How to assess risk when prescribing medications to a suicidal patient?

From the Guidelines

When prescribing medications to a suicidal patient, conduct a thorough risk assessment that balances therapeutic benefits against potential dangers, and consider using medications with established anti-suicidal properties like lithium or clozapine, as supported by recent guidelines 1. To assess risk when prescribing medications to a suicidal patient, several key steps should be taken:

• Evaluate the patient's current suicide risk level through direct questioning about suicidal thoughts, plans, intent, and past attempts.
• Consider prescribing medications with lower lethality in overdose, such as SSRIs like sertraline or fluoxetine rather than tricyclic antidepressants or MAOIs.
• Limit the quantity of medication dispensed initially, perhaps providing only a 1-2 week supply until stability improves.
• Involve family members or caregivers in medication management when appropriate.
• Monitor patients closely during the initial treatment period and dose changes, particularly with antidepressants which may temporarily increase suicide risk during the first few weeks of treatment.
• Create a clear safety plan that includes emergency contacts and steps to take if suicidal thoughts intensify.
• Document your risk assessment, medication choice rationale, and safety planning thoroughly.

Some medications have shown promise in reducing suicidal ideation, such as ketamine infusions, which have been found to result in rapid improvement of suicidal ideation symptoms, with benefits beginning within 24 hours of the infusion and continuing for at least 1 week 1. Lithium may also reduce the risk for suicide in patients with unipolar depression or bipolar disorder, with several cohort studies and systematic reviews finding that lithium maintenance therapy was associated with fewer suicidal behaviors and deaths 1. Clozapine may reduce suicidal behaviors in patients with schizophrenia or schizoaffective disorder, although its use requires careful monitoring due to the risk of agranulocytosis 1.

It's essential to use caution in assessing suicide risk and not rely exclusively on any one tool, as a reliable tool to stratify patients at risk for suicide remains elusive 1. Using several means to evaluate risk, such as self-reported measures and clinical interviews, is recommended. By taking a comprehensive and cautious approach to prescribing medications to suicidal patients, clinicians can help minimize the risk of suicide while providing essential treatment for underlying mental health conditions.

From the FDA Drug Label

Patients, their families, and their caregivers should be encouraged to be alert to the emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, other unusual changes in behavior, worsening of depression, and suicidal ideation, especially early during antidepressant treatment and when the dose is adjusted up or down. Symptoms such as these may be associated with an increased risk for suicidal thinking and behavior and indicate a need for very close monitoring and possibly changes in the medication

To assess risk when prescribing medications to a suicidal patient, monitor them for symptoms such as:

• Anxiety
• Agitation
• Panic attacks
• Insomnia
• Irritability
• Hostility
• Aggressiveness
• Impulsivity
• Akathisia
• Hypomania
• Mania
• Worsening of depression
• Suicidal ideation Especially early during antidepressant treatment and when the dose is adjusted up or down. These symptoms may be associated with an increased risk for suicidal thinking and behavior and indicate a need for very close monitoring and possibly changes in the medication 2

From the Research

Assessing Risk When Prescribing Medications to Suicidal Patients

To assess risk when prescribing medications to suicidal patients, several factors must be considered:

• The patient's history of suicidal ideation or attempts 3, 4, 5
• The type of medication being prescribed, as some may increase the risk of suicidal behavior, particularly in the first month of treatment 3, 6, 7
• The patient's age, as younger patients may be at higher risk 6, 7
• The presence of underlying psychiatric disorders, such as depression, anxiety, or substance abuse 4, 5
• The patient's social support system and access to means of suicide 4

Medication-Related Risks

Certain medications, such as antidepressants, may increase the risk of suicidal behavior, particularly in the first month of treatment:

• Antidepressants may induce or exacerbate suicidal tendencies in rare instances 3
• The risk of suicidal behavior is increased in the first month after starting antidepressants, especially during the first 1 to 9 days 7
• Certain antidepressants, such as paroxetine, may have a higher risk of suicidal behavior compared to others 7

Strategies for Reducing Risk

To reduce the risk of suicidal behavior in patients prescribed medications:

• Close monitoring of the patient's mental state, particularly in the first month of treatment 4, 6
• Regular follow-up appointments to assess the patient's response to treatment and adjust the treatment plan as needed 4, 5
• Involving the patient's family and social support system in the treatment plan 4
• Ensuring the patient has a safe and supportive environment, without access to means of suicide 4
• Considering alternative treatments, such as cognitive behavioral therapy, for patients at high risk of suicidal behavior 4