Medications as a part of the treatment plan

Determining whether a medication makes sense for an individual's mental health care requires thoughtful consideration of many factors. The risks and benefits on all sides must be weighed, ideally with the input and guidance of a psychiatrist or experienced medical or mental health professional. The health condition, how it is impacting the person's life, and the treatment options that are available all must be considered, alongside risks and benefits of recommended medications, other non-medication treatments, as well as the risks and benefits of going without the medication.

While medications have risks and benefits it is also true that not including medications also has risks and benefits. For example, when severe major depression is not addressed through treatment that includes medication, there are likely outcomes, including disability, suffering, increased medical comorbidity (other health conditions), negative impacts on medical conditions such as cardiac health, chronic pain, and autoimmune conditions, as much as a seven-times increased risk of suicide, as well a 50% increased risk of death by other causes as compared to people without depression or people whose depression is in remission (i.e. no longer experiencing symptoms).¹ In other words, the risks of not treating the mental health condition or treating the condition with only “non-biological” interventions must be weighed against the risks of including medication in a treatment plan. When considering a particular medication, it is also important to discuss alternative medications. This process of informed consent (the clinician informing the patient of the risks and benefits of a particular treatment and other options) is considered standard care in any treatment plan including medications — this is true for all medical health care, not just psychiatric care.

Before prescribing medication, a clinician should conduct a thorough evaluation to assess for any physical and mental health conditions, and suicide risk, in an effort to understand the person and their clinical status, make an accurate diagnosis and develop a treatment plan.

Determining the best medication or medications for an individual is a process because while medications do have clinical indications based on research and approved by the FDA for certain conditions, people respond differently to each medication. Generally, clinicians will start with a low dose to avoid unnecessary side effects. It is important for patients to follow up regularly with their clinician so together they can monitor and adjust the dosage of medication(s) based on their effectiveness and side effects. At each visit, the clinician will assess changes in symptoms, side effects and overall improvement. Adjustments are made to the treatment plan, including changing medications when necessary to maximize improvement. If possible, it is important to include a trusted family member or caregiver in conversations about medications so they can assist in checking for benefits and potential side effects as medications are introduced or changed.

Both clinician and patient may need to be patient during the process of finding the most helpful medication and maintaining a sense of well-being. It can be very helpful to include family and friends in the process as they often know the person well enough to notice changes in behavior, mood or other symptoms. The greatest treatment outcomes are often achieved through a combination of medication and therapy.

For people with treatment refractory (or treatment-resistant) conditions such as severe or psychotic depression, bipolar disorder or extreme suicide risk, electroconvulsive therapy (ECT) and several forms of transcranial magnetic stimulation (TMS) have been found to be helpful in reducing suicide risk.^{2, 3}

A few medications or classes of medication have additional data to consider related to suicide prevention:

• Lithium: One of the oldest treatments used in modern psychiatry; has been and still is underutilized. It has a suicide-preventive effect in the long-term treatment of both depression and bipolar mood disorders. However, it also can lead to significant side effects which need to be closely monitored through lab screening (i.e. bloodwork).
• Clozapine: The only medication to date with an FDA indication for suicide risk reduction, used primarily to treat patients with schizophrenia, and is also underutilized. However, it also has significant side effects which need to be closely monitored through lab monitoring (i.e. bloodwork).
• Ketamine: Ketamine is still being investigated to understand the longer term outcomes, but it has been found to lead to rapid reduction of depressive symptoms and suicidal ideation. Esketamine is FDA-approved with an indication for treatment-resistant depression and may also have short-term suicide risk reducing properties.
• Antidepressants: Antidepressants can be used judiciously and effectively to address depression and anxiety, and on a population level, increased use of antidepressants has been associated with reductions in suicide rates.

References

1. Li, G., Fife, D., Wang, G., Sheehan, J. J., Bodén, R., Brandt, L., … DiBernardo, A. (2019). All-cause mortality in patients with treatment-resistant depression: a cohort study in the US population. Annals of general psychiatry, 18, 23. doi:10.1186/s12991-019-0248-0
2. Moutier C, Pisani A, Stahl S.M. Stahl’s Handbooks: Suicide Prevention. Cambridge University Press; 2021.
3. Kellner, C. H., Fink, M., Knapp, R., Petrides, G., Husain, M., Rummans, T., … Malur, C. (2005). Relief of expressed suicidal intent by ECT: a consortium for research in ECT study. The American journal of psychiatry, 162(5), 977–982. doi:10.1176/appi.ajp.162.5.977
4. George, M.S., Raman, R., Benedek, D.M., Pelic, C.G., Grammer, G.G., Stokes, K.T., … Stein, M.B. (2014). A Two-site Pilot Randomized 3 Day Trial of High Dose Left Prefrontal Repetitive Transcranial Magnetic Stimulation (rTMS) for Suicidal Inpatients. Brain Stimul, 7(3):421-431.
5. Stahl, S.M. (2017). Stahl’s Essential Psychopharmacology Prescriber’s Guide, Sixth Ed.

There has been considerable confusion and unintended consequences following the U.S. and the UK issuing warnings related to medications and suicide risk in youth. The warning states, “Patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior.” This was erroneously taken to mean that antidepressants increase suicide risk, especially in children and young adults.

These decisions were based on data from randomized controlled trials by the drug makers, which found increased incidence of suicidal ideation and behavior in subjects on newer antidepressants compared with placebo. However, the decisions were controversial because the setup of these clinical trials did not include baseline assessments of suicidal ideation and behavior and therefore the ability to measure improvements in suicidal states was not assessed, and only the emergence of adverse events were identified. Other studies have found beneficial effects related both to depressive, anxiety, and eating disorders — all conditions that are potent risk factors for suicide. Further, population-level studies have found regional associations between higher rates of antidepressant prescribing and decreased rates of suicide.^{2, 3} A concern was that the progress that had been made especially in primary care with more aggressive identification and treatment of depression as one of the world’s leading causes of disability and a major driver of suicide risk, might be hindered. In fact, there was a substantial drop in diagnosing and treating depression — with fewer referrals to therapy as well as use of antidepressants following the warnings, and instead of declining as hoped, suicide attempts and suicides increased.^{4 ,5 ,6} With focused discussions, the individual and their mental health clinicians can determine the best options for addressing the person’s mental health.

References

1. Food and Drug Administration. (2016). Revisions to product labeling. Retrieved from http://www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM173233.pdf
2. Gibbons, R.D., Hur, K., Bhaumik, D.K., & Mann, J.J. (2016). The relationship between antidepressant prescription rates and rate of early adolescent suicide. Am J Psychiatry, 163(11):1898-1904.
3. Ludwig, J., Marcotte, D.E., & Norberg, K. (2009). Anti-depressants and suicide. J Health Econ, 28(3): 659-676.
4. Lu CY, Zhang F, Lakoma MD, Madden JM, Rusinak D, Penfold RB, et al. Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study. BMJ (2014) 348:g3596. 10.1136/bmj.g3596
5. Valuck RJ, Libby AM, Sills MR, Giese AA, Allen RR. Antidepressant treatment and risk of suicide attempt by adolescents with major depressive disorder. CNS drugs (2004) 18:1119–32. 10.2165/00023210-200418150-00006
6. Gibbons RD, Brown CH, Hur K, Marcus SM, Bhaumik DK, Mann JJ. Relationship between antidepressants and suicide attempts: an analysis of the Veterans Health Administration data sets. Am J Psychiatry (2007) 164(7):1044–9. 10.1176/ajp.2007.164.7.1044

There are many contributors to suicidal ideation and behavior and there are several options for interventions and treatments that can help. Some interventions are focused on managing suicidal ideation and behavior and are brief and focused. Some treatments address suicidal ideation and behavior as well as underlying risk factors. Medications and other treatments are available that are effective as well. Most often two or more interventions and treatments are combined for the best result. It can take time and patience to find the clinician and treatments that are best for you. Honest regular conversations with your provider and use of clinical measurement tools to track progress are most important to help you feel your best.