What antidepressant is suitable for patients with suicidal ideation?

From the Guidelines

For patients with suicidal ideation, lithium is a suitable antidepressant option as it has been shown to reduce the risk of suicide in patients with unipolar depression or bipolar disorder, as evidenced by several cohort studies and systematic reviews 1. When considering treatment for patients with suicidal ideation, it is essential to prioritize their safety and well-being. The goal is to minimize the risk of suicide while also addressing the underlying mental health condition.

• Key considerations include:
  • Close monitoring of the patient, especially during the initial treatment phase
  • Regular assessments of suicidal ideation and behavior
  • Development of a clear safety plan, including emergency contacts and removal of lethal means
  • Combination of medication with psychotherapy, such as cognitive behavioral therapy (CBT) or dialectical behavior therapy (DBT)
• Medication options, such as lithium, should be carefully selected based on the patient's specific needs and medical history.
  • Lithium has been shown to be effective in reducing suicidal behaviors and deaths in patients with unipolar depression or bipolar disorder 1
  • Other medications, such as ketamine, may also be considered for acute suicidal crisis, but should be used under close supervision 1
• Psychotherapy, particularly CBT and DBT, has been shown to be effective in reducing suicidal ideation and behavior, and should be considered as part of a comprehensive treatment plan 1

From the Research

Antidepressants for Patients with Suicidal Ideation

• The study 2 found that fluoxetine treatment did not result in greater worsening but was associated with greater improvement and faster resolution of ideation compared to placebo.
• Another study 3 compared escitalopram and nortriptyline, and found that in men, treatment with escitalopram was associated with a lower risk of suicidal ideation compared to nortriptyline.
• A review of psychopharmaceuticals for treatment of suicidal patients 4 noted that with the exception of lithium and clozapine, suicide-preventing effects of antidepressants and neuroleptics could not be demonstrated.
• The study 5 found that the risk of suicidal behavior after starting antidepressant treatment is similar among users of amitriptyline, fluoxetine, and paroxetine compared to the risk among users of dothiepin.
• A mega-analysis of adults with depression 6 found that the net effect of SSRIs on suicidality appears beneficial in people above the age of 24 and neutral in those aged 18-24.

Suitable Antidepressants

• Fluoxetine 2 and escitalopram 3 have been found to have a beneficial effect on suicidality in some studies.
• SSRIs, such as sertraline, paroxetine, and citalopram, have been found to have a neutral or beneficial effect on suicidality in adults 6.
• Lithium and clozapine have been noted to have suicide-preventing effects 4.

Important Considerations

• Clinicians should remain alert to suicidal ideation beyond the initial weeks of antidepressant treatment 3.
• The risk of suicidal behavior is increased in the first month after starting antidepressants, especially during the first 1 to 9 days 5.