How do Psychiatric Mental Health Nurse Practitioners (PMHNPs) manage depression, anxiety, and suicidal ideation exacerbated by job loss?

From the Guidelines

Psychiatric Mental Health Nurse Practitioners (PMHNPs) should prioritize a comprehensive approach combining medication management and therapeutic interventions, including cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT), to treat depression, anxiety, and suicidal ideation exacerbated by job loss, as supported by the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines 1.

When treating patients experiencing these conditions following unemployment, PMHNPs should consider the following key elements:

• Medication management: First-line medications for depression often include SSRIs such as sertraline (50-200mg daily), escitalopram (10-20mg daily), or fluoxetine (20-80mg daily), typically requiring 4-6 weeks for full effect and continued for at least 6-12 months after symptom resolution.
• Therapeutic interventions: CBT and DBT have been shown to be effective in reducing suicidal ideation and behavior, with CBT cutting the risk for a posttreatment suicide attempt in half compared with treatment as usual 1.
• Crisis response planning: A collaborative approach between patient and clinician, including a semi-structured interview, identification of clear signs of crisis, and review of crisis resources, can help reduce the number and proportion of suicide attempts 1.
• Regular follow-up appointments: Weekly initially, then biweekly to monthly, to monitor treatment response, adjust medications as needed, and provide ongoing support during this vulnerable period.

The use of problem-solving therapy, a type of CBT, and Window to Hope (WtoH), a problem-solving treatment, may also be beneficial for patients at risk for suicide, particularly those with moderate to severe traumatic brain injury 1. Additionally, periodic caring communications, such as postcards or letters, after a psychiatric hospitalization for suicidal ideation or a suicide attempt, have been shown to lower rates of suicide death, attempts, and ideation 1.

Key considerations for PMHNPs include:

• Removing access to lethal means and establishing emergency contacts for patients with suicidal ideation
• Providing supportive therapy focusing on coping strategies, cognitive restructuring, and practical guidance for job searching and financial management
• Collaborating with patients to identify clear signs of crisis and develop a crisis response plan
• Regularly reviewing and adjusting treatment plans to ensure optimal outcomes and minimize the risk of suicide.

From the FDA Drug Label

WARNINGS Clinical Worsening and Suicide Risk — Patients with major depressive disorder (MDD), both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior, whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have been reported in adult and pediatric patients being treated with antidepressants for major depressive disorder as well as for other indications, both psychiatric and nonpsychiatric

Key Considerations:

• Patients with major depressive disorder (MDD) may experience worsening of their depression and/or the emergence of suicidal ideation and behavior.
• Antidepressants, such as fluoxetine, may increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (ages 18-24) with MDD and other psychiatric disorders.
• Monitoring is crucial for patients being treated with antidepressants, especially during the initial few months of treatment or at times of dose changes.
• Symptoms to watch for include anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, and mania. 2

From the Research

Treatment of Depression, Anxiety, and Suicidal Ideation

• PMHNPs treat conditions such as depression, anxiety, and suicidal ideation, which can be worsened by job loss.
• Studies have shown that internet-based cognitive behavioral therapy (iCBT) can be effective in reducing suicidal ideation and depression severity 3.
• Additionally, interpersonal therapy (IPT) and medication have been found to be effective in reducing suicidal ideation, although these effects may be largely due to their impact on depression 4.

Effects of Treatment on Depression and Anxiety

• iCBT has been associated with significant reductions in depression severity, but not anxiety or hopelessness 3.
• A study on adolescent depression found that combined cognitive-behavioral therapy and pharmacotherapy (COMB) was effective in reducing depression and suicidal ideation, but the benefits of COMB over monotherapy are not universally supported 5.
• Another study found that antidepressant medications can reduce suicidal ideation, even among patients who do not respond to the medication overall 6.

Suicidal Ideation and Treatment

• Suicidal ideation is a complex phenomenon that can be influenced by various factors, including depression, hopelessness, and mental disorders 7.
• The ideation-to-action framework suggests that the development of suicidal ideation and the progression from ideation to suicide attempts are distinct phenomena with distinct explanations and predictors 7.
• Means restriction has been found to be an effective way to block progression from ideation to attempt 7.