What is the most appropriate medication for a 19-year-old patient with major depressive disorder (MDD) and suicidal ideation?

From the Guidelines

Ketamine infusions have been shown to result in rapid improvement of suicidal ideation symptoms in patients with major depression, with benefits beginning within 24 hours of the infusion and continuing for at least 1 week, making it a potential treatment option for a 19-year-old with depression and suicidal thoughts. However, it's essential to note that treatment for depression requires personalized care from a healthcare provider who can assess specific symptoms, medical history, and risk factors. If you're experiencing suicidal thoughts, please seek immediate help by going to your nearest emergency room, calling the National Suicide Prevention Lifeline (988), or texting HOME to the Crisis Text Line (741741).

Some key points to consider:

• Evidence from studies, such as those published in the Annals of Internal Medicine 1, suggests that ketamine infusions can be an effective treatment for suicidal ideation in patients with major depression.
• Cognitive behavioral therapy (CBT) has also been shown to be effective in reducing suicidal ideation and behavior in patients with a history of self-directed violence 1.
• Selective serotonin reuptake inhibitors (SSRIs) may be considered as a treatment option, but the risk of suicidal behavior, particularly in young adults, must be carefully weighed against the potential benefits 1.
• The treatment process often involves trying different approaches to find what works best for the individual, with close monitoring by healthcare providers, especially during the initial weeks of medication treatment.

It's crucial to prioritize the individual's safety and well-being, and to work closely with a healthcare provider to develop a personalized treatment plan.

From the FDA Drug Label

Short–term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo in adults beyond age 24; there was a reduction with antidepressants compared to placebo in adults aged 65 and older The pooled analyses of placebo–controlled trials in children and adolescents with MDD, obsessive compulsive disorder (OCD), or other psychiatric disorders included a total of 24 short–term trials of 9 antidepressant drugs in over 4400 patients There was considerable variation in risk of suicidality among drugs, but a tendency toward an increase in the younger patients for almost all drugs studied All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases

The patient is 19 years old, and the studies did not show a clear increase in the risk of suicidality with antidepressants in this age group. However, fluoxetine may be considered as a treatment option for depression, but it is crucial to monitor the patient closely for clinical worsening, suicidality, and unusual changes in behavior.

• The patient should be screened for bipolar disorder before initiating treatment with an antidepressant.
• Families and caregivers should be alerted about the need to monitor patients for the emergence of agitation, irritability, unusual changes in behavior, and the other symptoms described above, as well as the emergence of suicidality.
• The smallest quantity of capsules should be prescribed to reduce the risk of overdose 2.

From the Research

Medication Options for Depression and Suicidal Thoughts

• The most effective medication for a 19-year-old with depression and suicidal thoughts is not explicitly stated in the provided studies, but the studies suggest that selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine may be beneficial 3, 4, 5, 6.
• Fluoxetine has been shown to be effective in reducing suicidal thoughts and behavior in adults and geriatric patients, with a significant reduction in suicidal ideation and attempts compared to placebo 3, 6.
• In adolescents, the combination of fluoxetine with cognitive-behavioral therapy (CBT) has been shown to be superior to fluoxetine alone or CBT alone in reducing depressive symptoms and suicidal thoughts 4, 7.
• The study by 5 found that SSRI treatment, including fluoxetine, may reduce the risk of suicidal behavior in individuals aged 6-59 years, with the greatest risk reduction observed in the 30 days after treatment initiation.
• Another study by 6 found that fluoxetine and venlafaxine decreased suicidal thoughts and behavior in adult and geriatric patients, with the protective effect mediated by decreases in depressive symptoms.

Considerations for Treatment

• The choice of medication should be based on individual patient characteristics, such as age, severity of symptoms, and history of suicidal attempts 4, 7.
• CBT may be a useful adjunct to medication, particularly in adolescents and young adults, to reduce depressive symptoms and suicidal thoughts 4, 7.
• Regular monitoring of suicidal thoughts and behavior is essential when treating patients with depression, particularly in the initial stages of treatment 3, 6.