I’m taking Pristiq (desvenlafaxine) and 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—either call 911, go to the nearest emergency department, or contact the National Suicide Prevention Lifeline at 988—because the combination of Pristiq (desvenlafaxine) and systemic steroids has triggered suicidal thoughts that require urgent professional assessment and intervention. 1

Why This Combination Is Dangerous

Desvenlafaxine carries an FDA black-box warning for increased risk of suicidal thoughts and actions, particularly when treatment is started or doses are changed. 1 The addition of systemic corticosteroids creates a perfect storm:

• Steroids can independently trigger psychiatric symptoms including agitation, mood instability, psychosis, and suicidal ideation through multiple mechanisms including disruption of neurotransmitter systems 2
• The temporal relationship between starting steroids and developing suicidal thoughts strongly suggests a medication-induced crisis 1
• Desvenlafaxine's most common adverse events include suicidal ideation, and this risk is heightened during the first few months of treatment or when other medications alter brain chemistry 3

Critical Warning Signs Requiring Emergency Evaluation

Call 911 or go to the emergency department immediately if you have: 1

• Active thoughts about suicide or dying
• A specific plan for how you would end your life
• Access to means (firearms, medications, other lethal methods)
• Feeling that you cannot keep yourself safe
• New or worsening agitation, restlessness, or inability to sit still (akathisia)
• Feeling aggressive, angry, or violent
• Acting on dangerous impulses
• Extreme increase in activity or racing thoughts
• Panic attacks or severe anxiety

What Emergency Providers Will Do

Emergency psychiatric evaluation will assess your immediate safety and determine whether hospitalization is needed based on: 4

• Intent: Do you want to die, or are the thoughts unwanted intrusions?
• Plan: Have you thought through specific methods?
• Means: Do you have access to lethal methods?
• Previous attempts: Any history of self-harm or suicide attempts increases risk
• Current mental state: Presence of agitation, psychosis, hopelessness, or severe mood symptoms
• Support system: Who can monitor you and ensure safety?

Medication Management Strategy

The emergency team will likely: 2, 5

1. Evaluate whether desvenlafaxine should be continued, adjusted, or discontinued based on when you started it and your symptom timeline 1
2. Assess the steroid regimen to determine if dose reduction, tapering, or discontinuation is possible without compromising the medical condition being treated 2
3. Screen for akathisia (inner restlessness that can directly drive suicidal urges), which requires immediate medication changes 2, 6
4. Ensure all medications are controlled by a responsible third party (family member or caregiver) who dispenses them and monitors for behavioral changes 2, 5

Evidence-Based Safety Interventions

If you are evaluated and deemed safe for outpatient management, the following interventions reduce suicidal behavior by 43% (number needed to treat = 16): 4

Safety Planning Components 4, 5

• Identify specific warning signs that a crisis is developing
• List internal coping strategies (distraction activities, self-soothing techniques)
• Identify social contacts who can provide distraction and support
• List family members or friends who can help resolve the crisis
• Document mental health professionals and crisis services with contact numbers
• Restrict access to lethal means (remove firearms, lock up medications)

Lethal Means Restriction 5

• Remove all firearms from your home immediately—this is the single most important suicide prevention measure
• Lock up all medications with a trusted person controlling access
• Secure knives and other potentially lethal items

Cognitive Behavioral Therapy Is Essential

Cognitive behavioral therapy focused on suicide prevention should begin immediately alongside any medication changes, as it reduces suicidal ideation and cuts suicide attempt risk by approximately 50% compared to medication alone. 4, 2, 5 This typically involves fewer than 12 sessions and teaches you to identify and change problematic thinking patterns. 4

Alternative Medication Considerations

If desvenlafaxine is discontinued, evidence-based alternatives include: 2

• SSRIs (particularly fluoxetine or sertraline) have demonstrated efficacy in reducing both suicidal ideation and suicide attempts, with low lethality in overdose 2, 6
• Lithium has the strongest evidence for reducing suicide attempts and completed suicides in mood disorders, though it requires blood level monitoring 2, 7
• Ketamine infusion (0.5 mg/kg over 40 minutes) can produce rapid reduction in suicidal ideation within 24 hours for acute crisis situations 4, 2, 5

Medications to Avoid

Do not accept prescriptions for: 2, 5

• Tricyclic antidepressants (highly lethal in overdose)
• Benzodiazepines (may increase disinhibition and impulsive dangerous behavior)
• Large quantities of any medication (all prescriptions should be dispensed in small amounts)

Follow-Up Requirements

You must have follow-up within 24-72 hours if deemed high-risk, or within one week for lower-risk situations. 5, 6 The treating clinician should be reachable outside regular office hours or ensure adequate on-call coverage. 2

Common Pitfall to Avoid

Do not agree to a "no-suicide contract"—these have not been proven effective in preventing subsequent suicides, though the safety planning discussion itself remains essential. 5 What matters is the structured safety plan with specific coping strategies and support contacts, not a promise not to act.

This is a medical emergency. Seek help immediately. The combination of factors you describe—antidepressant treatment plus steroids triggering suicidal thoughts—requires urgent professional intervention to ensure your safety.