I’m taking desvenlafaxine (Pristiq) for depression and recently started systemic steroids, and now have suicidal thoughts—what should I do?

Immediate Action Required: This is a Psychiatric Emergency

You must seek immediate emergency psychiatric evaluation—call 911, go to the nearest emergency department, or contact the National Suicide Prevention Lifeline at 988 right now. The combination of desvenlafaxine (Pristiq) and systemic steroids has created a potentially dangerous situation requiring urgent professional assessment. 1, 2

Why This is Urgent

Dual Risk from Both Medications

• Desvenlafaxine carries an FDA black-box warning for increased risk of suicidal thoughts and behaviors, with the highest risk occurring during the first few months of treatment and after dose changes. 1, 3

• Systemic corticosteroids independently precipitate suicidal behavior, particularly in patients with underlying or undiagnosed depression. A longitudinal study demonstrated a positive correlation between corticosteroid treatment and suicidal behavior, with approximately 5.7% of corticosteroid-treated patients developing severe psychiatric disorders. 2

• The combination creates compounded risk: You are experiencing suicidal thoughts while taking two medications that each independently increase suicide risk—this represents a medical emergency requiring immediate intervention. 1, 2

Critical Time Window

• The risk for suicide attempts is greatest during the first 1-2 months of antidepressant treatment, with the highest danger in the first 1-9 days. 4, 3

• Corticosteroid-induced psychiatric effects typically emerge within 2 weeks of treatment initiation, as documented in case reports of steroid-induced suicidal behavior. 2

What Your Treatment Team Must Do Immediately

Urgent Assessment Requirements

• Direct evaluation for suicidal ideation severity: Your clinician must assess whether you have specific plans, intent, access to means, and timeline for self-harm. 5, 3

• Screen for medication-induced akathisia: This is a state of inner restlessness and motor agitation that has been directly linked to antidepressant-induced suicidality and can be mistaken for worsening depression. Ask specifically if you feel unable to sit still, have an inner sense of restlessness, or feel compelled to pace. 5, 6, 7

• Assess for other warning signs that indicate the depression or medication effects are worsening: increased anxiety, panic attacks, agitation, aggressiveness, impulsivity, insomnia, irritability, or any sense of disinhibition. 1, 3

Medication Management Decisions

For the desvenlafaxine:

• If suicidal ideation is severe, new-onset, or associated with akathisia, temporary discontinuation of desvenlafaxine should be strongly considered. However, this must be done under close medical supervision as abrupt discontinuation can cause serious withdrawal effects. 5, 1

• If ideation is mild to moderate, more frequent monitoring (potentially daily contact) may be appropriate while continuing the medication, but this decision requires in-person psychiatric evaluation. 5

For the corticosteroids:

• Treatment discontinuation should not be done systematically, but tapering should be considered in combination with psychiatric intervention. The underlying medical condition requiring steroids must be weighed against psychiatric risk. 2

• If steroids must be continued, close psychiatric monitoring and possible addition of mood-stabilizing medication may be necessary. 2

Safety Planning (Required Immediately)

• Remove all lethal means from your environment: firearms, large quantities of medications (including the Pristiq and steroids themselves), sharp objects, and other potential methods of self-harm. 5

• Establish 24-hour third-party monitoring: Family members or caregivers must be informed of the situation and instructed to watch for any worsening mood changes, increased agitation, or emergent suicidal thoughts. 5, 3

• Create emergency contacts: Program the 988 Suicide & Crisis Lifeline, your psychiatrist's emergency number, and local emergency services into your phone. 5

• Avoid medications that reduce self-control: Benzodiazepines (Xanax, Ativan, Valium, etc.) should be strictly avoided as they can disinhibit some individuals and potentially worsen suicidal impulses. 5, 6

Critical Context About These Medications

The Desvenlafaxine Black-Box Warning

• The absolute increase in suicidal ideation or behavior with antidepressants like desvenlafaxine is approximately 0.7% higher than placebo (2.7% vs 2.0%). 3

• No completed suicides occurred in over 4,400 youth participants across 24 clinical trials of antidepressants, though the adult data shows rare but real risk. 3, 8

• One completed suicide did occur during desvenlafaxine treatment in pooled adult trials of 1,834 patients, though causality cannot be definitively established. 8

The Corticosteroid Risk

• Corticosteroids can precipitate suicidal behavior in patients with premorbid undiagnosed depressive disorders, with effects typically emerging within 2 weeks of high-dose treatment. 2

• The mechanism appears to involve direct neurobiological effects on mood regulation, not simply "unmasking" of pre-existing depression. 2

• Early detection of psychiatric disorders before starting corticotherapy is essential but often missed in clinical practice. 2

Common Pitfalls to Avoid

• Do not assume these thoughts will pass on their own: The combination of two medications that independently increase suicide risk requires active intervention, not watchful waiting. 1, 2

• Do not stop either medication abruptly without medical supervision: Desvenlafaxine discontinuation can cause serious withdrawal symptoms, and stopping steroids suddenly can cause adrenal crisis depending on dose and duration. 1

• Do not accept reassurance that "this is just your depression talking": Medication-induced suicidality is a distinct phenomenon from disease-related suicidal ideation and requires different management. 5, 7

• Do not delay seeking help because you feel you should "tough it out": The risk of not seeking immediate care far exceeds any perceived stigma or inconvenience. 3

What Happens Next

After emergency evaluation, your treatment team will likely:

• Determine whether hospitalization is necessary based on severity of suicidal ideation, presence of plan/intent, and adequacy of outpatient support. 5

• Modify your medication regimen, potentially discontinuing or tapering the desvenlafaxine, adjusting the steroid dose/schedule, or adding protective medications. 5, 2

• Establish intensive outpatient monitoring if you are not hospitalized, with contact within 1 week and then regularly throughout the first few months. 3, 6

• Consider alternative treatments for your depression that may carry lower acute risk in the context of concurrent steroid use. 4

Again: This requires immediate emergency evaluation. Call 988, go to the emergency department, or call 911 now. Do not wait.