From the Guidelines
If you're experiencing thoughts of death, self-harm, suicide, depression, anxiety, hopelessness, emptiness, impulsiveness, aggression, concentration difficulties, fatigue, lack of motivation, anhedonia, racing thoughts, or negative self-talk, you should seek immediate professional help. Contact a mental health crisis line like the National Suicide Prevention Lifeline (988) or go to your nearest emergency room if you're having thoughts of harming yourself or others. These symptoms suggest a serious mental health condition that requires proper evaluation by a psychiatrist or psychologist. According to a recent meta-analysis on safety planning-type interventions for suicide prevention 1, brief interventions, including up to three encounters between a patient and a professional, have been linked to reduced risks of suicidal behavior.
While medications like SSRIs (fluoxetine, sertraline), SNRIs (venlafaxine, duloxetine), or mood stabilizers (lamotrigine, lithium) might be prescribed depending on your diagnosis, treatment should be personalized and monitored by a professional 1. Therapy approaches like Cognitive Behavioral Therapy (CBT) or Dialectical Behavior Therapy (DBT) can help develop coping strategies. The American Academy of Child and Adolescent Psychiatry recommends looking for signs of mania or hypomania, such as depressed mood, elated or irritable mood, inflated self-esteem, and decreased need for sleep 1.
Key considerations for managing these symptoms include:
- Seeking immediate professional help if you're having thoughts of harming yourself or others
- Contacting a mental health crisis line or going to the nearest emergency room
- Undergoing proper evaluation by a psychiatrist or psychologist
- Developing a personalized treatment plan, which may include medication and therapy
- Engaging in brief interventions, such as safety planning, to reduce the risk of suicidal behavior 1.
These symptoms affect your brain chemistry and thought patterns, interfering with daily functioning, but with proper treatment, they can improve significantly. Don't try to manage these symptoms alone, as professional intervention is essential for recovery.
From the FDA Drug Label
Pooled analyses of short-term placebo-controlled trials of antidepressant drugs (SSRIs and others) showed that these drugs increase the risk of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults (ages 18 to 24) with major depressive disorder (MDD) and other psychiatric disorders The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have been reported in adult and pediatric patients being treated with antidepressants for major depressive disorder as well as for other indications, both psychiatric and nonpsychiatric Although a causal link between the emergence of such symptoms and either the worsening of depression and/or the emergence of suicidal impulses has not been established, there is concern that such symptoms may represent precursors to emerging suicidality
The symptoms listed, such as death thoughts, feeling down, depressed, or hopeless, feeling nervous, anxious, or on edge, impulsiveness, and negative thoughts/negative self-talk, may be precursors to emerging suicidality or worsening depression in patients taking antidepressants, especially in children, adolescents, and young adults 2 3.
- Patients taking antidepressants should be monitored closely for these symptoms, especially during the initial few months of treatment or at times of dose changes.
- Daily observation by families and caregivers is recommended to report any symptoms immediately to healthcare providers.
- Consideration should be given to changing the therapeutic regimen or discontinuing the medication if these symptoms are severe, abrupt in onset, or were not part of the patient’s presenting symptoms.
From the Research
Symptoms of Depression and Anxiety
- Death thoughts (Thoughts of harm to self or others)
- Feeling down, depressed, or hopeless
- Feeling nervous, anxious, or on edge
- Feeling hopeless
- Feelings of emptiness
- Impulsiveness
- Buying things without thinking about it
- Frequent aggression
- Difficulty concentrating and/or easily distracted
- Feeling tired or having little energy
- Lack of motivation
- Little interest or pleasure in doing things
- Racing thoughts
- Thoughts of self-harm
- Thoughts of suicide
- Negative thoughts/negative self-talk
Treatment Options
- Selective serotonin-reuptake inhibitors (SSRIs) are a common treatment for depression and anxiety disorders 4, 5, 6
- SSRIs have been shown to be effective in treating major depression, dysthymia, panic disorder, obsessive-compulsive disorder, eating disorders, and premenstrual dysphoric disorder 4
- Examples of SSRIs include fluoxetine, sertraline, paroxetine, fluvoxamine, and citalopram 4, 5, 6, 7
- SSRIs have a relatively good side-effect profile compared to other antidepressants, but can still cause side effects such as gastrointestinal disturbances, headache, sedation, insomnia, activation, weight gain, impaired memory, excessive perspiration, paresthesia, and sexual dysfunction 4, 5
Suicidal Ideation and Behavior
- Suicidal behavior is a leading cause of death and disability worldwide 8
- The ideation-to-action framework suggests that the development of suicidal ideation and the progression from ideation to suicide attempts are distinct phenomena with distinct explanations and predictors 8
- Depression, hopelessness, and impulsivity are factors that predict suicidal ideation, but may not distinguish those who have attempted suicide from those who have only considered suicide 8
- Means restriction is a highly effective way to block progression from ideation to attempt 8
Comparison of SSRIs
- A study comparing sertraline and fluoxetine found that they had similar antidepressant efficacy, although sertraline may offer an advantage in patients with severe depression 7
- An umbrella review of systematic reviews found that escitalopram was more effective than other SSRIs in terms of response rate, remission rate, and withdrawal rate 6