What medication adjustments can be made for an 18-year-old patient with persistent suicidal thoughts and depression despite being on aripiprazole (5mg), Prozac (fluoxetine, 40mg), and Trazodone (50mg)?

From the Guidelines

For an 18-year-old patient with persistent suicidal thoughts and depression despite being on aripiprazole (5mg), Prozac (fluoxetine, 40mg), and Trazodone (50mg), ketamine infusions should be considered as an adjunctive treatment to rapidly improve suicidal ideation symptoms, as evidenced by a meta-analysis showing 55% of patients reported no suicidal ideation after 24 hours and 60% reported that they were no longer having suicidal ideations at 7 days 1. Given the patient's current medication regimen, several options could be explored to address the persistent suicidal thoughts and depression.

• Increasing the fluoxetine dose up to 60-80mg daily could be considered, as some patients require higher doses for full effect.
• The aripiprazole dose might be increased to 10-15mg daily, as augmentation often requires higher doses than the current 5mg.
• Adding or substituting with an SNRI like venlafaxine or duloxetine could provide dual neurotransmitter action. However, the most recent and highest quality evidence supports the use of ketamine infusions as a rapid and effective treatment for suicidal ideation, with benefits beginning within 24 hours of the infusion and continuing for at least 1 week 1. It is crucial to implement any medication changes gradually, with weekly monitoring during the first month, and to consider therapeutic blood level monitoring to optimize dosing, particularly for fluoxetine. Additionally, lithium may be considered as an alternative option to reduce the risk for suicide in patients with unipolar depression, as several cohort studies and systematic reviews found that lithium maintenance therapy was associated with fewer suicidal behaviors and deaths 1. Any medication changes should be accompanied by intensive psychotherapy and safety planning, as medication adjustments take time to become effective.

From the FDA Drug Label

Patients with major depressive disorder (MDD), both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior, whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs. Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse, or who are experiencing emergent suicidality or symptoms that might be precursors to worsening depression or suicidality, especially if these symptoms are severe, abrupt in onset, or were not part of the patient’s presenting symptoms

The patient is still experiencing suicidal thoughts and depression despite being on aripiprazole, Prozac, and Trazodone. Changing the therapeutic regimen should be considered, including possibly discontinuing or adjusting the dosage of one or more of the current medications. However, the FDA drug label does not provide specific guidance on which medication to add or increase in this scenario. Given the patient's persistent symptoms, it is essential to closely monitor their condition and consider alternative treatment options. Consultation with a specialist or further evaluation of the patient's condition may be necessary to determine the best course of action 2.

From the Research

Medication Adjustments for Persistent Suicidal Thoughts and Depression

The patient is currently on aripiprazole (5mg), Prozac (fluoxetine, 40mg), and Trazodone (50mg) but still experiencing suicidal thoughts and depression. Considering the current medication regimen, the following adjustments could be explored:

• Increasing the dose of aripiprazole, as studies have shown that adjunctive low-dose aripiprazole can augment the efficacy of standard-dose sertraline in treating major depressive disorder 3
• Adding another antidepressant, such as a selective serotonin reuptake inhibitor (SSRI) or a serotonin-norepinephrine reuptake inhibitor (SNRI), as these have been established as first-line treatments for generalized anxiety disorder and may also be effective for depression 4
• Considering the patient's persistent suicidal ideation, close monitoring and regular follow-up are crucial, as a considerable number of patients may experience persistent suicidal ideation despite 12 weeks of antidepressant treatment 5

Important Considerations

When evaluating and managing patients with suicidal thoughts, it is essential to:

• Assess the patient's intent, plan, and means, as well as their social support and previous attempts 6
• Ensure patient safety and medical stabilization, and activate support networks and therapy for psychiatric diseases 6
• Be aware that asking high-risk patients about suicidal intent can lead to better outcomes and does not increase the risk of suicide 6

Next Steps

Given the complexity of the patient's condition, it may be beneficial to:

• Consult with a specialist, such as a psychiatrist, to discuss further treatment options and adjustments to the current medication regimen
• Continue to closely monitor the patient's suicidal ideation and adjust the treatment plan as needed, taking into account the patient's response to treatment and any changes in their condition 5