Introduction

Substance use by adolescents is a significant public health concern because of its physical, legal, and psychiatric complications and likely progression to the development of substance-use disorders (SUD) in adolescence or adulthood. Substance use per se is not sufficient for a diagnosis of a use disorder in adolescents. Through the lens of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), adolescents meet the criteria of an SUD if there is evidence of a maladaptive pattern of substance use with clinically significant levels of impairment or distress, in addition to withdrawal, tolerance, and loss of control over use.1 The term ‘misuse’ is frequently used to indicate behaviors that may or may not result in an SUD diagnosis in adolescents. For instance, using a drug via a route not advised by medical guidelines would connote misuse rather than SUD.2

As self-harm and SUD are leading causes of Years of Life Lost (YLLs) among young people aged 10-24 years,3 we present the case of a young person, with a history of multiple serious suicidal attempts and SUD, who was misusing fluoxetine, a selective serotonin reuptake inhibitor (SSRI), as part of maladaptive coping strategy. SSRIs are not known to be commonly abused drugs let alone sniffed or snorted. To the best of our knowledge, this is the first reported case of an adolescent snorting fluoxetine.

Case

A 15-year-old female, who had recently immigrated, was referred to our community child and adolescent mental health service (CAMHS). The referral was made following a suicide attempt by jumping from a height that led to a right ankle bimalleolar fracture necessitating orthopedic surgery.

During the first outpatient psychiatric assessment at CAMHS, relevant history and collateral information were obtained from the patient and her father. The patient reported engaging in deliberate self-harm once a week during the past year, cutting herself using a blade, mainly to release her stress and tension. She explained that she had thoughts of jumping from the rooftop of her two-story house to end her life for almost a week prior to the attempt. She stated that she had disclosed her intentions to her friends, who did not take her seriously. She said that the decision to jump was partly influenced by the drive to prove her friends wrong. Although she had had suicidal ideation for a week before the attempt, her motivation right before jumping was ‘to seek help from anybody’. After she jumped, she telephoned her friends, who advised her to call the ambulance.

In this outpatient visit, she scored 40 on the Beck Depression Inventory-II (BDI-II) and denied having active thoughts or plans of severe self-harm or suicide. There were no clinical features suggestive of bipolar disorder. Developmental history was limited as the primary caregiver (mother) was in her homeland. Academic performance before immigration had been average, without any difficulties in learning or using academic skills; at present she had decreased interest in her online classes (remote learning). Her father reported that she had poor social functioning due to longstanding family conflicts.

Her past psychiatric history was significant with three previous admissions to a psychiatric hospital in the past year back in her home country. Reasons for admissions were suicidal attempts: overdose, hanging, and deep self-inflicted wrist lacerations in the first, second, and third admission respectively, all in the context of overwhelming academic pressure and interpersonal conflicts. She was diagnosed with Asperger’s syndrome and major depressive disorder. She was on fluoxetine 30 mg for about a year for major depressive disorder. Aripiprazole 5 mg was subsequently added after her second admission as adjuvant therapy. She reported being poorly adherent to both medications and resorting to self-harm by cutting herself, smoking cannabis and drinking alcohol weekly as means to cope with her difficulties. Her last joint and drink were five months ago, when she immigrated. She stated that when she began to struggle to cope with ongoing peer pressure and parental discord, she resorted to sniffing the contents of fluoxetine capsules because one of her best friends used to snort cocaine to deal with stress. She reported that she sniffed one capsule per week, and her mood would brighten temporarily. She denied any symptoms of tolerance, withdrawal, or dependence during these four weeks of sniffing/snorting fluoxetine capsules. Prior to jumping from the rooftop, she had sniffed ‘a few capsules to make the suicidal thoughts go away.’

Our working diagnosis was a relapse of her major depressive disorder with severe emotional dysregulation. Her presentation appeared to be potentially in line with traits of an emerging borderline personality disorder as evidenced by a pervasive pattern of instability in interpersonal relationships, recurrent episodes of non-suicidal self-injury and suicidal attempts, marked impulsivity, and affective instability. Aripiprazole was changed to quetiapine 25 mg twice daily for effective management of emotional dysregulation. Fluoxetine 20 mg once daily was continued, mainly to manage her depressive symptoms, under close observation provided by her caregiver. Weekly outpatient follow-up appointments were provided for regular risk assessment and to explore indications for inpatient admission. As part of a multidisciplinary approach, the psychologist and social worker provided psychosocial interventions, such as psychoeducation, supportive psychotherapy, distraction, and grounding techniques. However, the psychologist was unable to engage in any long-term psychological interventions as the patient was expected to return to her home country after three weeks. In her follow-ups, she improved in her mental state and relied no more on sniffing/snorting fluoxetine. Three weeks after the initial intake interview, her BDI-II score decreased by 50%, and she traveled back to her home country.

Discussion

Fluoxetine is an FDA-approved SSRI for major depressive disorder and obsessive-compulsive disorder in the pediatric population.4 It is mainly available in capsule, tablet and oral suspension preparations. Although snorting practices are uncommon with antidepressants, there is some evidence regarding snorting venlafaxine and bupropion in combination with recreational drugs such as opiates, cannabis, and cocaine.5 Snorting bupropion can lead to physical, affective and behavioral problems, as well as seizures.6 Consequently, as evidenced in this case, physicians should carefully evaluate for signs of misuse or abuse of fluoxetine and other prescribed medications in patients struggling with emotional regulation with past history of recreational drug use and self-harm, in addition to a screening and comprehensive assessment, despite limited reports in the scientific literature (Table 1).

Table 1. Essentials of Assessment
Screening assessment (especially at primary care level) The screening tool CRAFFT7:
C: Have you ridden in a car driven by someone (including self) who was high, drunk, or using drugs?
R: Have you ever used drugs or alcohol to relax?
A: Do you ever use alone?
F: Do you ever forget things that you did while using?
F: Do family/friends tell you to cut down?
T: Have you got into trouble when using?
Comprehensive assessment Thorough history taking includes, but is not limited to, substance use, psychiatric symptoms/disorders, family functioning, academic/vocational functioning, relationship with peers, hobbies/recreation, and past/current medical issues.
The Interview Be nonjudgmental.8
Toxicology The American Academy of Child and Adolescent Psychiatry recommends toxicology screening as a routine part for the assessment while ensuring confidentiality and consent.8
Confidentiality Adolescents are more likely to provide truthful information if they believe that their information will not be shared. Prior to the interview, the psychiatrist should review exactly what information the clinician is obliged to share and with whom.8
The validity of the adolescent report In a healthcare setting, there might be inconsistencies in reports of substance use. The use of a self-report questionnaire may be perceived as less threatening and may support or validate the self-report.

This paper also highlights the efficacy of quetiapine in regulating mood and impulsivity in a young person. Quetiapine was shown to reduce the severity of borderline personality disorder symptoms, compared with placebo, in adults.9 The pharmacological properties of quetiapine, and its metabolite norquetiapine, for the treatment of all phases of bipolar disorder may explain its ability to address affective instability, impulsivity, and self-harm in adolescents with borderline personality traits.10 In fact, quetiapine dosage as low as 150 mg/day has been reported to significantly reduce the severity of borderline personality disorder symptoms.9 In our case, we adopted a ‘start low and go slow’ approach in view of the patient’s previous history of drug overdose, being anti-psychotic naive, and the use of quetiapine as part of combination therapy with fluoxetine.

Conclusion

Substance use and SUDs in adolescents remain a critical problem due to their complexity. Child and adolescent mental health professionals seeking to understand the risk for substance misuse should consider incorporating in their assessment the risk of misuse of psychotropic medication administered through non-conventional routes e.g. sniffing/snorting fluoxetine. Moreover, psychiatric comorbidity in adolescents with SUDs is the rule rather than the exception. Quetiapine, even in low doses, also seems useful in adolescents with SUDs who engage in maladaptive coping strategies such as sniffing/snorting fluoxetine. Quetiapine is also a potential option to help with mood dysregulation in adolescents with emerging traits of borderline personality disorder and major depressive disorder, in addition to psychosocial interventions.


Acknowledgements & Ethics approval

The author thanks Dr. Yasser Saeed Khan (CAMHS Medical Lead, Hamad Medical Corporation) for his assistance in the manuscript preparation. Ethical approval to report this case was obtained from Medical Research Center of Hamad Medical Corporation (MRC-04-22-277).

Declaration of conflict of interest

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research authorship, and/or publication of this article.