Tricyclic Antidepressants and Suicidal Patients

Introduction to TCAs and Suicide Risk

• The American Academy of Child and Adolescent Psychiatry recommends that tricyclic antidepressants (TCAs) should not be prescribed to patients with a history of suicide due to their highly lethal potential in overdose, with a fatal toxicity index 5 to 8 times higher than newer antidepressants 1, 2

Safer Alternatives: SSRIs

• The American Academy of Child and Adolescent Psychiatry notes that SSRIs are the preferred antidepressant class for patients with suicide risk because they have dramatically lower lethal potential in overdose, with SSRIs having a hazard index of 0.5 compared to TCAs at 13.8 1, 2, 5

Critical Monitoring Requirements

• The American Academy of Child and Adolescent Psychiatry recommends monitoring for akathisia, which has been associated with SSRI-induced suicidal ideation, particularly with fluoxetine, and systematically inquiring about suicidal ideation before and after treatment initiation 1, 5
• The American Academy of Child and Adolescent Psychiatry also recommends ensuring third-party medication monitoring by family members who can regulate dosage and report mood changes, and watching for behavioral activation/agitation in the first month, which may require dose reduction 1, 5, 6

Additional Medications to Avoid

• The American Academy of Child and Adolescent Psychiatry recommends that benzodiazepines and phenobarbital should also be avoided in suicidal patients as they may reduce self-control and have disinhibiting effects that can precipitate suicide attempts, with phenobarbital additionally having high lethal potential in overdose 1, 2, 5