What are the appropriate steps for a patient experiencing suicidal ideation after initiating Selective Serotonin Reuptake Inhibitor (SSRI) therapy?

From the Guidelines

If you're feeling suicidal after starting an SSRI, seek immediate medical help by calling 988 (Suicide Prevention Lifeline), going to an emergency room, or contacting your doctor right away. This is a known potential side effect, particularly in the first few weeks of treatment, especially in young adults and adolescents, as reported in a study published in the Journal of the American Academy of Child and Adolescent Psychiatry 1. Do not stop taking the medication suddenly without medical guidance. Your doctor may need to adjust your dosage, switch you to a different medication like bupropion, mirtazapine, or an SNRI, or add additional support treatments. The suicidal thoughts can occur because SSRIs sometimes increase energy and activation before improving mood, potentially giving you more energy to act on negative thoughts before the antidepressant effect fully develops. Close monitoring during the first 1-4 weeks of treatment is crucial, and having a support person stay with you during this period is advisable, as suggested by the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines 1. Some key points to consider include:

• The importance of seeking immediate medical help if you're feeling suicidal
• The potential for SSRIs to increase energy and activation before improving mood
• The need for close monitoring during the first 1-4 weeks of treatment
• The possibility of adjusting dosage or switching to a different medication
• The importance of having a support person stay with you during this period Remember that this side effect is typically temporary, but it requires immediate professional attention. It's also worth noting that evidence supports the use of cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) for treating suicidal ideation and behavior, as well as the use of crisis response plans, as reported in studies published in the Annals of Internal Medicine 1.

From the Research

Feeling Suicidal After Starting SSRI

• If you are feeling suicidal after starting an SSRI, it is essential to seek help immediately.
• Contact your doctor, a crisis helpline, or an emergency service for support.

Risk of Suicidal Behavior with SSRIs

• Studies have shown that the risk of suicidal behavior is increased in the first month after starting antidepressants, especially during the first 1 to 9 days 2.
• A population-based cohort study found that the risk of suicidal behavior was highest in the 30 days before SSRI-treatment initiation, but decreased after treatment initiation 3.
• Another study concluded that SSRIs carry a small risk of inducing suicidal thoughts and suicide attempts, particularly in individuals under 25 years old 4.

What to Do If You Are Experiencing Suicidal Thoughts

• Inform your doctor about your suicidal thoughts, as they can help you manage your symptoms and adjust your treatment plan if necessary.
• Consider reaching out to a crisis helpline or a support group for additional help and guidance.
• It is crucial to weigh the potential benefits of SSRI treatment against the risks, and to work closely with your healthcare provider to minimize the risks 5.

Special Considerations

• The risk of suicide with SSRIs may be higher in certain populations, such as the elderly 6.
• Adults without certain risk factors do not seem to carry an increased risk of suicidality with SSRIs 5.
• A comprehensive review of publications related to SSRIs and suicidality found that the risk-benefit ratio of antidepressant treatment should be carefully considered, taking into account the potential benefits and harms 4.