The Appropriate Use of Medications in Suicidal Patients

Suicidal thoughts or behaviors can be one way that a person deals with problems associated with a significant life crisis or intense emotional pain. In our recent book, we stress that suicidality is not always driven by psychiatric illness, and that there is a psychotherapy tool set that is useful in managing a suicidal crisis derived from a variety of etiologies. Mental health professionals often find themselves dealing with a patient presenting with suicidal behaviors. The appropriate use of medication is an important tool both in treating a specific psychiatric illness and in reducing excess negative feelings (sadness, anxiety, or shame) that contribute to suicidal thoughts.

In contrast, if a prescribed medication proves ineffective, or when troublesome side effects occur, suicidal behavior can increase. In addition, the medication itself may be overdosed in a suicide attempt. Given these concerns, psychiatrists should be aware of issues specific to suicidality when initiating or altering a medication regimen in their patients.

The use of medications is made manageable by understanding some of the basic benefits and pitfalls of the four primary agents used to help suicidal patients: benzodiazepines, antidepressants, antipsychotics, and mood-stabilizing drugs. The first two are the most commonly used medications, but use of the latter two is rising, especially as a means of emotion regulation in patients with chronic suicidal ideation.

Benzodiazepines

Benzodiazepines are the recommended choice to help suicidal patients with heightened levels of anxiety and agitation. These medications are advantageous in that lethal overdoses are rare unless the drugs are combined with other medications or illicit substances. However, patients will develop tolerance to benzodiazepines over time, especially with rapid-acting agents, which makes overuse a potential problem.

A good general plan is to prescribe benzodiazepines for two to six weeks so that excessive emotional arousal does not interfere with ongoing therapy, after which point the medication is tapered over the next several weeks to prevent withdrawal. To avoid dependence, use a longer-acting drug such as clonazepam and set up a fixed-dose schedule as opposed to letting the patient use the medication “as needed.” Use longer than six weeks should be only for patients diagnosed with an anxiety disorder who have chronic and severe anxiety complaints.

Antidepressants

Antidepressants are often indicated when a patient has suicidality as part of a depressive disorder. Please note that the presence of suicidality alone is not enough to indicate depression, and antidepressants do not help with suicidality per se. Therefore, it is important to establish a diagnosis of depression prior to initiating medication. A second consideration is to ensure a prescription is less than a lethal dose. For selective serotonin reuptake inhibitors (SSRIs), this is less of an issue since most individuals would need a significant number of pills for a lethal overdose. However, if older antidepressants like tricyclic antidepressants are prescribed, limit the prescriptions to one to two weeks at a time. It would help if these older medications were available in individual packets, but this additional safety factor is not readily available.

A third issue to be aware of is the ongoing debate as to whether SSRIs and other antidepressants may increase suicidal thoughts or behaviors in some individuals, especially adolescents and young adults under 25 years. Currently, there is no definitive data to support or refute this connection, so prescribers should remain abreast of the situation, as new reports regularly appear.

In March, esketamine was approved by the Food and Drug Administration (FDA) as an adjunct for treatment-resistant depression. In addition to its ability to provide rapid relief of depressive symptoms, this medication can quickly reduce suicidal symptoms in depressed patients, according to recent research. Psychiatrists should consider providing this drug—which can be administered only in qualified medical settings—to patients with depression if they suspect an imminent risk of suicide. However, while the effects may be rapid, they may also be transient, so this medication is not a replacement for a comprehensive behavioral and pharmacological treatment strategy.

Antipsychotics, Mood Stabilizers

Both antipsychotics and mood stabilizers are used less frequently for acute suicidality but do have a role in reducing acute symptoms causing emotional dysphoria. Two medications are worth noting in the context of managing suicidal behavior. The first is clozapine, which is approved by the FDA to treat patients with schizophrenia and suicidal behaviors. This antipsychotic remains underutilized in the general treatment of schizophrenia, and it should certainly be considered if a patient with schizophrenia develops suicidal thoughts. Additionally, numerous clinical studies over the years have demonstrated that lithium can reduce the risk for suicide and suicide attempts in people with bipolar disorder.

When evaluating patients for potential suicidality, we like to refer to the three “I’s”; that is, does a patient have a problem they see as intolerable (I can’t stand it), interminable (It will never end), and/or inescapable (I cannot get away from it).

Additionally, when evaluating which medication to prescribe in patients with suicidality, psychiatrists can turn to the three “A’s”:

• Appropriateness. Is the diagnosis correct? Is the medication a correct treatment for the diagnosis? With polypharmacy, is there a legitimate reason for each medication? Is the medication effective? Are appropriate response criteria being used?

• Adherence. Is the patient taking the medication as directed? If not, why not?

• Adverse effects. Know the adverse effects of a medication. Ask the patient about them. Early recognition of side effects generally makes them much easier to manage. ■