:

• Seizure disorder is optimally controlled, as uncontrolled seizures can worsen depression 7
• No drug-drug interactions between antidepressant and antiepileptic medication
• Monitoring for any changes in seizure frequency after SSRI initiation

Psychotherapeutic Interventions

Cognitive-behavioral therapy (CBT) should be initiated during hospitalization and continued after discharge 1, 2:

• CBT has demonstrated efficacy in reducing suicidal ideation and behavior in depressed adolescents 1
• Can reduce risk of post-treatment suicide attempt by half compared to treatment as usual 2
• Addresses negative cognitions about self, environment, and future that characterize her presentation 1
• Treatment should include 12-16 weekly sessions with booster sessions monthly or bimonthly for 6 months 1

Trauma-focused therapy should be incorporated given her history of sexual abuse by her relative 1:

• Evidence shows trauma-focused treatments can be safely used in patients with suicidal ideation without causing symptom exacerbation 1
• History of childhood sexual abuse does not negatively affect treatment response to trauma-focused interventions 1
• Premature confrontation with traumatic memories does not lead to worsening suicidality as previously feared 1

Safety Planning and Discharge Criteria

The patient should not be discharged until 2, 3:

• Mental state and suicidality have stabilized
• She can form a therapeutic alliance with treatment providers
• A comprehensive safety plan is in place

Develop a collaborative crisis response plan before discharge 2:

• Identification of clear warning signs of crisis
• Self-management skills for distraction from stressors
• Identification of social support contacts (her friend, school counselor)
• Review of crisis resources (crisis hotline, emergency department)
• Scheduled follow-up appointments

Remove access to lethal means 2:

• Explicitly instruct mother to remove all medications from accessible areas and lock them up
• Remove any potential weapons from the home
• Warn about dangerous disinhibiting effects of alcohol and substances given her history of THC use

Post-Discharge Management

Schedule closely spaced follow-up appointments 2:

• Initial appointment within 48-72 hours of discharge
• Weekly appointments for first month, then biweekly as clinically indicated
• Maintain contact even after referrals are made
• Be flexible in arranging urgent appointments if crisis arises

Address environmental stressors through coordinated services 1, 2:

• Mandatory reporting of physical and sexual abuse to child protective services
• Family therapy to address domestic violence and parent-child conflicts
• School-based interventions for bullying and academic support given her IEP
• Consider temporary placement if home environment cannot be made safe

Common Pitfalls to Avoid

• Do not delay SSRI treatment due to seizure history - SSRIs are safe in epilepsy and depression worsens outcomes 5, 6
• Do not discharge prematurely - Multiple ED visits without hospitalization have failed to stabilize this patient 1, 3
• Do not ignore trauma history - Sexual abuse and domestic violence are treatable contributors to her suicidality 1
• Do not rely solely on medication - Combined pharmacotherapy and psychotherapy is essential 1, 2
• Do not underestimate ongoing risk - Her statement "if I die I die" indicates persistent passive suicidal ideation requiring intensive intervention 1, 2