What medication can be initiated for an 18-year-old patient with suicidal ideation and depression?

From the Guidelines

For an 18-year-old with suicidal ideation and depression, ketamine infusion is suggested as an adjunctive treatment for short-term reduction in suicidal ideation, as per the most recent guidelines 1. When considering treatment options, it's crucial to prioritize a thorough medical evaluation to determine the best course of action.

• The treatment for depression typically involves a combination of therapy and medication.
• Common first-line medications include selective serotonin reuptake inhibitors (SSRIs) like fluoxetine, sertraline, or escitalopram.
• However, medication selection must be personalized based on specific symptoms, medical history, and potential side effects.
• Only a qualified healthcare provider can prescribe appropriate medication after a thorough assessment.
• They will monitor response, adjust dosages as needed, and watch for side effects, particularly during the initial weeks when suicide risk may temporarily increase with some medications.
• Ketamine infusion has shown promise in reducing suicidal ideation in patients with major depressive disorder, with benefits beginning within 24 hours of the infusion and continuing for at least 1 week 1.
• It's essential to note that ketamine is not a replacement for standard treatment but can be used as an adjunctive therapy.
• Other options like lithium and clozapine may also be considered, but their use is more specific to certain patient populations, such as those with mood disorders or schizophrenia 1.
• Ultimately, seeking immediate help from a mental health professional or calling the National Suicide Prevention Lifeline at 988 is crucial for individuals experiencing suicidal thoughts.

From the FDA Drug Label

Patients with major depressive disorder (MDD), both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior, whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs 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 18–24) with major depressive disorder (MDD) and other psychiatric disorders

The patient is 18 years old, which puts them in the age group where the risk of suicidal thinking and behavior may be increased with antidepressant medication.

• Fluoxetine can be considered as a treatment option for depression, but it is crucial to monitor the patient closely for signs of worsening depression, suicidal ideation, or unusual changes in behavior.
• The patient should be instructed to report any changes in their mood, behavior, or thoughts, especially during the initial few months of treatment or when the dose is adjusted.
• Regular follow-up appointments should be scheduled to assess the patient's response to treatment and adjust the therapeutic regimen as needed.
• It is essential to weigh the potential benefits of fluoxetine against the potential risks and consider alternative treatment options if necessary 2.

From the Research

Medication Options for Suicidal Ideation and Depression

• The use of antidepressants, especially selective serotonin reuptake inhibitors (SSRIs), has been associated with an increased risk of suicidal ideation and behaviors, particularly in teenagers and young adults 3, 4.
• However, some studies suggest that SSRIs may not increase the risk of suicidal behavior in adults, and may even reduce the risk of suicidal attempts or deaths 5, 6.
• Fluoxetine, a type of SSRI, has been shown to be effective in reducing suicidal ideation and behaviors in adults, with some studies suggesting that it may even lead to greater improvement and faster resolution of ideation compared to placebo 5.

Considerations for Medication Selection

• When selecting a medication for an 18-year-old with suicidal ideation and depression, it is essential to consider the potential risks and benefits of each medication, as well as the individual's medical history and other factors 4, 7.
• Escitalopram, another type of SSRI, has been associated with the greatest risk reduction in suicidal behavior, although the confidence intervals for the incidence rate ratios of different SSRI types were overlapping 6.
• It is crucial to monitor the individual's response to medication and adjust the treatment plan as needed to minimize the risk of adverse effects, including suicidal ideation and behaviors 3, 7.

Important Notes

• The risk of suicidal behavior is increased in the first month after starting antidepressants, especially during the first 1 to 9 days 3.
• A possible small increase in risk among those starting the newest antidepressant, paroxetine, is of a magnitude that could readily be due to uncontrolled confounding by severity of depression 3.
• The use of SSRIs in children and adolescents requires careful consideration and monitoring due to the potential increased risk of suicidal ideation and behaviors 4.