What are the next steps for a client with osteogenesis imperfecta and ongoing depressive disorder who is not responding to Cymbalta (duloxetine) and is experiencing suicidal thoughts without a plan or intent?

Management of Suicidal Ideation in a Client with Osteogenesis Imperfecta and Depression Not Responding to Duloxetine

For a client with osteogenesis imperfecta and ongoing depressive disorder who is experiencing suicidal thoughts without plan or intent and not responding to Cymbalta (duloxetine), the most appropriate next step is to initiate cognitive behavioral therapy (CBT) focused on suicide prevention while considering medication changes such as switching to an SSRI or adding lithium. 1, 2

Immediate Assessment and Safety Planning

• Perform a thorough suicide risk assessment focusing on frequency and intensity of suicidal thoughts, access to lethal means, social support, and previous suicide attempts 1
• Develop a collaborative crisis response plan that includes:
  • Identification of warning signs of crisis (behavioral, cognitive, affective, physical)
  • Self-management coping skills
  • Social support contacts
  • Crisis resources including emergency contacts 1
• Ensure medication is monitored by a third party who can report any changes in mood, increases in agitation, or unwanted side effects 1, 2

Pharmacological Interventions

• Consider switching from duloxetine to an SSRI (particularly fluoxetine) which has better evidence for treating depression with suicidal features 2
• For patients with mood disorders and suicidal ideation, lithium may be beneficial as it has been associated with reduced suicidal behaviors and deaths 1, 2
• Avoid tricyclic antidepressants due to their greater lethality in overdose 1, 2
• Use benzodiazepines cautiously as they may increase disinhibition or impulsivity in some individuals 1, 2
• Consider ketamine infusion as an adjunctive treatment for rapid short-term reduction in suicidal ideation if symptoms are severe 1, 2

Psychotherapeutic Approaches

• Initiate cognitive behavioral therapy (CBT) focused on suicide prevention, which has been shown to reduce suicidal ideation and cut the risk of suicide attempts by half compared to treatment as usual 1
• Consider dialectical behavior therapy (DBT) which combines elements of CBT, skills training, and mindfulness techniques to help develop skills in emotion regulation, interpersonal effectiveness, and distress tolerance 1
• Problem-solving therapy (a type of CBT) can help improve coping with life stressors 1
• Offer closely spaced follow-up appointments and be flexible in arranging appointments if a crisis arises 1

Special Considerations for Osteogenesis Imperfecta

• Be aware that osteogenesis imperfecta (OI) is a genetic bone fragility disorder that requires multidisciplinary management 3
• Recognize that chronic pain and physical limitations associated with OI may contribute to depression and require specific attention in treatment planning 3, 4
• Consider how physical limitations might impact therapy attendance and medication adherence 3, 5

Follow-up and Monitoring

• Schedule definite, closely spaced follow-up appointments 1
• Contact the patient if appointments are missed 1
• Send periodic caring communications (e.g., postal mail, text messages) for 12 months following any hospitalization related to suicide risk 1
• Consider self-guided digital interventions (app or web) with cognitive behavioral-based therapeutic content for additional support 1

Common Pitfalls to Avoid

• Do not rely solely on no-suicide contracts as there is no empirical evidence supporting their efficacy 1
• Avoid coercive communications such as "unless you promise not to attempt suicide, I will keep you in the hospital" 1
• Do not assume that a patient who agrees to a no-suicide contract is no longer at risk 1
• Avoid prescribing medications with high lethality in overdose given the presence of suicidal thoughts 1