What is the appropriate treatment for someone experiencing suicidal ideation?

Management of Suicidal Ideation Potentially Related to Zepbound

If someone on Zepbound develops suicidal ideation, immediately assess safety and consider hospitalization if they cannot form a therapeutic alliance, remain agitated or hopeless, have a high-lethality plan, lack adequate support, or cannot be safely monitored—while simultaneously evaluating whether the medication itself may be contributing to these symptoms. 1

Immediate Safety Assessment and Triage

Hospitalization is indicated if the patient meets any of these criteria 1:

• Inability to form an alliance with the clinician or discuss emotions
• Persistent desire to die despite intervention
• Severe hopelessness or agitation
• High-lethality suicide plan with clear expectation of death
• Psychotic features, command hallucinations, or delusional thinking
• Current substance intoxication
• Inadequate home support or supervision
• Multiple previous serious suicide attempts

Before any discharge from emergency settings, you must 1:

• Obtain collateral information from a third party—never rely solely on the patient's self-report
• Verify that firearms and all lethal medications can be secured or removed from the home
• Confirm a responsible adult will be present for supervision
• Schedule a specific follow-up appointment within days

Medication-Related Considerations

Antidepressants and weight-loss medications can induce suicidal ideation, particularly in younger patients during the first few months of treatment 2. While Zepbound (tirzepatide) is not an antidepressant, any medication affecting mood or behavior warrants careful evaluation:

• Monitor for emergence of agitation, irritability, impulsivity, or unusual behavioral changes that may represent precursors to worsening suicidality 2
• Consider whether symptoms began or worsened after starting Zepbound
• If medication-induced suicidality is suspected, discuss risk-benefit of continuing versus discontinuing with psychiatry consultation

All medications must be monitored by a third party who controls dispensing and immediately reports behavioral changes or side effects 1, 3.

Evidence-Based Psychotherapy (Primary Treatment)

Cognitive-behavioral therapy focused on suicide prevention is the most effective intervention, reducing suicidal ideation and cutting suicide attempt risk by half compared to usual care 1, 4, 3. This should be initiated immediately, not deferred.

Dialectical behavior therapy is an alternative evidence-based option, particularly effective for patients with emotion dysregulation, impulsivity, or anger issues 1, 4. DBT combines CBT with skills training in distress tolerance and interpersonal effectiveness.

Pharmacological Interventions for Suicidal Ideation

For acute suicidal ideation with major depression, ketamine infusion as adjunctive treatment provides short-term reduction in suicidal thoughts 1, 3. However, evidence is insufficient regarding its effect on actual suicide attempts or deaths 1.

For patients with schizophrenia or schizoaffective disorder, clozapine reduces suicide attempt risk 1.

Lithium may benefit patients with mood disorders and suicidal ideation, though current evidence is insufficient to make a strong recommendation 1, 3.

Critical medication warnings 1, 3:

• Never prescribe tricyclic antidepressants—they have high lethality in overdose
• Use benzodiazepines and phenobarbital with extreme caution as they increase disinhibition
• Avoid any medication with narrow therapeutic-toxic windows

Safety Planning and Means Restriction

Means restriction is highly effective at preventing suicide progression from ideation to attempt 1. Most suicide attempts are impulsive, with 24% occurring within 5 minutes of deciding and 48% within 20 minutes 1.

Develop a collaborative safety plan that includes 1, 3:

• Identification of warning signs and triggers
• Specific coping strategies when suicidal thoughts return
• Healthy distraction activities
• Contact information for social supports
• Instructions for accessing emergency services
• Explicit means restriction counseling

Never rely on "no-suicide contracts"—they have no empirical evidence supporting efficacy and create false reassurance 1, 3. Safety planning discussions are valuable, but contracts are not.

Follow-Up Protocol

Schedule closely-spaced appointments (at least weekly initially) with the same clinician to ensure continuity 1, 3. The treating clinician must be available outside regular hours or ensure adequate crisis coverage 1, 4.

Send periodic caring communications (postal mail or text messages) for 12 months following any hospitalization related to suicide risk 1, 3. This intervention reduces suicide attempt risk.

Self-guided digital interventions with cognitive behavioral content may provide additional support for short-term reduction in suicidal ideation 1, 3.

Critical Pitfalls to Avoid

• Never discharge without third-party verification and confirmed supervision 1, 4
• Never assume medication alone is sufficient—psychotherapy is essential 1, 4, 3
• Never overlook substance use, which dramatically increases disinhibition and suicide risk 1
• Never assume a patient agreeing to safety is no longer at risk 3
• Never use coercive language like "unless you promise not to attempt suicide, I will hospitalize you" 3