Management of Increased Suicidal Ideation in a 19-Year-Old on Escitalopram (Lexapro)
A 19-year-old with increased suicidal ideation after 2 months on escitalopram requires immediate mental health professional evaluation and possible hospitalization, along with consideration of medication changes and enhanced safety measures.
Immediate Assessment and Intervention
For adolescents with increased suicidal ideation while on antidepressants, arrangements for immediate mental health professional evaluation should be made during the office visit 1
Options for immediate evaluation include:
- Hospitalization
- Transfer to emergency department
- Same-day appointment with mental health professional 1
Risk assessment should evaluate:
- Presence of a suicide plan
- Intent to act on suicidal thoughts
- Access to lethal means
- Previous suicide attempts
- Presence of severe depression or other psychiatric illness
- Substance use
- Level of impulse control
- Family support 1
Medication Management
The FDA black-box warning for escitalopram indicates increased risk of suicidality in children and adolescents, requiring close monitoring for "clinical worsening, suicidality, or unusual changes in behavior" 2
Consider the following medication options:
- Discontinuation of escitalopram if suicidal ideation appears to be medication-induced 2
- Gradual dose reduction rather than abrupt cessation to avoid discontinuation symptoms 2
- Possible switch to fluoxetine, which has better evidence for efficacy and safety in adolescents 1, 3
- Consultation with a psychiatrist regarding alternative medication strategies 1
Monitor closely during any medication changes, as the greatest risk of relapse occurs in the first 8-12 weeks after discontinuing an antidepressant 1
Safety Planning
Remove all firearms from the home - adolescents may find access even to locked guns 1
Lock up all medications, both prescription and over-the-counter 1
Develop a specific safety plan that includes:
- Identification of warning signs and triggers for suicidal ideation
- Coping strategies the patient can use
- Healthy distraction activities
- Responsible social supports to contact
- Professional contacts and emergency services information
- Means restriction 1
Maintain close follow-up - monitor on a monthly basis for 6-12 months after resolution of symptoms 1
Hospitalization Considerations
Hospitalization should be strongly considered if the patient:
- Continues to endorse a desire to die
- Remains agitated or severely hopeless
- Cannot engage in safety planning
- Lacks adequate support system
- Cannot be adequately monitored
- Has made a previous high-lethality attempt 1
Although no controlled studies prove that hospitalization saves lives, it is likely the safest course of action for high-risk patients, providing a protected environment for evaluation and treatment initiation 1
Follow-up Care
- If the patient is not hospitalized, ensure:
- Frequent monitoring, especially during the first few weeks after medication changes 2
- Collaborative care between primary care provider and mental health professionals 1
- Consideration of evidence-based psychotherapy such as cognitive behavioral therapy (CBT) or dialectical behavior therapy (DBT) 1
- Reassessment of diagnosis and treatment if no improvement is noted after 6-8 weeks 1
Important Caveats
- Suicidal ideation may be a symptom of the underlying depression rather than medication-induced 1
- Studies suggest the risk of not treating depression may be greater than the risk of antidepressant treatment 1
- Genetic factors may influence vulnerability to treatment-emergent suicidal ideation, particularly related to glutamate receptors 4
- The emergence of suicidal ideation is more common in younger patients, with risk increasing with decreasing age 3
- No-suicide contracts have not been proven effective but safety planning discussions are important 1