What is the best starting medication for a 47-year-old female (F) patient with self-identified depression and a history of suicidal ideation?

From the Guidelines

For a 47-year-old female patient with self-identified depression and a history of suicidal ideation, an SSRI such as sertraline (Zoloft) would be a recommended first-line medication, starting at 50 mg daily and gradually increasing to 100-200 mg daily as needed.

Key Considerations

• Sertraline is preferred in this case because it has a favorable safety profile, relatively low risk of side effects, and established efficacy for both depression and suicidal ideation 1.
• The patient should be closely monitored during the first few weeks of treatment, with follow-up appointments scheduled weekly initially, as SSRIs may temporarily increase suicidal thoughts before therapeutic effects begin, typically within 2-4 weeks.
• A comprehensive treatment approach should also include psychotherapy, particularly cognitive behavioral therapy (CBT), and the creation of a safety plan.
• Alternative medications like fluoxetine or escitalopram could be considered if sertraline is not tolerated.
• SSRIs work by increasing serotonin levels in the brain, which helps regulate mood, emotions, and anxiety.
• Side effects may include nausea, headache, sleep disturbances, and sexual dysfunction, but these often improve with time.

Additional Therapies

• Evidence exists to support the use of CBT to reduce suicidal ideation and behavior, and hopelessness in patients with a history of self-directed violence 1.
• Dialectical behavior therapy (DBT) is also effective in treating suicidal ideation and behavior, particularly in patients with borderline personality disorder 1.
• A crisis response plan can be an effective tool in managing suicidal ideation, and should include a collaborative approach between patient and clinician, identification of clear signs of crisis, and identification of social support 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Options for Depression

The patient in question is a 47-year-old female with self-identified depression and a history of suicidal ideation. When considering the best starting medication for this patient, several factors must be taken into account, including the severity of symptoms, presence of accompanying symptoms like anxiety or insomnia, and the patient's medical history.

Selective Serotonin Reuptake Inhibitors (SSRIs)

• SSRIs are commonly prescribed as first-line treatment for major depressive disorder (MDD) due to their efficacy and relatively favorable side effect profile 2, 3.
• Studies have compared the effectiveness of different SSRIs, including fluoxetine, escitalopram, sertraline, and paroxetine, in treating MDD and accompanying symptoms like anxiety and insomnia 4, 5, 3.
• While some studies suggest that escitalopram may have a slightly higher efficacy in terms of response rate, remission rate, and withdrawal rate compared to other SSRIs, the differences are often not statistically significant 2, 5, 3.

Considerations for This Patient

• Given the patient's history of suicidal ideation, it is crucial to select a medication with a relatively safe profile and to monitor the patient closely for any changes in mood or emergence of suicidal thoughts 6.
• The patient's denial of current suicidal ideation does not eliminate the need for careful consideration of this risk factor in treatment planning.
• Since there is no single "best" starting medication that applies to all patients with depression, the choice should be individualized based on the patient's specific symptoms, medical history, and personal preferences.

Evidence-Based Recommendations

• The available evidence suggests that SSRIs, such as fluoxetine, escitalopram, sertraline, and paroxetine, are effective treatments for MDD and may be considered as starting medications for this patient 4, 2, 5, 3.
• However, the decision should be made in consultation with the patient and should take into account the latest clinical guidelines and the patient's unique circumstances.
• It's also important to consider the role of psychotherapy, either alone or in combination with medication, as an effective treatment strategy for depression 6, 5.