How should a 15‑year‑old on duloxetine who is now experiencing visual and auditory hallucinations be evaluated and managed?

Immediate Discontinuation of Duloxetine and Urgent Psychiatric Evaluation

This 15-year-old experiencing visual and auditory hallucinations on duloxetine requires immediate discontinuation of the medication (with appropriate tapering if clinically feasible) and urgent psychiatric evaluation to rule out drug-induced psychosis, primary psychotic disorder, or other serious psychiatric conditions.

Immediate Management Steps

Discontinue Duloxetine

• Stop duloxetine immediately if hallucinations are severe or distressing, as these symptoms are not typical adverse effects of this medication and suggest either drug-induced psychosis or unmasking of an underlying psychotic disorder 1
• If the clinical situation allows for a brief taper (patient is stable, hallucinations are not severe), reduce the dose over 2-4 weeks to minimize withdrawal symptoms, though safety takes priority over gradual discontinuation 1
• Nausea, dizziness, and other discontinuation symptoms may occur but are preferable to continuing a medication that may be contributing to psychosis 2

Urgent Psychiatric Assessment Required

• Conduct a thorough diagnostic evaluation immediately to differentiate between drug-induced psychosis, primary psychotic disorder (schizophrenia, schizoaffective disorder), psychotic mood disorder (bipolar disorder with psychosis, psychotic depression), or other conditions 3
• Obtain detailed history of the hallucinations: onset timing relative to duloxetine initiation/dose changes, content (mood-congruent vs. mood-incongruent), frequency, and associated symptoms 3
• Assess for manic symptoms (decreased need for sleep, grandiosity, pressured speech, increased goal-directed activity) as bipolar disorder with psychosis is commonly misdiagnosed as schizophrenia in adolescents 3

Critical Differential Diagnosis Workup

Rule Out Medical and Substance-Related Causes

• Complete pediatric and neurological examination looking specifically for signs of delirium, seizure disorders, CNS lesions, metabolic disorders, or infectious diseases 3
• Obtain urine drug screen for amphetamines, cocaine, hallucinogens, phencyclidine, marijuana, and other substances of abuse that can cause psychotic symptoms 3
• Check for concomitant medications with serotonergic or dopaminergic properties that could contribute to toxicity 3
• Order basic laboratory tests: complete blood count, comprehensive metabolic panel, thyroid function tests, and urinalysis to exclude metabolic or endocrine causes 3

Assess for Primary Psychiatric Disorders

• Evaluate family psychiatric history, particularly for schizophrenia, bipolar disorder, and depression, as this helps differentiate diagnostic possibilities 3
• Review premorbid functioning and developmental history to determine if negative symptoms (social withdrawal, amotivation) preceded the hallucinations 3
• Determine if mood symptoms (depression or mania) are prominent and whether psychotic symptoms are mood-congruent, as psychotic depression and bipolar disorder frequently present with hallucinations in adolescents 3

Key Clinical Pitfalls to Avoid

Do Not Assume Drug-Induced Psychosis Without Full Evaluation

• While duloxetine can rarely cause psychotic symptoms, do not automatically attribute hallucinations to the medication without ruling out primary psychotic disorders, as adolescence is a common age for first presentation of schizophrenia and bipolar disorder 3
• Approximately 50% of adolescents with bipolar disorder may be initially misdiagnosed as having schizophrenia due to overlapping psychotic symptoms 3

Do Not Restart or Continue Duloxetine

• Never continue duloxetine in a patient experiencing hallucinations as this is not an expected adverse effect and suggests either drug-induced psychosis or unmasking of a serious psychiatric condition 1, 2
• Duloxetine is approved for generalized anxiety disorder in adolescents ≥7 years but is not indicated for psychotic disorders 1

Monitor for Serotonin Syndrome

• Assess for signs of serotonin syndrome (agitation, hallucinations, tachycardia, hyperthermia, hyperreflexia, altered coordination) particularly if the patient is on other serotonergic medications 4
• While hallucinations can be a feature of serotonin syndrome, isolated visual and auditory hallucinations without other autonomic features are more suggestive of primary psychosis 4

Disposition and Follow-Up

Immediate Psychiatric Referral

• Refer urgently to child and adolescent psychiatry for comprehensive diagnostic assessment and treatment planning 3
• Consider emergency department evaluation if hallucinations are command-type, distressing, or associated with safety concerns 3
• Periodic diagnostic reassessments are essential as the clinical picture may evolve over time and initial diagnosis may need revision 3

Antipsychotic Treatment May Be Required

• If psychotic symptoms persist after duloxetine discontinuation, antipsychotic medication will likely be necessary 3
• Atypical antipsychotics (risperidone, olanzapine, quetiapine, aripiprazole) are generally preferred over traditional neuroleptics due to lower risk of extrapyramidal symptoms in adolescents 3
• Document any preexisting abnormal movements before initiating antipsychotics to avoid later mislabeling them as medication side effects 3