What's the next step for a patient with increased anxiety and suicidal ideation after an EMDR session, currently taking Celexa (citalopram) 40 mg daily, Klonopin (clonazepam) 1 mg twice a day, and Latuda (lurasidone) 40 mg daily?

Immediate Management of Suicidal Ideation After EMDR Session

This patient requires immediate structured suicide risk assessment and hospitalization should be strongly considered given the acute emergence of suicidal ideation following EMDR, particularly in the context of borderline features and complex psychiatric comorbidity. 1, 2

Critical Safety Assessment (Within 24-48 Hours)

Perform an immediate structured suicide risk assessment focusing on:

• Current frequency and intensity of suicidal thoughts - specifically whether she has a desire to die, a plan, access to lethal means, and timeline for acting 1, 2
• Ability to engage in safety planning and adequacy of social support system - patients who cannot engage in safety discussions or lack adequate support require hospitalization 1, 2
• Severity of agitation and irritability - these symptoms increase acute risk and may indicate need for inpatient stabilization 2
• History of previous suicide attempts - this substantially increases risk for future attempts 1, 3

Hospitalize if: she expresses clear desire to die, cannot engage in safety discussions, lacks adequate support, or shows severe agitation. 2

Understanding EMDR-Related Symptom Exacerbation

• Session-to-session exacerbations in suicidal thoughts occur in 28% of patients receiving EMDR, but importantly, 43.5% of patients experience exacerbations while on waitlist (no therapy), suggesting EMDR is actually safer than no intervention 4
• Continuation of therapy following exacerbation led to decrease in suicidal thoughts in most patients - premature discontinuation is the greater risk 4
• EMDR shows promise for reducing suicidal ideation when targeting experiences associated with suicidal thinking, with preliminary evidence showing reductions in SI, depression, and anxiety 5, 6

However, this patient's acute decompensation requires stabilization before resuming EMDR.

Immediate Medication Management

Increase Celexa (citalopram) to 60 mg daily immediately - approximately 38% of patients fail to respond at initial SSRI doses, and dose optimization is critical before considering medication switches. 7

• The current 40 mg dose is subtherapeutic for many patients - allow 6-8 weeks at 60 mg before declaring treatment failure 7
• Monitor closely for treatment-emergent suicidality in the first 1-2 weeks after dose increase, as all SSRIs carry FDA black box warnings 7, 8, 9
• Dispense only 7-14 days of medication at a time to reduce overdose risk 2

Critical Safety Concern with Current Regimen

• Citalopram carries specific warnings about QT prolongation, particularly at doses above 40 mg in patients over 60 or with cardiac risk factors - obtain baseline EKG before increasing dose 8
• The combination of Celexa, Klonopin, and Latuda increases risk for serotonin syndrome - monitor for mental status changes, autonomic instability, neuromuscular symptoms 8
• Latuda (lurasidone) carries FDA warnings about increased suicidal thoughts in young adults and may be contributing to current presentation 9

Benzodiazepine Consideration

• Klonopin (clonazepam) should be avoided or tapered in suicidal patients - benzodiazepines may reduce self-control and disinhibit some individuals, leading to increased suicide attempts 7
• Consider replacing with short-term hydroxyzine or gabapentin for anxiety management during acute crisis 7

Collaborative Crisis Response Plan (Mandatory)

Develop a written crisis response plan that includes:

• Identification of clear warning signs - specific behavioral, cognitive, affective, or physical signs that precede suicidal urges 1, 2
• Self-management skills - concrete steps she can take to distract from stressors (e.g., calling specific friend, going to specific location, using specific coping skill) 1, 2
• Social support contacts - names and phone numbers of friends/family members who have helped in past crises 1, 2
• Professional crisis resources - your direct contact, crisis line (988), emergency department instructions 1, 2
• Lethal means restriction - remove firearms from home, lock up medications (especially the Klonopin and Celexa), restrict alcohol access 10

This is not optional - crisis response planning reduces suicide attempts with a number needed to treat that favors this intervention. 1

Psychotherapy: First-Line Treatment for Underlying Pathology

Initiate Dialectical Behavior Therapy (DBT) immediately - this is the evidence-based treatment specifically developed for patients with borderline features and suicidal behavior. 1, 10

• DBT combines CBT elements, skills training, and mindfulness to develop emotion regulation, interpersonal effectiveness, and distress tolerance 1, 10
• DBT reduces suicidal ideation and repetition of self-directed violence by more than 50% compared to treatment as usual in patients with borderline personality disorder 1
• Cognitive Behavioral Therapy focused on suicide prevention is an acceptable alternative if DBT unavailable, as it also reduces suicide attempts by 50% 1, 2

Pause EMDR temporarily until she stabilizes on optimized medication and establishes DBT skills - resuming trauma processing while acutely suicidal is contraindicated. 4

Follow-Up Strategy (Non-Negotiable)

• See her within 48-72 hours to assess response to medication increase and safety 2
• Continue weekly visits for the first month, then biweekly as she stabilizes 2
• Send periodic caring communications (texts or calls) for 12 months - this simple intervention reduces suicide attempts 1, 2, 10
• Contact her immediately if she misses any appointment - greatest risk for reattempting suicide occurs in months after initial crisis 10

Alternative Medication Strategy (If No Response After 6-8 Weeks at Celexa 60 mg)

• Switch to sertraline 50-200 mg daily - one in four patients becomes symptom-free after switching SSRIs 7
• Consider venlafaxine extended-release 75-225 mg daily - may have better response rates specifically for depression with prominent anxiety symptoms 7
• For severe, treatment-resistant suicidal ideation with major depression, consider ketamine infusion (0.5 mg/kg single dose) for rapid short-term reduction, with benefits beginning within 24 hours and lasting up to one week 1, 10

Common Pitfalls to Avoid

• Do not discontinue EMDR permanently based on one exacerbation - research shows continuation after exacerbation leads to improvement in most patients 4
• Do not rely solely on medication - combination of psychotherapy (DBT or CBT) plus medication is superior to either alone 7, 2
• Do not prescribe tricyclic antidepressants - they are highly lethal in overdose and should never be given to suicidal patients 7, 10
• Do not switch medications prematurely - allow full 6-8 weeks at therapeutic dose (60 mg citalopram) before declaring treatment failure 7