How do you manage a patient with a high risk of suicide and self-harm who requests a prescription for lorazepam (Ativan)?

From the Guidelines

I would not prescribe lorazepam to a patient at high risk for suicide and self-harm. Instead, I would conduct a thorough suicide risk assessment, including asking about specific plans, means, and intent, as recommended by the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines 1. If the patient is at imminent risk, I would arrange immediate psychiatric hospitalization, either voluntarily or involuntarily if necessary. For outpatient management of a patient with less imminent risk, I would develop a comprehensive safety plan including removal of lethal means, identification of warning signs, coping strategies, emergency contacts, and crisis resources.

Some key points to consider in managing a patient with a high risk of suicide and self-harm include:

• Conducting a thorough suicide risk assessment
• Developing a comprehensive safety plan
• Considering prescription of an SSRI antidepressant, such as sertraline 50mg daily or fluoxetine 20mg daily, for underlying depression, with close follow-up within 1-2 weeks
• Referring the patient to psychotherapy, particularly cognitive behavioral therapy (CBT) or dialectical behavior therapy (DBT), as these therapies have been shown to reduce suicidal ideation and behavior 1
• Ensuring the patient has 24-hour crisis resources, including the suicide prevention hotline

Benzodiazepines like lorazepam are generally avoided in suicidal patients as they can disinhibit behavior, worsen depression, and have high lethality in overdose, as well as carry addiction potential 1. If anxiety symptoms are severe, I might consider a small quantity (3-5 tablets) of a less lethal medication like hydroxyzine 25-50mg as needed, with frequent reassessment.

It's also important to note that evidence supports the use of a crisis response plan for persons with suicidal ideation, which involves a collaborative approach between patient and clinician, including a semi-structured interview, identification of clear signs of crisis, and collaborative identification of social support and crisis resources 1.

From the FDA Drug Label

The use of benzodiazepines, including lorazepam, exposes users to the risks of abuse, misuse, and addiction, which can lead to overdose or death Before prescribing lorazepam and throughout treatment, assess each patient's risk for abuse, misuse, and addiction (e.g., using a standardized screening tool). Use of lorazepam, particularly in patients at elevated risk, necessitates counseling about the risks and proper use of lorazepam along with monitoring for signs and symptoms of abuse, misuse, and addiction Lorazepam is not recommended for use in patients with a primary depressive disorder or psychosis.

Management of a patient with a high risk of suicide and self-harm who requests a prescription for lorazepam (Ativan) should involve:

• Assessing the patient's risk for abuse, misuse, and addiction using a standardized screening tool 2
• Counseling the patient about the risks and proper use of lorazepam
• Monitoring for signs and symptoms of abuse, misuse, and addiction
• Considering alternative treatment options, as lorazepam is not recommended for use in patients with a primary depressive disorder or psychosis 2
• A gradual taper to discontinue lorazepam or reduce the dosage to reduce the risk of withdrawal reactions 2

From the Research

Managing Patients with High Risk of Suicide and Self-Harm

When managing a patient with a high risk of suicide and self-harm who requests a prescription for lorazepam (Ativan), several factors should be considered:

• The patient's mental health history and current diagnosis
• The potential risks and benefits of prescribing lorazepam
• Alternative treatment options

Risks Associated with Antidepressants and Benzodiazepines

Studies have shown that certain antidepressants, such as mirtazapine, venlafaxine, and trazodone, are associated with a higher risk of suicide and self-harm 3. Additionally, benzodiazepines like lorazepam can increase the risk of suicidal behavior, particularly in the first 28 days of treatment 3, 4, 5.

• The risk of suicidal behavior is increased in the first month after starting antidepressants, especially during the first 1 to 9 days 4
• The risk of self-harm is also increased during this period, with rates remaining high in the first 28 days after stopping treatment 3

Considerations for Prescribing Lorazepam

Given the potential risks associated with lorazepam, it is essential to carefully evaluate the patient's needs and consider alternative treatment options:

• Lorazepam may be prescribed for short-term use in patients with severe anxiety or insomnia, but its use should be closely monitored 6
• Alternative treatments, such as cognitive-behavioral therapy or other medications, may be more effective and safer for patients with a high risk of suicide and self-harm 3, 4, 5, 7

Monitoring and Follow-up

Patients prescribed lorazepam or other medications that may increase the risk of suicidal behavior should be closely monitored:

• Regular follow-up appointments should be scheduled to assess the patient's mental health and adjust treatment as needed 3, 4, 5, 7
• Patients should be warned about the potential risks of suicidal behavior and instructed to seek immediate medical attention if they experience any symptoms of self-harm or suicidal ideation 7