What medication adjustments can be made for a patient with ongoing depression and suicidal ideation who is currently on Lexapro (escitalopram) 10mg daily, lithium (lithium carbonate) 300mg twice daily, and Latuda (lurasidone) 40mg daily?

Medication Adjustments for Ongoing Depression and Suicidal Ideation

For a patient with ongoing depression and suicidal ideation on Lexapro 10mg daily, lithium 300mg twice daily, and Latuda 40mg daily, the most effective medication adjustment would be to increase the lithium dosage to achieve therapeutic blood levels, as lithium has demonstrated significant efficacy in reducing suicidal behaviors and deaths in patients with mood disorders.

Current Medication Analysis

• The patient is currently on subtherapeutic doses of lithium at 300mg twice daily, which is unlikely to achieve the therapeutic blood levels needed for anti-suicidal effects 1
• Lexapro (escitalopram) 10mg is at the lower end of the therapeutic range for depression treatment 2
• Latuda (lurasidone) 40mg is within the therapeutic range but may be optimized 3

Recommended Medication Adjustments (In Order of Priority)

1. Increase lithium dose:

   • Lithium has demonstrated significant efficacy in reducing suicidal behaviors and deaths in patients with unipolar depression or bipolar disorder 1
   • Current dose of 300mg twice daily is likely subtherapeutic for anti-suicidal effects 3
   • Gradually increase lithium dose to achieve therapeutic blood levels (0.6-1.2 mEq/L), with appropriate monitoring of serum levels 3

2. Consider optimizing Latuda (lurasidone):

   • Consider increasing Latuda to 60-80mg daily if the patient shows partial response 3
   • Lurasidone combined with D-cycloserine has shown promise in maintaining improvement in depression and reducing suicidal ideation in patients with bipolar depression 4

3. Optimize Lexapro (escitalopram):

   • Consider increasing Lexapro to 20mg daily if no significant improvement at current dose 5, 2
   • Monitor closely for emergence or worsening of suicidal ideation, especially during dose adjustments 2, 6

Additional Considerations

• Ketamine infusion for acute management:

  • For patients with persistent suicidal ideation despite medication adjustments, ketamine infusion (0.5 mg/kg) should be considered as an adjunctive treatment 1, 3
  • Ketamine has shown rapid reduction in suicidal ideation within 24 hours, with effects lasting up to 1 week 1
  • In meta-analyses, 55% of patients reported no suicidal ideation after 24 hours, and 60% reported no suicidal ideations at 7 days 1

• Clozapine consideration:

  • If the patient has schizophrenia or schizoaffective disorder features, clozapine should be considered as it has demonstrated efficacy in reducing suicidal behaviors 1
  • The required monitoring through the Clozapine Risk Evaluation and Mitigation Strategy program provides additional oversight 1

Monitoring and Follow-up

• Schedule frequent follow-up appointments, especially during medication adjustments 3, 5
• Use multiple assessment methods to evaluate suicide risk, including clinical interviews and standardized measures 3, 5
• Monitor for emergence or worsening of suicidal ideation, especially during the first few weeks after medication changes 2, 6
• Consider adding cognitive behavioral therapy (CBT) as evidence supports its use to reduce suicidal ideation and behavior 1

Cautions and Pitfalls

• Avoid relying solely on antidepressants without adequate mood stabilization in patients with bipolar features, as they may trigger manic episodes or worsen rapid cycling 3, 5
• Be aware that some patients may experience worsening suicidal ideation on antidepressants, particularly during the initial treatment period or dose adjustments 2, 7, 6
• Benzodiazepines should be used cautiously as they may reduce self-control and potentially disinhibit some individuals 3, 5
• Tricyclic antidepressants should be avoided due to their greater lethality in overdose 3, 5