What is the appropriate management for a 52-year-old patient with a history of adjustment disorder and overactive bladder, currently taking Lexapro (escitalopram), who reports suicidal ideation without a plan, and has refused a crisis assessment and safety plan?

From the Guidelines

The patient requires immediate mental health intervention due to passive suicidal ideation, and a comprehensive approach including medication adherence, safety planning, and regular follow-up with her mental health provider is essential to reduce her suicide risk. The patient is a 52-year-old woman with adjustment disorder and overactive bladder, currently taking Lexapro which she reports is helpful, but there appears to be medication adherence issues as her last prescription pickup was January 17,2025, for a 30-day supply. She mentions using medication from Mexico and stopping medications during antibiotic treatment. The patient refused crisis services from Star Care and declined to complete a safety plan, though she identified her children as protective factors. She is currently seeing a psychiatrist named Rachel and had counseling a few weeks ago.

Key Considerations

• The patient's passive suicidal ideation, although without a plan or intent to harm herself, necessitates careful monitoring and intervention to prevent escalation of suicidal thoughts 1.
• Medication adherence is crucial, and the patient should be educated on the importance of consistent medication use, including during antibiotic treatment, to minimize the risk of suicidal ideation 1.
• Safety planning is a critical component of suicide prevention, and the patient's refusal to complete a safety plan should be addressed through gentle persuasion and education on its benefits 1.
• Regular follow-up with her mental health provider, including her psychiatrist and counselor, is essential to monitor her suicide risk and adjust her treatment plan as needed 1.

Recommendations

• Prompt follow-up with her mental health provider to assess her suicide risk and adjust her treatment plan accordingly.
• Clarification of her medication regimen, including education on the importance of consistent medication use and potential interactions with other medications.
• Continued assessment of her suicide risk with appropriate safety planning, including the development of a crisis response plan.
• Encouragement to complete a safety plan, with emphasis on its benefits in reducing suicide risk.
• Regular monitoring of her mental health status, including her suicidal ideation, and adjustment of her treatment plan as needed to ensure her safety and well-being.

From the FDA Drug Label

1. 1 Suicidal Thoughts and Behaviors in Adolescents and Young Adults In pooled analyses of placebo-controlled trials of antidepressant drugs (SSRIs and other antidepressant classes) that included approximately 77,000 adult patients and 4,500 pediatric patients, the incidence of suicidal thoughts and behaviors in the antidepressant-treated patients age 24 years and younger was greater than in placebo-treated patients. Monitor all antidepressant-treated patients for any indication for clinical worsening and emergence of suicidal thoughts and behaviors, especially during the initial few months of drug therapy, and at times of dosage changes.

The patient is a 52-year-old, and according to the provided text, the risk of suicidal thoughts and behaviors is decreased in patients ≥65 years old (6 fewer patients) and there is 1 fewer patient in the 25 to 64 years old range. Given the patient's age and the information provided, monitoring for suicidal thoughts and behaviors is still necessary, especially since the patient has reported having thoughts of "I wonder what it would be like without me". Counseling the patient and monitoring for changes in behavior is recommended, as well as considering changing the therapeutic regimen if the patient's depression worsens or if suicidal thoughts or behaviors emerge 2.

From the Research

Patient's Condition and Treatment

• The patient has a past medical history of adjustment disorder and overactive bladder, and is currently taking Lexapro, which she reports helps her condition 3, 4.
• The patient was started on Lexapro but was told to stop all her other medication when taking antibiotics, and has been seeing a psychiatrist 3, 4.
• The patient reports having thoughts of "I wonder what it would be like without me" but has never thought of a plan or acted on a plan, and these thoughts mostly occur at night 5, 6.

Suicidal Ideation and Risk Assessment

• The patient's thoughts of suicidal ideation are a concern, and the nursing staff attempted to fill out a safety plan, but the patient refused, indicating that her kids are a main reason she would never hurt herself 5, 6.
• The patient was given a Star Care number for a crisis assessment but refused to call, and instead will follow up with Rachel 5, 6.
• The decision to hospitalize patients at imminent risk for suicide requires careful assessment of risk factors, including sociodemographic, psychiatric, general medical, and mental status considerations 5.

Pharmacotherapy and Treatment Options

• Pharmacotherapy interventions, such as antidepressants, benzodiazepines, and etifoxine, may be considered for adjustment disorder, especially in cases with severe symptoms or suicidal ideation 4, 7.
• Psychotherapy interventions, such as cognitive behavioral therapy, mindfulness, and bibliotherapy, may also be effective for mildly symptomatic adjustment disorder 4.
• The patient's current treatment with Lexapro may be beneficial, but additional treatment options or adjustments to her current regimen may be necessary to address her ongoing symptoms and suicidal ideation 3, 4, 7.