What if a patient with depression starts to experience suicidal thoughts?

Immediate Management of Suicidal Thoughts in Depression

A patient with depression who develops suicidal thoughts requires immediate safety assessment, close monitoring with weekly follow-up within 1-2 weeks, initiation of cognitive behavioral therapy focused on suicide prevention, and consideration of pharmacological interventions—with the understanding that patients with major depressive disorder face an 8.62-fold increased risk of death by suicide compared to the general population, with the highest risk occurring in the first year of treatment. 1, 2

Immediate Safety Assessment and Disposition

Assess imminent risk factors including intent and means, severity of psychiatric illness, presence of psychosis or hopelessness, lack of personal resources, and history of prior suicide attempts. 3

• Hospitalize immediately if there is imminent risk, active intent with plan, severe psychiatric illness with psychosis, or lack of adequate support systems. 3, 4
• Remove access to lethal means, particularly firearms, which must either be removed from the home or locked to prevent access. 5
• Do not leave the patient alone during transport to hospital or during initial evaluation. 3

Monitoring Protocol

Implement structured surveillance with weekly monitoring within 1-2 weeks of treatment initiation or any medication dose changes, as this represents the highest-risk period. 2, 6, 7

• The first year following diagnosis or hospital discharge carries the greatest suicide risk, requiring vigilant monitoring, support, and assistance to ensure overall well-being. 1
• Document at each visit: medication adherence, duration of current depressive episode, social support availability, and emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, or akathisia. 6, 8
• Implement caring communications such as brief, supportive postal mail or text messages sent at regular intervals over 12 months, which reduces suicide attempts by 43%. 2

Pharmacological Management

Initiate a second-generation antidepressant (SSRI or SNRI) as first-line treatment, with selection based on adverse effect profiles rather than efficacy, as no single agent demonstrates superior effectiveness. 2

• SSRIs (particularly fluoxetine) are preferred for unipolar depression with suicidal features due to lower lethality in overdose compared to tricyclic antidepressants. 1, 9
• Critical FDA warning: SSRIs increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (ages 18-24), with 14 additional cases per 1000 patients treated in those under 18, and 5 additional cases per 1000 in ages 18-24. 7, 8
• Adults beyond age 24 show no increased risk, and adults 65 and older show 6 fewer cases of suicidality per 1000 patients treated compared to placebo. 7, 8

Consider lithium augmentation or monotherapy, which has the strongest historical evidence for suicide prevention in mood disorders and should be titrated to therapeutic serum levels of 0.8-1.2 mEq/L. 9, 5

Avoid medications that may worsen outcomes:

• Tricyclic antidepressants due to high lethality in overdose. 1, 9
• Benzodiazepines, which may reduce self-control and potentially disinhibit some individuals, leading to increased aggression or suicide attempts. 1, 9

Psychotherapeutic Interventions

Initiate cognitive behavioral therapy (CBT) focused on suicide prevention immediately, as it demonstrates the strongest evidence for reducing suicide attempts in patients with recent suicidal behavior and decreasing suicidal ideation, cutting suicide attempt risk by half compared to treatment as usual. 9, 2, 6

• CBT should be added to pharmacotherapy rather than used as monotherapy in acute suicidality. 2
• Most effective CBT protocols involve fewer than 12 sessions. 9

Rapid Intervention for Severe Cases

For patients requiring rapid reduction of suicidal ideation, ketamine infusion (0.5 mg/kg over 40 minutes) shows improvement within 24 hours, though evidence remains preliminary with limitations including small sample sizes and unclear long-term maintenance of antisuicidal effects. 9, 2, 6

Treatment Duration and Follow-Up

Continue antidepressant treatment for 4-9 months after achieving satisfactory response in first-episode major depression. 2

• For patients with two or more depressive episodes, extend treatment duration beyond 9 months. 2
• Do not prematurely discontinue or switch antidepressants before completing adequate 6-8 week trials, as inadequate treatment duration is a modifiable risk factor for persistent suicidality. 2

High-Risk Populations Requiring Enhanced Monitoring

Women with major depression face 9.40 times higher odds of death by suicide compared to the general population, requiring particularly close monitoring. 1, 2, 6

Additional high-risk factors include:

• History of suicide attempts, which substantially increases risk of death by suicide. 1
• Comorbid substance use disorders or anxiety disorders. 1, 6
• Financial difficulties, legal problems, unemployment, or interpersonal conflicts. 1
• Postpartum depression with self-harm (70-fold increased risk). 1
• Early age of onset, family history, psychotic symptoms, or treatment resistance. 6

Common Pitfalls to Avoid

Be particularly vigilant for akathisia during early SSRI treatment, as fluoxetine-induced akathisia has been associated with emergence of suicidal ideation. 1

Social support is protective: A recent meta-analysis demonstrated that social support reduces suicide attempts and deaths in both major depressive disorder and bipolar disorder, with notable efficacy among female and adult patients. 1

The relationship between antidepressants and suicidality is complex: While SSRIs increase suicidality risk in younger patients during initial treatment, there is substantial evidence that antidepressants can delay recurrence of depression in longer-term use. 7, 8