From the Guidelines
The recommended management for a 58-year-old woman with active suicidal ideation, a plan, and bipolar disorder requires immediate psychiatric hospitalization for safety. This patient should be evaluated in an emergency department or crisis center without delay, as she presents with high-risk features requiring 24-hour monitoring. While maintaining her current medications (Lamictal 200mg daily, Abilify 30mg daily, Clonazepam 1mg three times daily, and Remeron 15mg daily), an inpatient psychiatric team should conduct a comprehensive evaluation to optimize her medication regimen. This may include adjusting dosages, considering alternative mood stabilizers, or adding additional medications to address both suicidality and bipolar symptoms, such as ketamine infusion as an adjunctive treatment for short-term reduction in suicidal ideation, as suggested by the 2024 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines 1.
During hospitalization, the patient should receive intensive individual therapy, safety planning, and family involvement in treatment when appropriate. Following discharge, she will need close outpatient follow-up within 7 days, continued therapy, and a clear safety plan with identified emergency contacts and resources. This approach prioritizes immediate safety while addressing the underlying bipolar disorder that may be contributing to her suicidal crisis, as inadequately treated mood disorders significantly increase suicide risk. The use of evidence-based therapies such as cognitive behavioral therapy (CBT) or dialectical behavior therapy (DBT) may also be beneficial in reducing suicidal ideation and behavior, as supported by previous studies 1.
Key considerations in her management include:
- Immediate psychiatric hospitalization for safety
- Comprehensive evaluation and optimization of her medication regimen
- Intensive individual therapy and safety planning during hospitalization
- Close outpatient follow-up and continued therapy after discharge
- Consideration of adjunctive treatments such as ketamine infusion for short-term reduction in suicidal ideation
- Involvement of family in treatment when appropriate
- Development of a clear safety plan with identified emergency contacts and resources.
From the Research
Management of Suicidal Ideation in Bipolar Disorder
The patient's history of bipolar disorder and current presentation of active suicidal ideation with a plan require immediate attention and careful management.
- The patient is currently taking Lamictal (lamotrigine) 200mg QD, Abilify (aripiprazole) 30mg QD, Clonazepam (clonazepam) 1mg TID, and Remeron (mirtazapine) 15mg QD.
- According to 2, first-line therapy for bipolar disorder includes mood stabilizers, such as lithium, anticonvulsants, such as valproate and lamotrigine, and atypical antipsychotic drugs, such as quetiapine, aripiprazole, asenapine, lurasidone, and cariprazine.
- The use of antidepressants, such as Remeron (mirtazapine), in bipolar disorder is controversial, as they may increase the risk of suicidal behavior, especially when used as monotherapy 3, 4.
- Electroconvulsive therapy (ECT) has been shown to be effective in reducing suicidal ideation and behavior in patients with bipolar disorder, particularly in those with severe or treatment-resistant symptoms 5.
Treatment Considerations
- Close monitoring of the patient's suicidal ideation and behavior is essential, particularly during the initial treatment period.
- The patient's current medication regimen may need to be adjusted or augmented to better manage their symptoms and reduce the risk of suicidal behavior.
- Consideration should be given to the use of ECT, particularly if the patient's symptoms are severe or have not responded to pharmacological treatment.
- The patient's treatment plan should be individualized and tailored to their specific needs and circumstances, taking into account their medical history, current symptoms, and personal preferences.
Risk Assessment and Monitoring
- Regular assessment of the patient's suicidal ideation and behavior is crucial to identify any changes or increases in risk.
- The patient's treatment plan should include regular follow-up appointments and monitoring of their symptoms and medication adherence.
- Collaboration with the patient's healthcare team, including their psychiatrist, primary care physician, and other mental health professionals, is essential to ensure comprehensive and coordinated care.