What is the best course of action for a patient with worsening depressive symptoms and suicidal ideation with a plan, currently taking fluoxetine (selective serotonin reuptake inhibitor) 40 mg daily?

Management of Patient with Worsening Depression and Suicidal Ideation with Plan

The patient should be immediately referred to emergency services to assess the need for hospitalization due to active suicidal ideation with a plan, which represents an acute safety risk requiring urgent intervention. 1

Rationale for Emergency Services Referral

The patient presents with several high-risk factors that necessitate immediate intervention:

• Worsening depressive symptoms despite medication increase
• Active suicidal ideation for the past 2 days
• Presence of a suicide plan (even if details are withheld)
• Recent medication change (fluoxetine increased from 20mg to 40mg 2 weeks ago)

Clinical Decision-Making Process

1. Severity Assessment: The patient has progressed from depressive symptoms to active suicidal ideation with a plan, representing a significant escalation in risk 1

2. Safety Concerns: When a patient has both suicidal ideation AND a plan, this indicates high acute risk requiring immediate safety measures 2

3. Medication Considerations:

   • The recent increase in fluoxetine dose may be contributing to the worsening symptoms
   • Fluoxetine and other SSRIs can occasionally worsen suicidal ideation, particularly after dose changes 3, 4
   • While rare, some patients develop intense suicidal preoccupation after fluoxetine dose increases 5

Why Other Options Are Not Appropriate

• Increasing fluoxetine to 60mg daily: This would be contraindicated as the patient is already experiencing worsening symptoms after a recent dose increase. Further increasing the dose could potentially exacerbate suicidal ideation 4

• Adding lithium 300mg at bedtime: While lithium has evidence for reducing suicide risk in mood disorders 2, it is not appropriate as a first-line intervention for acute suicidal crisis before safety assessment. The patient requires immediate safety evaluation before medication adjustments.

• Cross-titration to nortriptyline: Switching to a tricyclic antidepressant is inappropriate during an acute suicidal crisis. Additionally, tricyclic antidepressants have higher lethality in overdose compared to SSRIs, making them a poor choice for actively suicidal patients 2

Management After Emergency Assessment

If hospitalization is not deemed necessary after emergency evaluation:

1. Safety Planning:

   • Remove access to lethal means
   • Establish frequent follow-up appointments
   • Involve family/support system in monitoring

2. Medication Adjustments (after safety is established):

   • Consider returning to previous fluoxetine dose (20mg)
   • Consider adjunctive treatments under close supervision

3. Psychotherapy:

   • Cognitive behavioral therapy focused on suicide prevention is recommended to reduce suicide attempt risk 1
   • Regular therapeutic contact and support

Important Clinical Considerations

• Monitoring: The incidence of suicide among patients with depression is twice that of the general population 1

• Medication Effects: A small subset of patients may experience akathisia and increased suicidal ideation with fluoxetine, particularly after dose changes 3, 4

• Common Pitfall: Relying solely on medication adjustments without addressing immediate safety concerns can place the patient at significant risk 2

• Follow-up: If emergency services determine hospitalization is not needed, ensure very close follow-up (within 24-48 hours) and establish a comprehensive safety plan

The evidence clearly supports that for a patient with active suicidal ideation with a plan, immediate safety assessment through emergency services is the appropriate first step before any medication adjustments can be considered.