What medication should be prescribed for a patient with a mood disorder who is impulsive and suicidal?

Medication Management for Mood Disorder with Impulsivity and Suicidality

Lithium is the first-line medication for patients with mood disorders who are impulsive and suicidal, due to its significant evidence in reducing suicide risk independent of its mood-stabilizing effects. 1, 2

First-Line Treatment Options

• Lithium should be the primary medication choice for patients with bipolar disorder and suicidal features, as it significantly reduces suicide risk by 8.6-fold compared to the general population 2
• For unipolar depression with suicidal features, SSRIs (particularly fluoxetine) are recommended as first-line treatment, always with careful monitoring during the initial treatment period 1
• Patients with bipolar disorder are at 8.66 times higher risk of dying by suicide compared to the general population, making suicide prevention a critical treatment goal 3
• Lithium's anti-suicidal properties appear to be independent of its mood-stabilizing effects, making it particularly valuable for patients with active suicidal ideation 2, 4

Second-Line and Adjunctive Options

• Valproate can be considered as an alternative mood stabilizer if lithium is contraindicated or not tolerated, though evidence suggests it may be less effective than lithium in reducing suicidal behavior 5, 6
• Olanzapine (in a dose range of 5-20 mg/day) has demonstrated efficacy in bipolar disorder, either as monotherapy or in combination with lithium or valproate 7
• Clozapine has received FDA approval for "reducing the risk of recurrent suicidal behavior," primarily based on data from patients with schizophrenia or schizoaffective disorder 3
• Ketamine has shown promise as a rapid-acting antisuicidal agent, with effects beginning within hours rather than weeks, making it valuable for acute crisis management 3, 1

Treatment Algorithm

1. For bipolar disorder with suicidality:

   • Start with lithium (first-line) with careful monitoring of blood levels 1, 2
   • If lithium is contraindicated, consider valproate or carbamazepine 5, 8
   • For acute manic or mixed episodes, add an atypical antipsychotic such as olanzapine 3, 7
   • Avoid prescribing antidepressants without mood stabilizers as they may trigger manic episodes 1

2. For unipolar depression with suicidality:

   • Start with an SSRI (preferably fluoxetine) 1
   • Avoid tricyclic antidepressants due to their greater lethality in overdose 1
   • Consider lithium augmentation if response to antidepressant is inadequate 2

3. For acute suicidal crisis requiring rapid intervention:

   • Consider ketamine infusion (0.5 mg/kg) for rapid reduction of suicidal ideation 3, 1
   • Electroconvulsive therapy (ECT) should be considered for severely depressed patients with acute suicidal risk 3, 1

Important Clinical Considerations

• All suicidal patients on medication should have dosage regulated and monitored by a third party who can report any unexpected changes in mood or increases in agitation 1
• Maintenance treatment with lithium or other mood stabilizers should continue for at least 2 years after the last episode of bipolar disorder 3
• Benzodiazepines should be used cautiously as they may reduce self-control and potentially disinhibit some individuals 1
• Psychoeducation should be routinely offered to individuals with psychotic and bipolar disorders and their family members/caregivers 3

Monitoring and Follow-up

• Systematically inquire about suicidal ideation before and after treatment is started, especially with SSRIs 1
• Be particularly vigilant during the early stages of treatment when medication changes are made 1
• For lithium, baseline laboratory testing should include complete blood count, thyroid function, urinalysis, BUN, creatinine, and serum calcium levels 2
• Premature discontinuation of lithium can lead to a 7-fold increase in suicide attempts, highlighting the importance of maintenance therapy 2

Common Pitfalls to Avoid

• Inadequate duration of medication trials before changing treatment approach (trials should be 6-8 weeks) 2
• Failure to monitor for metabolic side effects of medications, particularly with atypical antipsychotics 5
• Overlooking the need for psychosocial interventions alongside pharmacotherapy 3, 1
• Underestimating the risk of suicide in the first year following hospital discharge 2, 9