How should I manage a 14‑year‑old transgender male (assigned female at birth) with active suicidal ideation and a specific plan to overdose, who has a family history of bipolar disorder, is taking fluoxetine 40 mg daily for six weeks, and is on aripiprazole (Abilify) with a proposed plan to increase fluoxetine to 60 mg, discontinue aripiprazole, start lurasidone (Latuda) and, if needed, add risperidone?

Management of a 14-Year-Old Transgender Male with Active Suicidal Ideation on Fluoxetine

Immediate Safety Interventions (Do Not Discharge Without These)

This patient requires immediate psychiatric hospitalization or emergency department transfer due to active suicidal ideation with a specific plan to overdose, which represents a high-risk indicator that mandates inpatient psychiatric evaluation. 1

• Remove all firearms from the home immediately—firearms are the most common method adolescents use to complete suicide in the United States, and having a gun in the house doubles suicide risk. 1, 2
• Secure or dispose of all medications in the home, including over-the-counter analgesics, as medication ingestion is the most common suicide attempt method in adolescents. 3, 1
• Establish third-party medication monitoring where a responsible adult controls and dispenses all medications, reporting any behavioral changes immediately. 1, 4
• Do not rely on "no-suicide contracts"—these have no proven value and should never substitute for environmental safety measures and clinical vigilance. 1, 4, 2

Critical Assessment for Treatment-Emergent Suicidality

Immediately assess for akathisia (motor restlessness, inner sense of restlessness, inability to sit still), as fluoxetine-induced akathisia has been specifically linked to treatment-emergent suicidal ideation. 1

• If akathisia is present, reduce the fluoxetine dose or add propranolol—case reports demonstrate that resolution of akathisia leads to resolution of suicidal thoughts. 1
• Evaluate for behavioral activation (motor restlessness, insomnia, impulsiveness, disinhibited behavior, aggression), which is more common in younger patients on SSRIs and can precipitate suicidal behavior. 1

Pharmacological Management Strategy

Do NOT Increase Fluoxetine to 60 mg at This Time

Given active suicidal ideation with a plan, increasing the SSRI dose now would be premature and potentially dangerous without first stabilizing the patient in a supervised setting and ruling out akathisia or behavioral activation. 1, 5

Regarding the Proposed Medication Changes

The plan to discontinue aripiprazole and trial lurasidone is reasonable IF the family history suggests bipolar disorder rather than unipolar depression, but this decision requires urgent psychiatric evaluation to clarify the diagnosis. 6, 7

• Lurasidone is FDA-approved and first-line for bipolar depression in adolescents aged 10 years and older, with efficacy demonstrated in controlled trials (large effect size) and relatively limited metabolic side effects compared to other atypicals. 8, 6, 7
• Lurasidone must be taken with food (at least 350 calories) to ensure adequate absorption. 9
• Monitor for treatment-emergent suicidal ideation, as the FDA black-box warning applies to lurasidone when used for bipolar depression in adolescents. 9

Risperidone should be reserved as a third-line option due to higher risk of weight gain, metabolic side effects, and prolactin elevation compared to lurasidone. 6, 7

If Unipolar Depression is Confirmed

Fluoxetine remains the preferred SSRI, 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). 1, 4

• However, any SSRI continuation requires intensive monitoring with weekly visits for at least 4 weeks to assess for new or worsening suicidal ideation, akathisia, and behavioral activation. 1
• The number needed to treat for SSRI response is 3, compared to number needed to harm of 143 for suicidal ideation, supporting continued SSRI use with appropriate monitoring. 1

Essential Psychotherapy Component

Dialectical Behavior Therapy (DBT) is the optimal psychotherapy choice, as it is the only psychotherapy proven to reduce suicidality in controlled trials. 1, 4

• DBT combines cognitive-behavioral techniques with skills training in distress tolerance, emotion regulation, and interpersonal effectiveness. 1, 4
• 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. 4, 2
• Psychotherapy must accompany medication management—medication alone is insufficient for suicidal adolescents. 1

Intensive Monitoring Protocol

Schedule weekly clinical visits for a minimum of 4 weeks to systematically assess for new or worsening suicidal ideation, behavioral activation, and akathisia. 1

• At each visit, inquire systematically about suicidal thoughts both before and after treatment initiation, with heightened vigilance if akathisia is present. 1
• The treating clinician must be available outside regular therapeutic hours or ensure adequate physician coverage for crisis situations. 1, 4
• Educate the family on warning signs requiring immediate contact: new or more frequent thoughts of wanting to die, self-destructive behavior, increased agitation, or severe hopelessness. 1

Family History of Bipolar Disorder: Diagnostic Implications

The family history of bipolar disorder significantly increases this patient's risk of having bipolar disorder rather than unipolar depression, which would fundamentally change the treatment approach. 3

• Adolescents with bipolar disorder are at higher risk for suicide attempts and completion. 3
• If bipolar disorder is confirmed, lithium should be considered as first-line treatment due to its unique anti-suicide effects—lithium greatly reduces the rate of both suicides and suicide attempts in patients with bipolar disorder. 1
• Antidepressant monotherapy (fluoxetine alone) is contraindicated in bipolar disorder due to risk of inducing mania or rapid cycling. 10, 7

Transgender-Specific Considerations

Transgender adolescents carry a 2- to 7-fold increased risk for suicidal ideation and attempt behavior, with higher rates of drug and alcohol use, earlier substance use, and increased likelihood of bullying and victimization at school. 3

• Ensure the treatment team is affirming and knowledgeable about transgender health issues to maintain therapeutic alliance. 3
• Address any psychosocial stressors related to gender identity, family acceptance, or peer relationships as part of comprehensive treatment. 3

Critical Pitfalls to Avoid

• Never discharge without third-party verification of adequate supervision and environmental safety measures (firearms removed, medications secured). 4
• Do not prescribe benzodiazepines as first-line anxiety treatment, as these may increase disinhibition or impulsivity in suicidal adolescents. 1, 4
• Do not abruptly discontinue psychiatric medications without safety planning and close follow-up, as this increases suicide risk. 4
• Untreated depression carries significant suicide risk—98.4% of adolescent suicide victims were not receiving antidepressants at time of death. 4
• Assuming low risk based on passive suicidal ideation is dangerous—this patient has progressed to having a specific plan, which represents escalation. 3

Recommended Immediate Action Plan

1. Arrange urgent psychiatric evaluation within 24-48 hours (or immediate hospitalization if patient cannot be safely monitored at home). 1
2. Implement all environmental safety measures before discharge from this visit. 1, 2
3. Hold the fluoxetine dose increase until psychiatric evaluation clarifies diagnosis and assesses for akathisia/behavioral activation. 1
4. Initiate or intensify psychotherapy (DBT preferred) immediately. 1, 4
5. Schedule weekly follow-up with the same clinician to ensure continuity and establish therapeutic alliance. 1