What should be included in a patient's assessment and safety plan when onboarding an antidepressant, considering their demographic information, past medical history, and comorbidities?

Safety Assessment and Plan When Initiating Antidepressant Therapy

Your assessment and plan must prioritize suicide risk monitoring, particularly during the first 1-2 months of treatment, as SSRIs are associated with increased nonfatal suicide attempts (odds ratio 2.25) and the risk is greatest early in treatment. 1, 2

Baseline Safety Assessment

Suicide Risk Evaluation

• Document current suicidal ideation, intent, plan, and access to means at every visit, with heightened vigilance during initial treatment and dose adjustments 2, 3
• Screen for risk factors including prior suicide attempts, family history of suicide, bipolar disorder, substance use, and recent psychosocial stressors 2
• Establish a safety plan with emergency contacts and crisis resources before prescribing 2

Medical Contraindications and Drug Interactions

• Review all current medications for serotonergic agents (triptans, tramadol, MAOIs) to prevent serotonin syndrome, which requires immediate hospitalization if advanced symptoms develop 2
• Screen for bleeding risk factors if patient takes NSAIDs, aspirin, or warfarin, as SSRIs increase bleeding risk when combined with these agents 2
• Assess cardiovascular history, particularly for venlafaxine (increased cardiovascular events) and escitalopram doses >20mg (QT prolongation) 1
• Document seizure history if considering bupropion (increased seizure risk) and hepatic function if considering nefazodone (hepatotoxicity risk) 1

Comorbidity Screening

• Screen for bipolar disorder history, as antidepressants can precipitate mania without mood stabilizer coverage 2
• Assess for substance use disorders that may interfere with treatment adherence 4
• In diabetic patients, monitor for depression recurrence as this population has elevated rates requiring ongoing surveillance 1

Safety Plan Documentation

Monitoring Schedule

• Schedule follow-up within 1-2 weeks of initiation, then every 2-4 weeks during dose titration, then monthly once stable 4, 2
• Use standardized depression scales (PHQ-9) at each visit to objectively track response 4

Patient and Family Education (FDA-Mandated)

• Provide the FDA Medication Guide and review it with patient and family members present 2
• Instruct patient and caregivers to monitor daily for: new or worsening anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, mania, worsening depression, and suicidal ideation 2
• Emphasize these symptoms may be abrupt in onset and require immediate contact with prescriber 2
• Warn against abrupt discontinuation without medical supervision due to discontinuation syndrome risk 2

Specific Adverse Effect Monitoring

• Common side effects to anticipate and document: nausea (most common reason for discontinuation), vomiting, constipation, diarrhea, dizziness, headache, insomnia, sexual dysfunction, and somnolence 1
• Paroxetine specifically carries higher sexual dysfunction risk and should be avoided in older adults 1
• Monitor for behavioral activation/agitation, particularly in younger patients, supporting gradual dose titration 5

Treatment Response Timeline

• Document that full response requires 6-8 weeks at therapeutic dose before declaring treatment failure 4, 3
• Plan to reassess and modify treatment if inadequate response after 6-8 weeks 4

Critical Safety Documentation

Assessment Section

• Current suicidal ideation: present/absent, with severity rating
• Prior suicide attempts and psychiatric hospitalizations
• Complete medication list with attention to serotonergic agents, anticoagulants, and CYP2D6 substrates
• Cardiovascular risk factors, seizure history, hepatic function
• Bipolar screening results
• Baseline depression severity score (PHQ-9)
• Patient and family understanding of warning signs

Plan Section

• Specific antidepressant chosen with rationale based on adverse effect profile, drug interactions, and patient preference 1
• Starting dose (typically subtherapeutic "test dose" to minimize initial activation) with titration schedule 5
• Follow-up interval (1-2 weeks initially) 4, 2
• Emergency contact plan and crisis resources provided
• FDA Medication Guide provided and reviewed
• Family/caregiver education completed
• Plan for reassessment at 6-8 weeks 4
• Duration of continuation therapy after remission: minimum 6-12 months for first episode, longer for recurrent depression 4, 3

Common Pitfalls to Avoid

• Never prescribe antidepressants without establishing suicide risk monitoring protocol, as the increased risk of nonfatal suicide attempts with SSRIs is well-documented 1
• Do not combine multiple serotonergic agents without careful risk-benefit analysis due to serotonin syndrome risk 2
• Avoid declaring treatment failure before 6-8 weeks at therapeutic dose 4, 3
• Do not omit family/caregiver education, as they are essential for monitoring day-to-day behavioral changes 2