What is the best management approach for a patient with major depressive disorder (MDD) presenting with suicidal ideation in a general practice (GP) clinic?

From the Guidelines

The best management approach for a patient with major depressive disorder presenting with suicidal ideation in a GP clinic is to immediately assess suicide risk and implement a comprehensive treatment plan, including pharmacotherapy with ketamine infusion as an adjunctive treatment for short-term reduction in suicidal ideation, as suggested by the most recent guidelines 1.

Key Components of Management

• Assess suicide risk by evaluating the presence of a plan, intent, means, and protective factors.
• If the patient is at imminent risk, arrange urgent psychiatric evaluation through emergency services or direct hospital admission.
• For patients who can be managed as outpatients, implement a safety plan that includes removing access to lethal means, identifying warning signs, coping strategies, emergency contacts, and ensuring social support.
• Pharmacotherapy may include ketamine infusion, which has been shown 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.

Pharmacologic Treatment

• Ketamine infusion is suggested as an adjunctive treatment for short-term reduction in suicidal ideation in patients with major depressive disorder and suicidal ideation, as recommended by the 2024 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines 1.
• Other pharmacologic treatments, such as lithium and clozapine, may also be considered, although the evidence for their use in reducing suicidal ideation is less clear 1.

Psychotherapy

• Refer for psychotherapy, particularly cognitive behavioral therapy or interpersonal therapy, which have proven efficacy for depression and suicidality, although the most recent guidelines do not provide strong recommendations for specific types of therapy 1.

Follow-up

• Regular follow-up appointments should be scheduled every 1-2 weeks initially until symptoms improve, with close monitoring for side effects and worsening suicidal thoughts.

From the FDA Drug Label

All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have been reported in adult and pediatric patients being treated with antidepressants for Major Depressive Disorder as well as for other indications, both psychiatric and nonpsychiatric Although a causal link between the emergence of such symptoms and either the worsening of depression and/or the emergence of suicidal impulses has not been established, there is concern that such symptoms may represent precursors to emerging suicidality 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 best management approach for a patient with major depressive disorder (MDD) presenting with suicidal ideation in a general practice (GP) clinic is to:

• Monitor closely for clinical worsening, suicidality, and unusual changes in behavior
• Watch for symptoms such as anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, and mania
• Consider changing the therapeutic regimen if the patient's depression is persistently worse or if they are experiencing emergent suicidality or symptoms that might be precursors to worsening depression or suicidality
• Alert families and caregivers to monitor patients for the emergence of agitation, irritability, unusual changes in behavior, and other symptoms, and to report such symptoms immediately to healthcare providers 2, 3

From the Research

Management Approach for Major Depressive Disorder with Suicidal Ideation

The management of patients with major depressive disorder (MDD) presenting with suicidal ideation in a general practice (GP) clinic requires a comprehensive approach.

• Assessment of suicidal risk is crucial and should precede any attempt to treat psychiatric illness 4.
• Electroconvulsive therapy (ECT) has been shown to be effective in resolving suicidal ideation, particularly in the acute treatment phase, and should be considered as an early treatment option for suicidal patients 5.
• Pharmacotherapy, including selective serotonin reuptake inhibitors (SSRIs), can also be effective in reducing suicidal ideation and depressive symptoms 6, 7, 8.
• Treatment patterns for patients with MDD and suicidal ideation often involve multiple classes of medications and therapies, highlighting the complexity and variability of treatment approaches for this patient population 6.

Treatment Options

• ECT has been found to be superior to fluoxetine in resolving suicidal ideation during acute treatment, although both treatments were equally effective in preventing recurrence of suicidal ideation in the follow-up period 5.
• SSRIs, such as paroxetine, may have a modest advantage over other antidepressants, such as bupropion, in reducing suicidal ideation and depressive symptoms in patients with MDD and elevated suicidal risk factors 8.
• Psychotherapy, including empirically supported treatments (ESTs) for depression, can also be effective in reducing suicidal ideation and depressive symptoms, although the relationship between suicidal ideation and treatment efficacy is not fully understood 7.

Clinical Considerations

• Routine suicide risk assessments are essential to identify any signs of suicidal relapse and to monitor treatment response 5.
• Treatment approaches should be individualized and tailored to the patient's specific needs and circumstances.
• Further research is needed to fully understand the most effective treatment approaches for patients with MDD and suicidal ideation, particularly in the context of GP clinics.