From the Guidelines
For acute management of depression with suicidal ideation while waiting for an SSRI to take effect, ketamine infusions (0.5 mg/kg) are recommended as they have been shown to rapidly improve suicidal ideation symptoms within 24 hours and last for at least 1 week 1.
Key Considerations
- The benefits of ketamine infusions for suicidal ideation have been demonstrated in multiple studies, with a meta-analysis showing that 55% of patients who received ketamine reported no suicidal ideation after 24 hours and 60% reported that they were no longer having suicidal ideations at 7 days 1.
- Lithium and clozapine may also have a role in reducing suicidal behaviors, but their use is more complex and may be limited by side effects and monitoring requirements 1.
- Non-pharmacologic interventions, such as cognitive behavioral therapy (CBT), can also be effective in reducing suicidal ideation and behavior, but may not provide the rapid relief offered by ketamine infusions 1.
Treatment Approach
- Ketamine infusions should be considered as a first-line treatment for acute management of depression with suicidal ideation, particularly in patients who are at high risk of harm to themselves.
- Close monitoring is essential, particularly in the first weeks of treatment, and regular follow-up appointments (at least weekly initially) are crucial to assess response and adjust treatment.
- Any patient with active suicidal ideation should be evaluated for possible hospitalization for safety.
- Other medications, such as benzodiazepines or low-dose antipsychotics, may be considered as adjunctive treatments, but should be used with caution and tapered once the SSRI begins working due to their potential risks and side effects.
From the Research
Medication Options for Acute Depression with Suicidal Ideation
- Quetiapine has been shown to reduce irritability and risk of suicide in patients with agitated depression, with rapid improvement in symptoms 2.
- Olanzapine combined with lithium or divalproex has been found to reduce suicidal ideation in bipolar I disorder mixed-episode patients 3.
- Antipsychotics, such as clozapine, have been effective in managing suicidal ideation in schizophrenia patients, with a significant decrease in suicidal ideation severity over time 4.
Considerations for SSRI Treatment
- SSRI treatment has been associated with a lower risk of treatment-emergent suicidal ideation compared to interpersonal psychotherapy (IPT) 5.
- However, it is essential to monitor patients closely, as worsening of suicidal ideation can occur, especially in patients with a history of suicidal attempts 5.
Psychotherapy and Treatment Efficacy
- Empirically supported treatments (ESTs) for depression can lead to significant reductions in both depressive symptoms and suicidal ideation, even in patients with suicidal ideation at baseline 6.
- The relationship between suicidal ideation at baseline and depression scores at follow-up has been found to be non-significant, suggesting that suicidal ideation does not limit the efficacy of ESTs for depression 6.