Management of Suicidal Ideation in a 71-Year-Old Female with Previous Attempt
For this 71-year-old female with increasing suicidal thoughts, history of a recent suicide attempt, and inadequate response to escitalopram, the most appropriate next step is to add lithium as an adjunctive treatment while maintaining the current escitalopram dose of 10mg/day. 1
Risk Assessment Factors
- The patient has multiple high-risk factors: increasing suicidal thoughts, previous suicide attempt by overdose within the past 2 months, and inadequate response to medication trials 2, 3
- Older adults (>65 years) generally have a lower risk of suicidal thoughts and behaviors with antidepressant treatment compared to younger populations (6 fewer cases per 1000 patients compared to placebo) 4
- Recent discontinuation of Wellbutrin may have contributed to destabilization, as medication changes can increase risk during transition periods 5
Pharmacological Management
First-Line Approach
- Add lithium to the current escitalopram regimen:
- Lithium significantly reduces suicide risk by 8.6-fold in patients with mood disorders 1, 2
- Lithium's anti-suicidal properties appear independent of its mood-stabilizing effects, making it particularly valuable for patients with active suicidal ideation 1
- Discontinuation of lithium is associated with a 7-fold increase in suicide attempts, highlighting the importance of maintenance treatment 2, 1
Medication Considerations
- Maintain escitalopram at 10mg/day rather than increasing to 20mg again, as the patient did not benefit from the higher dose 5
- Avoid tricyclic antidepressants due to their high lethality in overdose, particularly important given this patient's previous overdose attempt 2, 5
- Consider ketamine infusion as an adjunctive treatment for short-term reduction in suicidal ideation while waiting for lithium to take effect 2, 5
Monitoring Requirements
- Baseline laboratory testing before starting lithium: complete blood count, thyroid function, urinalysis, BUN, creatinine, and serum calcium levels 1
- Regular lithium level monitoring with target therapeutic range of 0.6-1.2 mEq/L 1
- Arrange for medication supervision by a third party due to the patient's recent suicide attempt 2, 5
- Monitor for signs of serotonin syndrome with the combination therapy (mental status changes, autonomic instability, neuromuscular symptoms) 4
Psychotherapeutic Interventions
- Implement cognitive behavioral therapy (CBT) focused on suicide prevention, which has been shown to reduce the risk of suicide attempts in patients with recent suicidal behavior 2, 3
- Develop a detailed safety plan that includes:
- Identification of warning signs and potential triggers
- Personal coping strategies
- List of healthy activities and distractions
- Contact information for social supports and emergency services 3
- Consider dialectical behavior therapy (DBT) if the patient continues to struggle with emotional regulation, though evidence for its efficacy specifically for suicide prevention is limited 2, 3
Follow-up and Continuity of Care
- Schedule frequent follow-up appointments, particularly during the first few weeks of lithium initiation 1
- Implement caring communications (e.g., phone calls, text messages) between appointments to maintain engagement 3
- Ensure restriction of access to lethal means, particularly medications that could be used in overdose 3, 6
- Consider self-guided digital CBT interventions as an adjunct to in-person therapy 3
Common Pitfalls to Avoid
- Failing to recognize that the greatest risk of a new suicide attempt occurs in the months following an initial attempt 3, 7
- Inadequate duration of medication trials before changing approach (trials should be 6-8 weeks) 1
- Premature discontinuation of lithium once symptoms improve 1
- Neglecting to involve family members in safety planning and medication supervision 6
- Underestimating the risk of impulsive suicide attempts (24% of patients implement their plan within 5 minutes of deciding) 3, 7