What follow‑up questions should I ask a patient who experienced suicidal ideation after a recent change in psychiatric medication?

Follow-Up Questions After Medication Change in a Patient with Previous Suicidal Ideation

Begin by directly asking about current suicidal thoughts using specific, sequential questions that assess both passive and active ideation, then systematically evaluate changes in psychiatric symptoms, medication effects, and safety factors. 1

Essential Direct Questions to Ask

Current Suicidal State Assessment

Start with these specific questions in sequence:

• "Have you ever thought about killing yourself or wished you were dead?" 1
• "Have you ever done anything on purpose to hurt or kill yourself?" 1
• "If you were to kill yourself, how would you do it?" (to assess for specific plans) 1
• "Have you thought about being better off dead since your medication was changed?" 2, 3

These questions should be embedded within broader symptom assessment rather than asked in isolation, and asking them does not increase suicide risk. 1, 4

Assess Intent and Planning

• Determine the balance between wish to die versus wish to live 1, 2
• Ask about any steps taken to prepare for suicide (e.g., "Have you done anything to get ready to kill yourself?") 1
• Evaluate efforts to conceal suicidal behavior or avoid discovery 1, 5
• Assess motivating feelings: attention-seeking, escaping intolerable situations, reuniting with deceased relatives, or revenge 1, 4

Critical pitfall: If the patient denies current ideation but underlying motivations remain unmet, significant intent may still be present. 1, 4

Medication-Specific Assessment

Warning Signs Related to Antidepressant Changes

Ask specifically about these FDA black-box warning symptoms that may emerge after medication changes:

• New or more frequent thoughts of wanting to die 1
• Signs of increased anxiety, panic, agitation, aggressiveness, or impulsivity 1
• New or worsening insomnia or irritability 1
• Involuntary restlessness (akathisia) such as pacing or fidgeting 1
• Extreme elation, energy, fast speech, racing thoughts (suggesting mania/hypomania) 1, 5
• New onset of unrealistic plans or goals 1

Patients with depression should be monitored with appropriately frequent appointments after medication initiation and dose changes. 1

Psychiatric Symptom Evaluation

Look systematically for signs of clinical depression:

• Depressed or irritable mood most of the day 1, 5
• Weight changes, sleep disturbances (insomnia or hypersomnia) 1, 5
• Psychomotor agitation or retardation 5
• Fatigue or loss of energy 1
• Feelings of worthlessness, guilt, or hopelessness 5
• Difficulty concentrating or indecisiveness 1, 5
• Diminished interest or pleasure in activities 1

Screen for mania or hypomania:

• Elated, expansive, or irritable mood 5
• Decreased need for sleep 5
• Pressured speech, racing thoughts 5
• Inflated self-esteem or grandiosity 5
• Impulsive or excessive goal-directed behaviors 5

Assess for psychotic symptoms (delusions, hallucinations, threatening violence), as these require immediate psychiatric evaluation. 1, 5

Safety and Risk Factor Assessment

Access to Lethal Means

• "Are there firearms in your home? Do you know where they are stored?" 1, 2
• "What medications are available to you at home?" 2, 5
• Verify that a responsible adult has removed firearms and secured/disposed of potentially lethal medications 1, 5

Social Support and Supervision

• Assess availability of adequate supervision and support at home 1, 5
• Evaluate family response and engagement 1, 5
• Identify recent interpersonal conflicts, separation, or relationship disruptions 5, 4

Substance Use

• "Have you been using alcohol or drugs since your medication changed?" 1, 5
• Substance use dramatically increases risk through disinhibition and often co-occurs with mood disorders. 1, 5

Prior History Review

• Document all previous suicide attempts, as prior attempts are among the strongest predictors of future attempts 1, 5, 4
• Ask about the method, timing, and impulsivity of past attempts 5, 4
• Assess for non-suicidal self-injury (cutting, burning) 5
• Obtain family history of suicide 5

Psychosocial Stressors

• "How have things been going with school, friends, parents, sports?" 1
• Screen for bullying victimization or perpetration 1
• Assess for physical or sexual abuse history 5, 4
• Ask about sexual orientation (LGBTQ youth have significantly higher suicide risk) 5, 4

Disposition-Critical Assessment

Hospitalization is required if the patient has:

• Persistent wish to die or clearly abnormal mental state 1, 5
• Active suicidal intent with specific plans 2, 5
• Current mental disorder complicated by substance abuse 1
• Irritability, agitation, threatening violence, delusions, or hallucinations 1, 5
• Inadequate supervision or support at home 1, 5

Outpatient management is appropriate only when:

• Adequate supervision and support are confirmed 1, 5
• A responsible adult has agreed to remove firearms and secure medications 1, 5
• The patient's mental state has stabilized sufficiently 5
• A follow-up appointment is scheduled before discharge 2, 5

Critical Pitfalls to Avoid

• Never dismiss suicidal statements as "attention-seeking" or "gestures"—even seemingly minor statements require full evaluation. 5, 4
• Never rely on "no-suicide contracts"—these have no proven efficacy and create false reassurance. 1, 2, 5
• Never assume the absence of current ideation means safety if precipitating factors or motivations remain unchanged. 1, 4
• Never discharge without collateral information from family or other sources—the patient's self-report alone is insufficient. 5

Follow-Up Planning

• Schedule immediate follow-up before discharge and emphasize consistent attendance 2, 4
• The greatest risk of reattempting occurs in the months after an initial attempt, with highest risk in the first year 2, 4
• Maintain contact after referral to ensure adherence and monitor for recurrence 4