What medication can be initiated for an 18-year-old patient with suicidal ideation without a plan and depression?

From the Guidelines

For an 18-year-old with suicidal ideation without a plan and depression, ketamine infusion is suggested as an adjunctive treatment for short-term reduction in suicidal ideation, as evidenced by the most recent guidelines 1. When considering medication for this patient, it's essential to prioritize treatments that have shown rapid improvement in suicidal ideation symptoms.

• Ketamine infusion has been found to result in rapid improvement of suicidal ideation symptoms, with benefits beginning within 24 hours of the infusion and continuing for at least 1 week 1.
• The use of ketamine infusion as an adjunctive treatment is supported by recent guidelines, which suggest its use for short-term reduction in suicidal ideation in patients with major depressive disorder 1.
• Other medications, such as lithium and clozapine, may also be considered, but the evidence for their use in reducing suicidal ideation is less clear 1.
• Selective serotonin reuptake inhibitors (SSRIs) are typically used to treat depression, but they carry a black box warning for potentially increased suicidal thoughts in young people, especially during the first few weeks of treatment 1.
• Cognitive behavioral therapy (CBT) is also an essential part of a comprehensive treatment plan, as it has been shown to reduce suicidal ideation and behavior in patients with a history of self-directed violence 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Medication Options for Suicidal Ideation and Depression

• For an 18-year-old with suicidal ideation without a plan and depression, medication options may include selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, escitalopram, sertraline, and paroxetine 2, 3, 4, 5.
• Fluoxetine has been shown to be effective in treating major depressive disorder in adolescents, with a response rate of 60.6% compared to 34.8% for placebo 2.
• The combination of fluoxetine with cognitive-behavioral therapy (CBT) has been found to be superior to fluoxetine alone, with a response rate of 71.0% 2.
• Other SSRIs, such as escitalopram and sertraline, have also been shown to be effective in treating depression, although the evidence is limited by inconsistency and imprecision 4.

Considerations for Treatment

• The choice of medication should be based on the individual's specific symptoms and needs, as well as the potential side effects and interactions with other medications 4.
• CBT has been shown to be an effective adjunct to medication, with a lower recurrence rate of depression compared to medication alone 5.
• The prophylactic efficacy of SSRIs in preventing recurrence of depression is limited, with a recurrence rate of 82.0% for SSRI-only treatment compared to 59.0% for concomitant CBT 5.

Safety and Efficacy

• The safety and efficacy of SSRIs in adolescents and young adults have been established, although the risk of suicidal ideation and behavior should be carefully monitored 2, 3.
• The combination of fluoxetine with CBT has been found to be safe and effective, with a low risk of suicidal ideation and behavior 2.