Adjunctive Treatment for Suicidal Ideation in Patients Already on Antidepressants
For a patient with suicidal ideation already taking an antidepressant, ketamine infusion (0.5 mg/kg over 40 minutes) is the best adjunctive treatment for rapid reduction of acute suicidal crisis, providing relief within 24 hours to 1 week, while increasing Abilify from 5 to 10 mg is NOT supported by evidence for treating suicidal ideation specifically. 1, 2
Why Ketamine is the Preferred Adjunct
The 2024 VA/DoD guidelines suggest offering ketamine infusion as adjunctive treatment for short-term reduction in suicidal ideation in patients with major depressive disorder and active suicidal thoughts (weak for recommendation). 1
Ketamine produces rapid antisuicidal effects within 24 hours, with benefits lasting 1-6 weeks, making it uniquely suited for acute suicidal crisis while other interventions take effect. 1, 2
Unlike standard antidepressants that require 4-6 weeks for full effect, ketamine's rapid onset addresses the immediate mortality risk that defines suicidal emergencies. 1
Why Aripiprazole Dose Increase is NOT Recommended for Suicidal Ideation
There is no evidence supporting aripiprazole (Abilify) for treatment of suicidal ideation in depression. The FDA approval for aripiprazole covers schizophrenia, bipolar disorder, and adjunctive treatment of major depressive disorder, but none of these indications include suicidal ideation as a target symptom. 3
In the VAST-D trial examining next-step antidepressant treatments, augmentation with aripiprazole (A-ARI) was actually associated with LESS reduction in suicidal ideation compared to switching or combining with bupropion. 4
Aripiprazole's mechanism as a dopamine partial agonist does not target the neurotransmitter systems most implicated in acute suicidality (primarily serotonergic and glutamatergic pathways). 1, 5
Evidence-Based Adjunctive Strategies Beyond Ketamine
Lithium Augmentation for Long-Term Prevention
Lithium has the strongest evidence for reducing suicide risk in mood disorders over the long term, though it does not provide acute relief in the immediate crisis. 1, 5
The 2024 VA/DoD guidelines note insufficient evidence to recommend for or against lithium specifically for reducing suicide attempts, representing a downgrade from previous recommendations, but older literature consistently supports its long-term protective effects. 1
Clozapine for Schizophrenia Spectrum Only
The 2024 VA/DoD guidelines suggest clozapine to reduce suicide attempts specifically for patients with schizophrenia or schizoaffective disorder and suicidal ideation (weak for recommendation). 1
Clozapine has FDA approval for "reducing the risk of recurrent suicidal behavior" but only in schizophrenia/schizoaffective disorder, NOT mood disorders, and does not provide acute relief. 1, 5
Cognitive Behavioral Therapy
- CBT focused on suicide prevention reduces suicidal ideation and cuts suicide attempt risk by half compared to medication alone, making it an essential adjunct regardless of medication choices. 6, 2
Critical Safety Monitoring Required
Implement weekly face-to-face or phone contact for the next 4 weeks, as suicide risk is highest during the first 10-14 days after any antidepressant treatment change, particularly in patients under age 24. 7, 8
Assess immediately for akathisia (inner restlessness, inability to sit still), as this medication-induced side effect can directly drive suicidal urges and requires immediate intervention if present. 6, 2, 9
Implement lethal means restriction counseling, including removing firearms from the home, locking up all medications, and securing other potentially lethal means—this intervention alone reduces suicide risk significantly. 6
Create a structured safety plan identifying warning signs, coping strategies, designated support persons, and emergency contacts—this reduces suicidal behavior with a number needed to treat of 16. 6
Optimizing the Current Antidepressant First
Before adding any adjunct, ensure the current antidepressant is optimized:
Verify medication adherence through pharmacy records and patient interview, as approximately 38% of patients fail to respond to initial SSRI doses, but non-adherence must be ruled out before adding medications. 7
If the patient has been on an adequate dose for 6-8 weeks without response, consider switching to a different antidepressant class (such as an SNRI like venlafaxine) rather than augmenting with aripiprazole. 7, 4
Serotoninergic antidepressants (SSRIs/SNRIs) have neutral or mildly protective effects on suicidal behavior, while noradrenergic agents may have activating effects that could worsen suicidal ideation in certain illness phases. 5
Common Pitfalls to Avoid
Do not use aripiprazole as an antisuicidal agent—while it is FDA-approved for adjunctive treatment of depression, this does not translate to efficacy for suicidal ideation specifically. 3, 4
Do not prescribe benzodiazepines for anxiety or agitation, as they may reduce self-control and potentially increase suicide attempts through disinhibition. 1, 6, 2
Do not assume the black box warning means antidepressants cause suicide—evidence shows antidepressants reduce suicidal thoughts overall in mood disorders, but careful monitoring during the first 2 weeks is mandatory. 7, 8
Do not discharge to outpatient care without intensive follow-up structure—weekly contact is mandatory for the first month given acute suicidality. 7, 6