What is the best management approach for a 16-year-old patient with a history of Traumatic Brain Injury (TBI), presenting with aggression and suicidal ideation (SI), currently on Prozac (fluoxetine) 10 mg and hydroxyzine?

Management of 16-Year-Old with TBI, Aggression, and Suicidal Ideation on Prozac 10mg

This patient requires immediate assessment for fluoxetine-induced akathisia and consideration of adding an atypical antipsychotic, as the combination of TBI, aggression, and suicidal ideation represents a high-risk clinical scenario that demands urgent intervention beyond the current low-dose SSRI monotherapy. 1, 2, 3

Immediate Safety Assessment and Medication Evaluation

Assess for Akathisia and Treatment-Emergent Suicidality

• Evaluate immediately for akathisia (motor restlessness), as this adverse effect is strongly associated with fluoxetine and emergent suicidal ideation, particularly in adolescents. 4, 2, 3
• Document whether suicidal thoughts represent worsening of pre-existing ideation or completely new-onset thoughts since starting Prozac, as the FDA label explicitly warns that suicidal ideation may emerge or worsen early during antidepressant treatment. 2, 3
• If akathisia is present, this requires immediate dose reduction or discontinuation of fluoxetine. 2
• The current 10mg dose is subtherapeutic for depression (therapeutic range 20-60mg), which may explain inadequate symptom control, but increasing the dose carries risk of worsening agitation and suicidality. 4, 3

Determine if Psychotic Features are Present

• Screen for hallucinations, delusions, or disorganized thinking, as depression with psychotic features requires concomitant antipsychotic medication. 1
• TBI patients have increased risk of post-traumatic psychosis and aggression, making this assessment critical. 4, 5

Recommended Pharmacological Management

Add Atypical Antipsychotic (First-Line Intervention)

Add an atypical antipsychotic to the current Prozac regimen rather than switching antidepressants, given the combination of aggression, suicidal ideation, and TBI. 1, 6

Specific options in order of preference:

• Aripiprazole 2-5mg daily, titrating to 10-15mg: Lower metabolic risk, potential benefits for anxiety, and well-studied in adolescents. 1
• Risperidone 0.5-1mg daily, titrating to 2-4mg: Well-studied profile in adolescents, effective for psychotic symptoms and aggression. 1
• Quetiapine 25-50mg at bedtime, titrating to 150-300mg: Sedating properties may help with anxiety and insomnia common in TBI. 1

Rationale: Antipsychotics address aggression more effectively than SSRIs alone in TBI patients, and this patient's presentation suggests inadequate response to SSRI monotherapy. 1, 6

Avoid Contraindicated Medications

• Do not prescribe benzodiazepines or phenobarbital: These medications reduce self-control and may disinhibit individuals, leading to increased aggression and suicide attempts in suicidal adolescents. 4, 2
• Avoid typical antipsychotics (haloperidol): Not supported by evidence in TBI-related aggression and carry higher risk of extrapyramidal symptoms. 7, 6
• Hydroxyzine can be continued for anxiety as needed, but should not be the primary intervention for aggression or suicidality. 4

Consider Mood Stabilizers as Alternative/Adjunct

• Carbamazepine or valproate are recommended as first-line treatment for agitation and aggression in TBI (Expert Consensus). 6
• These may be particularly useful if antipsychotics are not tolerated or if there is concern for bipolar disorder (which must be screened for before continuing antidepressant treatment). 4, 3, 6
• Propranolol (beta-blocker) can improve aggression in TBI (Grade B evidence), typically dosed 20-40mg twice daily, titrating to effect. 6

Enhanced Monitoring Protocol

Intensive Suicide Risk Monitoring

Schedule follow-up within 48-72 hours, then weekly for the first month after any medication change. 2, 3

Monitor specifically for:

• Emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, mania, worsening depression, and suicidal ideation. 2, 3
• Severe, abrupt onset of symptoms that were not part of the patient's presenting symptoms. 2, 3
• Patients with impulsivity diagnosed before TBI have a 21-fold increased risk of suicide attempts, making this population extremely high-risk. 8

Family/Caregiver Involvement

• Ensure family members or caregivers can report any unexpected mood changes, increased agitation, or emergent suicidal thoughts between appointments. 2, 3
• Parental oversight of medication administration is paramount to ensure adherence and prevent overdose. 1
• Families should be instructed to monitor for warning signs on a day-to-day basis, as changes may be abrupt. 3

Metabolic and Safety Monitoring

• Monitor for metabolic effects of antipsychotics (weight, glucose, lipids) at baseline, 3 months, and annually. 1
• Watch for serotonin syndrome, activation syndrome, and extrapyramidal symptoms. 1, 3
• Document all assessments of suicidal ideation, presence or absence of akathisia, safety planning interventions, and medication changes at every visit. 2

Treatment Algorithm

Week 1-2: Initiation Phase

• Add atypical antipsychotic (aripiprazole 2-5mg or risperidone 0.5-1mg) to current Prozac 10mg. 1
• Consider increasing Prozac to 20mg (therapeutic dose) only if no akathisia present and patient is stable. 4, 2
• Weekly monitoring for suicidality, akathisia, and activation. 1, 2
• Implement safety planning with patient and family. 4

Week 3-4: Titration Phase

• Titrate antipsychotic to therapeutic dose (aripiprazole 10-15mg or risperidone 2-4mg). 1
• Assess response: reduction in aggression, improvement in mood, decrease in suicidal ideation. 1
• Continue close monitoring for adverse effects. 1

Week 6-8: Optimization Phase

• If inadequate response, consider switching SSRI to SNRI (venlafaxine 37.5-75mg daily, titrating to 150-225mg), as SNRIs may address both depression and anxiety disorders in adolescents. 1
• If partial response, optimize antipsychotic dose or consider adding mood stabilizer (carbamazepine or valproate). 1, 6
• If good response, continue current regimen and transition to biweekly monitoring for 3 months. 1

Essential Adjunctive Treatment

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) is essential and should be initiated immediately, as combination CBT + medication is superior to either alone for adolescent anxiety/depression. 4, 1

Specific CBT approaches for this patient:

• Problem-solving therapy for TBI-related cognitive deficits. 4
• Safety planning and crisis intervention skills. 4
• Behavioral activation and cognitive restructuring. 4

Lethal Means Safety

• Implement lethal means safety counseling, including firearm restrictions and reduced access to medications that could be used in overdose. 4
• Prescribe the smallest quantity of medication consistent with good patient management to reduce overdose risk. 3

Critical Pitfalls to Avoid

• Do not treat with antidepressant monotherapy: This patient's presentation (TBI + aggression + suicidal ideation) requires more aggressive intervention. 1, 6
• Do not abruptly stop Prozac: Gradual taper is required if discontinuation is necessary, though fluoxetine's long half-life minimizes discontinuation syndrome risk. 3
• Do not prescribe benzodiazepines for anxiety/agitation: These worsen disinhibition and increase suicide risk. 4, 2
• Do not underestimate suicide risk in TBI patients: TBI with impulsivity carries dramatically elevated suicide risk requiring intensive monitoring. 8, 5
• Do not increase fluoxetine dose without ruling out akathisia: Dose increases can precipitate or worsen treatment-emergent suicidality. 2, 3