From the Guidelines
For a patient with depression who has not responded to bupropion and fluoxetine and is experiencing occasional suicidal ideation without a plan, I would recommend starting ketamine infusions as a single dose (0.5 mg/kg) to rapidly improve suicidal ideation symptoms, as evidence suggests benefits begin within 24 hours and continue for at least 1 week 1. This approach is prioritized due to the patient's history of non-response to traditional antidepressants and the urgent need to address suicidal ideation. Key points to consider:
- Ketamine has shown rapid improvement in suicidal ideation symptoms, with 55% of patients reporting no suicidal ideation after 24 hours and 60% reporting no suicidal ideations at 7 days 1.
- Close follow-up is essential, with appointments every 1-2 weeks initially to monitor for side effects, suicidal ideation, and treatment response.
- A comprehensive approach should also include referral for psychotherapy, particularly cognitive behavioral therapy (CBT), which has shown efficacy when combined with medication in reducing suicidal ideation and behavior 1.
- If ketamine infusions are not feasible or effective, consider alternative treatment options, such as lithium maintenance therapy, which has been associated with fewer suicidal behaviors and deaths in patients with unipolar depression or bipolar disorder 1.
From the Research
Medication Options for Depression with Suicidal Ideation
The patient has reported that bupropion and fluoxetine do not work for her depression, and she experiences occasional suicidal ideation (SI) with no plan. Considering this, the following medication options can be explored:
- Paroxetine: Studies have shown that paroxetine may have a superior effect on reducing suicidal ideation compared to bupropion, especially in patients with high anxiety 2, 3, 4.
- Other SSRIs: While paroxetine is specifically mentioned in the studies, other selective serotonin reuptake inhibitors (SSRIs) may also be effective in reducing suicidal ideation 2, 3.
- Alternative antidepressants: If the patient has not responded to bupropion and fluoxetine, other antidepressants such as venlafaxine or duloxetine may be considered, although their effectiveness in reducing suicidal ideation is not well established in the provided studies.
Considerations for Medication Selection
When selecting a medication, the following factors should be considered:
- Genetic makeup: The patient's genetic makeup, including polymorphisms in genes related to pharmacokinetics and pharmacodynamics, may influence their response to medication 5.
- Anxiety levels: Patients with high anxiety may benefit from paroxetine, which has shown a trend toward faster reduction of suicidal ideation in this population 4.
- Suicidal ideation severity: The severity of suicidal ideation should be carefully monitored, and medications with a potential to reduce suicidal ideation should be prioritized 2, 3.
Monitoring and Follow-up
Regular monitoring and follow-up are crucial to assess the patient's response to medication and adjust the treatment plan as needed. This includes:
- Regular assessments of suicidal ideation and behavior
- Monitoring of anxiety levels and other depressive symptoms
- Adjustments to medication dosage or type based on patient response and side effects.