From the Guidelines
If a patient on trazodone and olanzapine develops suicidal thoughts, immediate medical attention is required, and lithium may be considered as an adjunct therapy to reduce the risk of suicide, as evidenced by several cohort studies and systematic reviews 1. The patient's healthcare provider should be contacted right away, or the patient should go to the emergency room if the thoughts are severe or there's an immediate risk.
- Do not abruptly stop these medications without medical supervision, as this can lead to withdrawal symptoms and potentially worsen the patient's condition.
- Both trazodone and olanzapine can paradoxically increase suicidal thoughts, particularly when starting treatment or changing doses, and this risk is higher in younger patients and those with a history of suicidal ideation.
- The healthcare provider may need to adjust medication dosages, switch medications, add additional treatments, such as cognitive behavioral therapy (CBT) or dialectical behavior therapy (DBT), or increase monitoring, as these therapies have been shown to reduce suicidal ideation and behavior 1.
- During this time, ensure the patient has support, remove access to means of self-harm, and consider having someone stay with them.
- The emergence of suicidal thoughts may indicate that the current treatment regimen is not adequately addressing the underlying condition or that the medications are causing adverse effects that need immediate attention, and alternative treatments, such as clozapine, may be considered for patients with schizophrenia or schizoaffective disorder, although its use is associated with a risk of agranulocytosis 1.
From the Research
Patient on Trazodone and Olanzapine with Suicidal Thoughts
- The development of suicidal thoughts in a patient on trazodone and olanzapine requires careful assessment of risk factors, including sociodemographic, psychiatric, general medical, and mental status considerations 2.
- Key issues regarding imminent suicide risk are intent and means, severity of psychiatric illness, the presence of psychosis or hopelessness, lack of personal resources, and older age among men 2.
- A study on bipolar I disorder mixed-episode patients found that combination therapy with olanzapine and lithium or divalproex reduced suicidal ideation by 58% within 1 week, compared to 29% with placebo 3.
- Suicidality in adult, mixed-episode, bipolar I disorder patients was associated with somatic discomfort, agitated depression, and psychosis 3.
- Emergency clinicians should estimate suicide risk by taking into account baseline risk factors, such as previous suicide attempts, as well as acute risk factors, such as the presence of a suicide plan 4.
- Important elements of the patient history include the intent, plan, and means; availability of social support; previous attempts; and the presence of comorbid psychiatric illness or substance misuse 5.
- Care plans for patients with chronic suicidal ideation include ensuring patient safety and medical stabilization, activating support networks, and initiating therapy for psychiatric diseases 5.
- The ideation-to-action framework stipulates that the development of suicidal ideation and the progression from ideation to suicide attempts are distinct phenomena with distinct explanations and predictors 6.
- Means restriction is emerging as a highly effective way to block progression from ideation to attempt 6.