What to do when an adolescent on a Selective Serotonin Reuptake Inhibitor (SSRI) experiences suicidal thoughts?

Management of Adolescents on SSRIs with Suicidal Thoughts

When an adolescent on an SSRI develops suicidal thoughts, immediate psychiatric evaluation should be arranged during the office visit, with options including hospitalization, transfer to an emergency department, or a same-day appointment with a mental health professional. 1

Immediate Risk Assessment and Safety Planning

• Risk stratification is crucial:

  • Low risk: Close follow-up, timely mental health evaluation, or both if there is significant dysfunction or distress 1
  • Moderate to high risk: Immediate mental health professional evaluation during the office visit 1
  • Indicators of high risk: Previous attempts, high intent to commit suicide, serious depression/psychiatric illness, substance use, low impulse control, or unwilling family 1

• Safety measures to implement immediately:

  • Remove all firearms from the home 1
  • Lock up all medications (prescription and over-the-counter) 1
  • Develop a safety plan with specific steps to take during moments of distress 1
  • Consider psychiatric hospitalization for high-risk patients to provide a safe environment 1

Medication Management

• Continue monitoring the SSRI closely:

  • Be particularly vigilant during the early stages of SSRI treatment 1
  • Systematically inquire about suicidal ideation before and after treatment starts 1
  • Be especially alert if SSRI treatment is associated with akathisia (restlessness) 1
  • Have a third party monitor for mood changes, increased agitation, or unwanted side effects 1

• Medication considerations:

  • Do not abruptly discontinue the SSRI as this may worsen symptoms 2
  • SSRIs remain the preferred pharmacological treatment for adolescent depression, despite the need for careful monitoring 1
  • Avoid tricyclic antidepressants due to high lethality in overdose and lack of efficacy in adolescents 1
  • Use benzodiazepines with extreme caution as they may increase risk of self-harm events 3

Follow-up Care

• Maintain contact with the adolescent even after referrals are made 1

  • Collaborative care between primary care and mental health providers leads to greater reduction in depressive symptoms 1
  • Schedule follow-up within 1 week for moderate-risk patients
  • For high-risk patients, ensure a clear transition plan from hospital to outpatient care

• Psychotherapy should be part of the treatment plan:

  • Cognitive-behavioral therapy (CBT), interpersonal psychotherapy for adolescents (IPT-A), dialectical-behavioral therapy (DBT), or family therapy 1, 4
  • Therapy should be tailored to the adolescent's specific needs 1

Monitoring and Timing Considerations

• Most critical monitoring period:

  • Median time to a suicidal event is 3 weeks after medication changes 3
  • Higher baseline suicidal ideation, family conflict, and substance use predict earlier suicidal events 3
  • Most self-harm events occur early in treatment, emphasizing the need for close initial monitoring 3

• Risk factors requiring heightened vigilance:

  • Female sex 5
  • Previous history of suicidal ideation or attempts 5
  • Depression as the indication for SSRI treatment 5
  • Previous non-suicidal self-injury 5

Important Clinical Perspective

Despite concerns about SSRIs and suicidality, evidence suggests that most adolescents who die by suicide were not taking SSRIs at the time of death (only 1.6% had recent SSRI exposure in one study) 6. This suggests that untreated depression may pose a greater risk than carefully monitored SSRI treatment.

Recent research shows that while systematic monitoring detects higher rates of suicidal ideation (20.8% vs. 8.8%), the overall proportion of patients with suicidality often decreases following SSRI initiation (38.5% to 24.2% in one study) 5. This highlights the importance of both treatment and careful monitoring.