What treatment options are available for a college freshman with a history of major depressive disorder, generalized anxiety disorder, attention deficit hyperactivity disorder (ADHD), binge eating disorder, chronic migraines, vitamin D deficiency, and psychotic symptoms, who recently discontinued medication due to increased suicidal ideation and has a history of substance use and suicidal thoughts?

Treatment Approach for Complex Adolescent with Major Depression, Suicidal Ideation, and Multiple Comorbidities

Immediate Safety Interventions (Priority #1)

All lethal means must be removed from the patient's environment immediately, with explicit instructions to family/support persons to secure or dispose of all medications and remove any firearms. 1, 2 Given the recent medication-induced increase in suicidal ideation and baseline passive suicidality, this patient requires third-party medication monitoring where a responsible adult controls and dispenses all medications, reporting any behavioral changes immediately. 1, 2

• The patient's multiple migraine medications (triptans, ergots) that affect serotonin must be inventoried and controlled by a third party to prevent overdose, as medication ingestion is the most common suicide attempt method in adolescents. 1
• Warn the patient and family about the dangerous disinhibiting effects of alcohol and other drugs, which can precipitate impulsive suicidal behavior. 1, 2
• Do not rely on "no-suicide contracts"—these have no proven value and should never substitute for environmental safety measures and clinical vigilance. 1, 2, 3

Pharmacological Management Strategy

SSRIs remain the first-line pharmacological treatment despite the recent adverse reaction, but require careful selection and intensive monitoring. 1 The patient's experience of increased suicidal ideation with the recently started medication (likely an SSRI given the context) represents a known but uncommon risk that occurs in approximately 1% of patients versus 0.2% with placebo. 3

Medication Selection:

• Fluoxetine is the preferred SSRI for this patient, as it is the only FDA-approved antidepressant for major depression in children and adolescents aged 8 years or older with established efficacy (response rate 46.6% vs 16.5% placebo). 3
• Start with a subtherapeutic "test" dose as fluoxetine can initially increase anxiety or agitation, then gradually titrate upward. 3
• The longer half-life of fluoxetine provides more stable blood levels and reduced discontinuation symptoms compared to other SSRIs. 3
• Tricyclic antidepressants must not be prescribed given the high suicide risk—they are potentially lethal due to the small difference between therapeutic and toxic levels and have not proven effective in adolescents. 1, 2

Critical Monitoring Protocol:

• Schedule weekly visits during the first month to systematically assess for new or worsening suicidal ideation, particularly during weeks 1-2 when risk is highest. 3, 4
• Monitor specifically for SSRI-induced akathisia (restlessness, inability to sit still), which can increase suicidal ideation and requires immediate intervention. 1
• The number needed to treat for SSRI response is 3, compared to number needed to harm of 143 for suicidal ideation, strongly supporting continued SSRI use with appropriate monitoring. 3

Addressing Comorbid Conditions:

• Vitamin D supplementation must be optimized immediately given the documented deficiency and emerging evidence linking hypovitaminosis D to psychotic symptoms, negative symptoms, suicide risk, and impaired functioning. 5, 6, 7
• The patient's stress-related hallucinations (visual and olfactory) may be partially mediated by vitamin D deficiency, which is associated with psychotic features in adolescents (OR 3.5). 6
• ADHD should be addressed after mood stabilization, as untreated ADHD contributes to academic decline and functional impairment, but stimulants should be introduced cautiously given the complex psychiatric presentation. 1

Evidence-Based Psychotherapy (Essential Component)

Dialectical Behavior Therapy (DBT) is the optimal psychotherapy choice for this patient, as it is the only psychotherapy proven to reduce suicidality in controlled trials and specifically addresses the patient's anger issues, impulsivity, binge eating, and emotion dysregulation. 2, 3, 4

• DBT combines cognitive-behavioral techniques with skills training in distress tolerance, emotion regulation, and interpersonal effectiveness. 2, 3
• Alternative evidence-based options include Cognitive-Behavioral Therapy (CBT) focused on suicide prevention, which reduces suicidal ideation and cuts suicide attempt risk by half compared to treatment as usual. 2
• Interpersonal Therapy for Adolescents (IPT-A) can address the patient's history of childhood trauma, family dysfunction, and current adjustment to college. 1, 3
• Medication alone is insufficient for suicide prevention—psychotherapy is a mandatory component of treatment. 2

Family and Environmental Support

Family-based interventions are critical despite the patient living on campus, as they help reframe understanding of problems, alter maladaptive problem-solving, and reduce expressed emotion. 1, 2

• Psychoeducation helps family members identify changes in mental state that may herald suicide attempt repetition. 1, 2
• The family must understand their role in restricting access to lethal medications and firearms and conveying the importance of treatment adherence. 1
• Address the patient's history of severe childhood trauma (domestic violence, abuse) through trauma-informed care approaches. 1

Clinician Availability and Follow-Up

The treating clinician must be available outside regular therapeutic hours or ensure adequate physician coverage for crisis situations. 1, 2, 3

• Schedule closely-spaced follow-up appointments (at least weekly initially) with the same clinician to ensure continuity and establish therapeutic alliance. 1, 2
• The clinician should have experience managing suicidal crises and support available for themselves given the complexity and risk. 1, 2
• Once therapeutic alliance is established and the patient attends initial sessions, treatment continuation becomes more likely. 1

Management of Serotonin Syndrome Risk

Given the patient's multiple serotonin-affecting migraine medications (triptans, ergots) combined with SSRI treatment, monitor for serotonin syndrome: mental status changes, neuromuscular hyperactivity (tremor, rigidity, myoclonus), and autonomic hyperactivity (hyperthermia, tachycardia, diaphoresis). 3

• Coordinate with neurology regarding migraine management to minimize serotonergic medication overlap.
• Consider non-serotonergic migraine prophylaxis options if feasible.

Critical Pitfalls to Avoid

• Never discharge without third-party verification of adequate supervision and environmental safety measures. 2
• Do not prescribe benzodiazepines or phenobarbital as first-line anxiety treatment, as these may increase disinhibition or impulsivity in suicidal adolescents. 1
• Do not abruptly discontinue psychiatric medications without safety planning and close follow-up, as this increases suicide risk. 3
• Do not overlook the academic decline (A student to B's)—this represents functional impairment requiring intervention and may reflect inadequately treated ADHD or worsening depression. 1
• Untreated depression carries significant suicide risk—98.4% of adolescent suicide victims were not receiving antidepressants at time of death. 3

Addressing Binge Eating Disorder

While the patient reports managing binge eating relatively well with calorie tracking, note that it worsens with stress. 1

• DBT's emotion regulation and distress tolerance skills directly address binge eating triggers. 2
• Fluoxetine has evidence for treating bulimia nervosa in adults and may provide dual benefit. 1

Sleep Disturbance Management

The patient's chronic sleep disturbances (difficulty falling asleep, energy boost at midnight, daytime lethargy) suggest possible delayed sleep phase disorder requiring evaluation. 1

• Address sleep hygiene and consider chronotherapy or melatonin after mood stabilization.
• Short-term supplementary anxiolytics or hypnotics may be considered for severe insomnia but prescribe with caution given suicide risk. 4