From the Guidelines
For a patient with active suicidal ideation and bipolar disorder, lithium should be considered as a first-line treatment due to its proven efficacy in reducing the risk of suicide, as evidenced by several cohort studies and systematic reviews 1.
Medication Adjustments
When managing a patient with active suicidal ideation and bipolar disorder, the primary goal is to reduce the risk of suicide while stabilizing mood. The following adjustments can be considered:
- Optimizing mood stabilizers such as lithium (600-1200 mg/day) to therapeutic blood levels, as it has been shown to reduce suicidal behaviors in patients with unipolar depression or bipolar disorder 1.
- Adding antipsychotics like quetiapine (300-800 mg/day), olanzapine (5-20 mg/day), or risperidone (2-6 mg/day) for acute stabilization.
- Considering the use of ketamine infusions (0.5 mg/kg) for rapid improvement of suicidal ideation symptoms, with benefits beginning within 24 hours and continuing for at least 1 week 1.
Nonpharmacologic Interventions
In addition to pharmacologic treatments, nonpharmacologic interventions such as cognitive behavioral therapy (CBT) can be effective in reducing suicidal ideation and behavior 1. CBT teaches patients to identify and change problematic thinking and behavioral patterns, which can help reduce hopelessness and suicidal thoughts.
Monitoring and Follow-up
Close monitoring is essential during medication changes, with follow-up appointments scheduled within days, not weeks. This allows for timely adjustments to the treatment plan and reduces the risk of adverse outcomes. Benzodiazepines like lorazepam (0.5-2 mg every 4-6 hours) may provide short-term anxiety relief while other medications take effect. The primary focus should be on reducing the risk of suicide and stabilizing mood, with medication adjustments and nonpharmacologic interventions tailored to the individual patient's needs 1.
From the FDA Drug Label
The possibility of a suicide attempt is inherent in schizophrenia and in bipolar I disorder, and close supervision of high-risk patients should accompany drug therapy. Prescriptions for olanzapine should be written for the smallest quantity of tablets consistent with good patient management, in order to reduce the risk of overdose.
For a patient with active suicidal ideation and bipolar disorder, close supervision is recommended. The FDA drug label does not provide specific medication changes, but it emphasizes the importance of reducing the risk of overdose by prescribing the smallest quantity of tablets consistent with good patient management 2.
From the Research
Recommended Medication Changes for Bipolar Disorder with Active Suicidal Ideation
- For patients with bipolar disorder and active suicidal ideation, medication changes should prioritize mood stabilizers and antipsychotics over antidepressants, as the latter may exacerbate suicidal thoughts 3.
- Lithium, valproate, and lamotrigine are recommended as first-line treatments for bipolar disorder, with lithium showing a reduced risk of suicidal behavior 4, 5.
- Atypical antipsychotics like olanzapine, quetiapine, and aripiprazole may also be effective in reducing suicidal ideation, particularly when combined with mood stabilizers 6, 7.
- Antidepressants should be used with caution and only in combination with mood stabilizers, as they may increase the risk of suicidal behavior in patients with bipolar disorder 3, 7.
Considerations for Medication Changes
- The choice of medication should be individualized based on the patient's specific symptoms, medical history, and previous treatment responses 5, 3.
- Patients with a history of suicidal behavior or current suicidal ideation should be closely monitored, and their treatment plans should be regularly reviewed and adjusted as needed 4, 7.
- Psychotherapy, such as cognitive-behavioral therapy, may be a useful adjunct to pharmacotherapy in managing bipolar disorder and reducing suicidal ideation 5, 7.