What is the best course of management for an 18-year-old female (Female, F) patient with a history of Major Depressive Disorder (MDD), recurrent episode, with panic attacks, and previous suicidal attempts, who presented to the emergency room (ER) with symptoms of toxicity after ingesting 15 tablets each of Escitalopram (Escitalopram) and Aripiprazole (Aripiprazole), and has a past medical history (PMHx) of Allergic Rhinitis and Scoliosis, and is currently experiencing oculogyric crises, tachycardia, and hypothermia?

Management of Acute Overdose with Oculogyric Crisis in Recurrent Major Depressive Disorder

Discontinue aripiprazole permanently and continue escitalopram monotherapy after medical stabilization, as the patient has experienced a serious acute dystonic reaction (oculogyric crisis) from aripiprazole overdose, and escitalopram alone is appropriate first-line treatment for recurrent MDD. 1, 2, 3

Immediate Emergency Management

Acute Dystonia Treatment

• Administer diphenhydramine 50 mg IV immediately for ongoing oculogyric crises, which typically resolves symptoms within one hour 3, 4
• Keep diphenhydramine available PRN for recurrent episodes during the acute phase 3
• Monitor for resolution of upward conjugate gaze deviation, anxiety, and associated autonomic symptoms 3, 4

Overdose Monitoring

• Continue close observation for serotonin syndrome, given the ingestion of 15 tablets (150 mg) of escitalopram, monitoring specifically for mental status changes, autonomic instability (tachycardia, labile blood pressure, hyperthermia), neuromuscular symptoms (tremor, rigidity, myoclonus, hyperreflexia), and gastrointestinal symptoms 1
• The patient's current vital signs (HR 107, BP 134/86, T 35.8) show tachycardia and hypothermia, requiring continued monitoring 1
• Supportive care remains the mainstay of overdose management with both agents 1, 2

Suicide Risk Management

• Maintain strict SHEA precautions with continuous observation given moderate suicide risk on C-SSRS and low-to-moderate risk on MSPS-6 5
• Ensure responsible adult watcher at all times during and after hospitalization 5
• The patient's denial of remorse and future intent requires heightened vigilance despite current euthymic presentation 5

Medication Management Post-Stabilization

Discontinue Aripiprazole

• Permanently discontinue aripiprazole due to the acute dystonic reaction (oculogyric crisis), which is a serious extrapyramidal side effect 2, 3, 4
• Young males are at particularly high risk for aripiprazole-induced dystonia, and this patient experienced the reaction at therapeutic doses before the overdose 3, 4
• Aripiprazole carries FDA warnings about neuroleptic malignant syndrome and tardive dyskinesia, making rechallenge inappropriate after acute dystonia 2

Continue Escitalopram Monotherapy

• Resume escitalopram 10 mg daily once medically cleared, as this is appropriate first-line treatment for recurrent MDD 6, 7
• Second-generation antidepressants like escitalopram have equivalent efficacy to cognitive behavioral therapy for MDD 6
• Continue escitalopram for 4-9 months minimum after achieving response, with longer maintenance (≥1 year) indicated for recurrent episodes, which this patient has 6, 7
• The patient had good prior response to escitalopram before running out of medication one month prior to presentation 6, 7

Adjunctive Medications

• Start hydroxyzine 25 mg PRN for anxiety or insomnia as planned, which addresses panic attacks without extrapyramidal risk 6
• Avoid benzodiazepines for initial treatment of depressive symptoms, as they are not indicated for MDD management 6

Monitoring and Follow-up

Early Assessment Timeline

• Begin assessment within 1-2 weeks of restarting escitalopram, monitoring specifically for increased suicidal thoughts, agitation, irritability, or unusual behavioral changes 7, 1, 2
• The FDA requires close monitoring during initial treatment months and at dose changes for emergence of suicidality 1, 2
• Continue regular monitoring throughout the continuation phase (4-9 months) 7

Response Assessment

• Evaluate treatment response at 6-8 weeks of optimized escitalopram therapy 7
• If inadequate response occurs, consider switching to another second-generation antidepressant, adding cognitive behavioral therapy, or augmentation strategies 7
• Response rates to initial antidepressant therapy may be as low as 50%, requiring treatment modification 7

Psychosocial Interventions

Cognitive Behavioral Therapy

• Initiate or continue CBT concurrently with pharmacotherapy, as the patient recently started with a psychologist 6
• CBT has equivalent efficacy to antidepressants and is strongly recommended for MDD 6
• Problem-solving treatment and interpersonal therapy are also evidence-based options 6

Safety Planning

• Complete comprehensive safety planning before discharge, addressing specific triggers (academic stress, grief over sister's death, scholarship concerns) 5
• Identify warning signs, coping strategies, social supports, and crisis resources 5
• The patient's tendency to keep problems to herself requires explicit discussion of help-seeking behaviors 5, 8

Laboratory Evaluation

Recommended Testing

• Complete FBS, lipid panel, TSH, FT4, and urinalysis with pregnancy test as planned to rule out medical contributors to depression and establish baseline 6, 9
• These tests exclude thyroid dysfunction, metabolic abnormalities, and pregnancy before continuing antidepressant therapy 6, 9

Critical Pitfalls to Avoid

• Never rechallenge with aripiprazole after acute dystonia, as recurrence risk is high and the patient has no clear indication for antipsychotic augmentation 2, 3, 4
• Do not abruptly discontinue escitalopram once restarted; gradual taper over weeks is required if discontinuation becomes necessary to avoid withdrawal symptoms (dysphoria, dizziness, paresthesias, anxiety) 1
• Do not discharge without ensuring medication access, as the patient's recent decompensation occurred after running out of escitalopram for one month 6, 7
• Address the panic attacks specifically, as panic disorder independently increases suicide risk with an adjusted odds ratio of 2.62 for suicide attempts, even controlling for depression 8
• Monitor for hyponatremia with escitalopram, particularly given the recent overdose, as SIADH can occur with SSRIs 1