What medications help with suicidal thoughts?

Medications for Suicidal Thoughts

Lithium is the first-line pharmacological treatment for suicidal ideation in patients with bipolar disorder, as it significantly reduces both suicide attempts and completed suicides. 1

First-Line Medication Options by Diagnosis

For Bipolar Disorder:

• Lithium should be prescribed before any antidepressant in bipolar patients 1
• Mood stabilizers are essential for managing suicidal ideation in bipolar disorder 2

For Major Depressive Disorder:

• SSRIs (Selective Serotonin Reuptake Inhibitors) are the preferred pharmacological treatment for depression with suicidal ideation 2, 1
  • Require careful monitoring during initial treatment due to potential increased risk of suicidal ideation, especially in adolescents and young adults 3
  • Be particularly observant during early stages of SSRI treatment and systematically inquire about suicidal ideation before and after treatment initiation 2

For Schizophrenia/Schizoaffective Disorder:

• Clozapine is recommended to reduce suicide attempt risk in patients with schizophrenia or schizoaffective disorder who have suicidal ideation or past attempts 1, 4

Emerging Treatment Options

• Ketamine infusion may be considered as an adjunctive treatment for short-term reduction in suicidal ideation in patients with treatment-resistant depression 2, 1
  • While promising for patients at imminent risk of suicide, further controlled trials are needed before making definitive clinical recommendations 2

Medications to Use with Caution or Avoid

• Tricyclic antidepressants should not be prescribed as first-line treatment due to high lethality in overdose 2, 1
• Benzodiazepines should be used with extreme caution as they may:
  • Reduce self-control 2
  • Disinhibit some individuals, potentially increasing aggression and suicide attempts 2, 1
• Phenobarbital has high lethal potential in overdose and may reduce self-control 2, 1
• Amphetamines or stimulants should only be prescribed when treating suicidal children and adolescents with ADHD 2

Special Considerations

1. Monitoring is crucial:

   • All medication administration must be carefully monitored by a third party who can report unexpected mood changes, increased agitation, or unwanted side effects 2
   • Pay close attention to any changes, especially sudden changes in mood, behaviors, thoughts, or feelings 3, 4

2. Age-specific considerations:

   • For adolescents and children, medication choices should be made with even greater caution 1
   • SSRIs are the preferred psychopharmacological treatment for childhood and adolescent depression, but require vigilant monitoring 2

3. Comprehensive approach:

   • Medication should always be part of a comprehensive treatment plan that includes appropriate psychotherapy, such as Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), or Interpersonal Therapy (IPT) 1
   • Regular follow-up appointments, safety planning, and removal of lethal means from the patient's environment are essential 1

Common Pitfalls to Avoid

• Never abruptly discontinue antidepressant medications as this can cause withdrawal symptoms and worsen suicidal ideation 3, 4
• Don't overlook the potential for akathisia with SSRIs, which has been associated with increased suicidality 2
• Don't rely solely on medication without implementing appropriate psychotherapy and safety planning 1
• Be aware that many individuals with suicidal thoughts don't seek professional help, making proactive screening and outreach critical 5, 6

By following these evidence-based guidelines for medication selection and monitoring, clinicians can help reduce the risk of suicide while effectively treating the underlying mental health conditions that contribute to suicidal ideation.