Management of Depression with Suicidal Ideation in Family Medicine
Patients expressing suicidal ideation require immediate psychiatric evaluation and should be considered for hospitalization if they continue to express a desire to die, remain agitated or hopeless, cannot participate in safety planning, lack adequate support, or have a history of high-lethality attempts. 1
Immediate Risk Assessment
Screen using PHQ-9 item 9, which has been validated to predict both suicide attempts and death within one year of administration in primary care settings. 2 Do not rely on the Columbia-Suicide Severity Rating Scale (C-SSRS), as insufficient evidence supports its accuracy for suicide risk screening. 2
Use multiple assessment methods rather than relying on any single tool, as no instrument can sufficiently stratify risk level. 2 Combine self-reported measures with clinical interviews to reduce misclassification risk. 2
High-Risk Indicators Requiring Immediate Action
Evaluate for these specific factors that signal elevated mortality risk:
- Persistent desire to die despite intervention 1
- Severe agitation or hopelessness that does not respond to initial management 1
- Inability to engage in safety planning 1
- Inadequate social support system 1
- History of high-lethality suicide attempts 1
- Male gender, ages 16-19 (highest risk demographic) 2
- Comorbid substance abuse with depression 2
- High levels of anger or impulsivity 1
Consider immediate psychiatric hospitalization for patients meeting these criteria, as up to 90% of completed suicides involve an underlying psychiatric disorder. 2, 3
Safety Planning (Essential Before Any Other Intervention)
Conduct a safety planning discussion immediately, which must include: 1
- Identification of warning signs and triggers for suicidal thoughts
- Specific coping strategies the patient can use
- List of healthy activities and distractions
- Names and contact information of responsible social supports
- Professional support contacts with explicit instructions on accessing emergency services 1
Counsel on lethal means restriction as a fundamental discharge component: secure knives, lock medications, and remove firearms from the home. 1 This is critical because 24% of suicide attempts are implemented within 0-5 minutes of deciding to act. 1
Treatment Approach
Psychotherapy (First-Line for Suicidal Ideation)
Initiate cognitive-behavioral therapy (CBT) focused on suicide prevention for patients with suicidal ideation or recent suicidal behavior within the last 6 months. 1 CBT reduces both suicide attempts and suicidal ideation in patients with self-directed violence history. 2 Most patients require fewer than 12 sessions. 2
Combine CBT with antidepressant medication for major depression, as nonpharmacological interventions should be used in combination with medications rather than as monotherapy. 2
Pharmacological Management
Start antidepressant therapy (SSRIs preferred) for underlying major depression, as treatment decreases suicide risk among depressed patients. 3 However, monitor intensively during the first 10-14 days of treatment when suicide risk paradoxically increases. 3
Monitor for these specific warning signs during antidepressant initiation: anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, or mania. 4, 5, 6 These symptoms may represent precursors to emerging suicidality. 4, 5, 6
Prescribe the smallest quantity of medication consistent with good management to reduce overdose risk. 4, 5, 6
Specialized Pharmacological Options
For patients with persistent suicidal ideation despite standard treatment:
Ketamine infusion (0.5 mg/kg single dose) provides rapid improvement in suicidal ideation within 24 hours, lasting at least 1 week and potentially up to 6 weeks. 2, 1 In meta-analyses, 55% of patients reported no suicidal ideation at 24 hours and 60% at 7 days. 2
Lithium maintenance therapy reduces suicidal behaviors and deaths in patients with unipolar or bipolar depression. 2
Clozapine reduces suicidal behaviors in patients with schizophrenia or schizoaffective disorder who exhibit suicidal ideation. 2, 1
Ongoing Monitoring Requirements
Observe closely during the initial months of treatment and at any dose changes (increases or decreases). 4, 5, 6 The greatest risk for new suicide attempts occurs in the months following an initial attempt. 1
Instruct families and caregivers to monitor daily for emergence of agitation, irritability, unusual behavior changes, and suicidality, with instructions to report immediately. 4, 5, 6
Send periodic caring communications (postal mail or text messages) for 12 months after any hospitalization related to suicide risk, as this reduces subsequent suicide attempts. 1
Mental Health Referral Criteria
Refer immediately to mental health professionals for: 2
- Suicidal ideation with verbalized plan to harm themselves (determination based on intent, likelihood of self-harm, and staff availability for observation)
- Depression with psychotic features
- Failure to respond to 6 or more weeks of treatment 2
Negotiate comanagement responsibilities between primary care and mental health when referral is made, with designated case coordination. 2 Primary care should maintain contact and continue monitoring after referral. 2
Critical Pitfalls to Avoid
Do not screen for bipolar disorder before initiating antidepressants. Obtain detailed psychiatric history including family history of suicide, bipolar disorder, and depression, as treating bipolar depression with antidepressants alone may precipitate mixed/manic episodes. 4, 5, 6
Do not discharge patients without third-party information, regardless of how mild the suicidal behavior appears. 2
Do not use the MDS (Minimum Data Set) alone for depression screening, as it is inadequate by itself. 2
Do not taper antidepressants abruptly if discontinuation is necessary; taper as rapidly as feasible while recognizing abrupt discontinuation causes withdrawal symptoms. 4, 5, 6