What medication should be prescribed for a 20-year-old patient with a Patient Health Questionnaire-9 (PHQ-9) score of 16, indicating moderate to severe depression, with suicidal thoughts but no plan?

From the Guidelines

For a 20-year-old patient with a PHQ-9 score of 16 and suicidal thoughts without a plan, I would recommend starting with an SSRI such as sertraline (Zoloft) at 50mg daily, taken in the morning, with plans to increase to 100mg after 1-2 weeks if tolerated, as supported by the American College of Physicians guidelines 1. This approach is based on the most recent and highest quality evidence available, which prioritizes the patient's morbidity, mortality, and quality of life as the primary outcomes.

Key Considerations

• The patient's suicidal thoughts without a plan necessitate urgent psychiatric evaluation and possible consideration for hospitalization depending on risk assessment.
• Weekly follow-up appointments should be scheduled for the first month to monitor for side effects, worsening suicidal ideation, and treatment response.
• Psychotherapy, particularly cognitive behavioral therapy, should be initiated alongside medication for optimal outcomes, as evidenced by studies supporting its effectiveness in reducing suicidal ideation and behavior 1.
• The patient should be educated about potential side effects including nausea, headache, insomnia, and sexual dysfunction, and that full therapeutic effect may take 4-6 weeks.

Medication and Therapy

• Sertraline is a good first-line choice due to its favorable side effect profile, effectiveness for depression and anxiety, and relatively lower risk of worsening suicidal ideation in young adults compared to some other antidepressants.
• Cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) are supported by evidence as effective treatments for reducing suicidal ideation and behavior, and should be considered as part of a comprehensive treatment plan 1.

Monitoring and Follow-Up

• Regular monitoring for side effects, treatment response, and worsening suicidal ideation is crucial, particularly in the first 1-2 weeks of treatment.
• The patient's treatment plan should be regularly assessed and modified as necessary to ensure optimal outcomes and minimize risks.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Medication Options for a 20-year-old Patient with PHQ9 Score of 16 and Suicidal Thoughts

• The patient's PHQ9 score of 16 indicates moderate to severe depression, and the presence of suicidal thoughts without a plan requires careful consideration of treatment options 2.
• Studies have shown that selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine can be effective in reducing suicidal ideation and behaviors in adults with major depressive disorder 3, 4, 5.
• A meta-analysis of fluoxetine trials found that the medication was associated with greater improvement and faster resolution of suicidal ideation compared to placebo 3.
• Another study found that fluoxetine treatment led to a reduction in suicidal thoughts and behaviors in adults, and that this effect was mediated by a reduction in depressive symptoms 5.
• However, it is essential to note that the patient's age and individual characteristics should be taken into account when selecting a medication, and that close monitoring of suicidal thoughts and behaviors is crucial during treatment 2, 5.
• The use of antidepressant medications such as fluoxetine or venlafaxine may be considered, but it is crucial to weigh the potential benefits and risks and to closely monitor the patient's response to treatment 4, 6, 5.

Key Considerations

• The patient's suicidal thoughts and behaviors should be closely monitored during treatment, and a plan for emergency situations should be established 2, 5.
• The patient's response to treatment should be regularly assessed, and adjustments to the treatment plan should be made as needed 6.
• The use of cognitive-behavioral therapy (CBT) or other psychotherapies may be considered in conjunction with medication to address the patient's depressive symptoms and suicidal thoughts 6.