What medications should be added to Seroquel (quetiapine) 300 mg qhs (every night at bedtime) for a patient with Major Depressive Disorder (MDD) who remains suicidal?

Management of Suicidal Patient with MDD on Quetiapine

For a patient with Major Depressive Disorder who remains suicidal while on Quetiapine 300 mg qhs, the most effective medication to add is an SSRI antidepressant such as sertraline, starting at 25-50 mg daily and titrating to 50-200 mg daily over 4-6 weeks. 1

Rationale for Adding an Antidepressant

While quetiapine has some antidepressant properties, it is often insufficient as monotherapy for severe MDD with suicidality. The current evidence supports a stepwise approach:

1. First-line augmentation: SSRI antidepressant

   • Sertraline is recommended as a first choice due to its efficacy for both depression and anxiety symptoms 1
   • Start at 25-50 mg daily for 1 week, then increase to 50-100 mg daily for another week, with target dose of 50-200 mg daily 1
   • Reassess every 2 weeks using standardized instruments to evaluate effectiveness

2. Alternative SSRI options if sertraline is not tolerated:

   • Escitalopram: 10 mg daily (maximum 20 mg daily)
   • Fluoxetine: 20 mg daily (maximum 80 mg daily)
   • Paroxetine: 10 mg daily (maximum 40 mg daily)

Special Considerations for Suicidal Patients

For patients with active suicidal ideation, additional considerations are necessary:

• Ketamine infusion should be considered as an adjunctive treatment for short-term reduction in suicidal ideation in patients with MDD and suicidal ideation 2

  • The VA/DoD guidelines support ketamine infusions as an adjunctive treatment for short-term reduction in suicidal ideation 2
  • Ketamine used in conjunction with an antidepressant in patients with treatment-resistant depression has shown significant improvement in depressive symptoms 2

• Close monitoring is essential during the first weeks of treatment with regular evaluation of suicidal risk 1

  • Prescribe limited amounts of medication
  • Consider more frequent follow-up appointments (weekly initially)
  • Develop a safety plan with the patient

Treatment Algorithm

1. Add sertraline to current quetiapine regimen

   • Start at 25-50 mg daily
   • Titrate to 50-200 mg daily over 4-6 weeks
   • Continue quetiapine 300 mg qhs

2. If inadequate response after 4-6 weeks:

   • Consider switching to another SSRI or SNRI
   • Venlafaxine is a good option, starting at 37.5 mg daily and increasing to 150-225 mg daily 3

3. For persistent suicidal ideation despite medication changes:

   • Consider ketamine infusion as adjunctive treatment 2
   • Referral for intensive outpatient program or hospitalization may be necessary

4. For treatment-resistant cases:

   • Consider augmentation with lithium (target blood level 0.6-1.2 mmol/L) 4
   • Alternatively, add bupropion (start 100 mg daily, target 300 mg daily) 1

Monitoring and Follow-up

• Reassess symptoms every 2 weeks using standardized instruments 1
• Monitor for side effects and emergence of suicidal ideation, especially during medication transitions
• Evaluate for drug interactions between quetiapine and added medications
• Consider cognitive behavioral therapy focused on suicide prevention to reduce the risk of suicide attempts 2

Cautions and Pitfalls

• Avoid premature medication changes; allow 4-8 weeks for full response to antidepressants 1
• Be cautious with benzodiazepines in suicidal patients due to potential disinhibition and risk of overdose
• Monitor for serotonin syndrome when combining quetiapine with serotonergic medications
• Recognize that approximately 38% of patients do not achieve treatment response during 6-12 weeks of initial antidepressant treatment 1

Adding an SSRI to the current quetiapine regimen provides the best balance of efficacy and safety for this patient with MDD who remains suicidal, with ketamine infusion as an important consideration for rapid reduction in suicidal ideation if the patient's condition warrants immediate intervention.