Medications That Can Cause Mood Swings and Suicidal Ideation
Several medications can cause mood swings and suicidal ideation, with antidepressants, weight management drugs, and certain neurological medications carrying the highest risk. Based on the available evidence, I'll outline the medications most associated with these adverse effects.
Antidepressants
- Selective Serotonin Reuptake Inhibitors (SSRIs) have been associated with an increased risk of suicidal ideation and nonfatal suicide attempts, particularly in the initial treatment period 1
- Case reports have specifically identified fluoxetine as potentially inducing suicidal preoccupations in some patients, especially when treatment is first initiated 1
- Patients experiencing akathisia (restlessness) as a side effect of SSRIs may be at higher risk for developing suicidal ideation 1
- Tricyclic antidepressants (particularly imipramine and clomipramine) can have pro-suicidal effects due to their "asynchronous cognitive-psychomotor pharmacodynamic action" 2
- Paroxetine has been associated with higher rates of sexual dysfunction and mood changes compared to other antidepressants 1
Weight Management Medications
- Naltrexone/bupropion combination carries a black box warning for suicidal behavior/ideation specifically in people younger than 24 years old who have depression 1, 3
- Bupropion alone has been associated with neuropsychiatric adverse events including changes in mood, psychosis, hallucinations, paranoia, delusions, homicidal ideation, aggression, hostility, agitation, anxiety, panic, suicidal ideation, and suicide attempts 4
Mood Stabilizers and Anticonvulsants
- Topiramate, used for seizures and weight management, has been associated with mood changes 1
- Carbamazepine has been linked to mood alterations and psychological side effects 1
Benzodiazepines and Other Sedatives
- Benzodiazepines may disinhibit some individuals who then exhibit aggression and suicide attempts 1
- Phenobarbital has been associated with reduced self-control and potential suicidal behavior 1
Stimulants
- Amphetamines have been linked to potential disinhibition and suicidal behavior in some individuals 1
- Stimulant medications should be prescribed only when treating patients with ADHD, and with careful monitoring 1
Monitoring Recommendations
- For patients on SSRIs, clinicians should be particularly observant during the early stages of treatment 1
- Systematic inquiry about suicidal ideation before and after treatment is started is essential 1
- Be especially alert to the possibility of suicidality if treatment is associated with the onset of akathisia 1
- All medication administration for patients with suicidal tendencies must be carefully monitored by a third party who can report any unexpected change of mood, increase in agitation, or unwanted side effects 1
High-Risk Patient Factors
- Patients with a history of past suicide attempts are at higher risk (OR 1.72) for worsening of suicidal ideation when starting antidepressants 5
- Patients with comorbid medical illness (OR 2.23) and family history of drug abuse (OR 1.69) may experience worsening of suicidal ideation with antidepressant treatment 5
- Young adults (18-24 years) appear to have the greatest odds of experiencing suicidal events regardless of treatment 6
Medication Selection Considerations
- Bupropion has been associated with lower rates of suicidal ideation in some studies (OR 0.24) compared to other antidepressants 5
- For patients with weight concerns, consider that mirtazapine and paroxetine are associated with greater weight gain, while bupropion is consistently associated with weight loss 7
- For patients with treatment-resistant depression who show worsening suicidal ideation despite medication trials, consider non-pharmacological approaches 5
Remember that improvement in suicidal ideation is strongly correlated with improvement in overall depression symptoms 5. Close monitoring during medication initiation and dose changes is essential for all patients, particularly those with risk factors for suicidal behavior.