Suicidal ideation comes in different varieties (stress-driven, intoxicated, baseline, obsessional, secondary to an illness), and each calls for a different response. Formulate before you prescribe: an SSRI is not the answer to suicidality itself, while lithium and clozapine are the two medications shown to reduce it.
Kinds of suicidal ideation
Stress-based ideation is a response to a stressor. With enough time or resolution of the stressor, we expect it to go away; it is not a baseline feature for that person.
“In this particular kind of patient, we anticipate that with enough time or with resolution of the stressor, the suicidal ideation will go away. It's not a baseline feature for them”
27:03Suicide Risk Assessment: Acute vs Chronic Risk, Formulation, and Suicidal Ideation TypesJun 2026 Intoxicants lower the ability to cope and stressors raise distress. The combination of the two is where involuntary detainment is extremely applicable.
“You have things that lower your ability to cope. Intoxicants, drugs, alcohol, and you have things that raise your level of distress, stressors, major life conflicts and issues. When you combine those two in particular, that's when the involuntary detainment is extremely applicable”
31:10Suicide Risk Assessment: Acute vs Chronic Risk, Formulation, and Suicidal Ideation TypesJun 2026 Some people have, at baseline and without any particular stress, thoughts about not wanting to be alive or wanting to hurt or kill themselves most of the time.
“for some people, they do simply have at their baseline, even without a particular stress in their life, just thoughts about not wanting to be alive, wanting to hurt or kill themselves. most of the time”
32:23Suicide Risk Assessment: Acute vs Chronic Risk, Formulation, and Suicidal Ideation TypesJun 2026 Suicidal thoughts can be part of OCD: an ego-dystonic obsession with matching compulsions.
“People can have thoughts about suicide as part of the obsessive and compulsive disorder type process. Properly, it will be called a ego dystonic obsession with matching compulsions”
41:27Suicide Risk Assessment: Acute vs Chronic Risk, Formulation, and Suicidal Ideation TypesJun 2026 Even when the wish seems rational, the fact that the person is in front of a psychiatrist means the pretest probability is high that it is not purely rational.
“even if there seems to be something rational, the fact that someone is in front of you as a psychiatrist means that the pretest probability is high, that they are not of the variety where it's purely rational”
25:23Suicide Risk Assessment: Acute vs Chronic Risk, Formulation, and Suicidal Ideation TypesJun 2026
Treatment by type
For stress-based ideation, the short-term involuntary detention model used across the United States is warranted.
“This is a variety where the short term involuntary detention model, which you see in most of the United States, all of the United States, I believe, is warranted”
28:58Suicide Risk Assessment: Acute vs Chronic Risk, Formulation, and Suicidal Ideation TypesJun 2026 For baseline ideation, the indicated treatment may not be hospital admission, and admission can slow overall progress toward getting better.
“sometimes the indicated treatment may not be hospital admission. Sometimes hospital admission can potentially slow down the overall progress towards getting better”
36:31Suicide Risk Assessment: Acute vs Chronic Risk, Formulation, and Suicidal Ideation TypesJun 2026 When ideation comes from bipolar disorder, don't forget lithium; in schizophrenia, if the patient is appropriate for it, don't forget clozapine. They are the two medications with evidence of actually reducing suicidality.
“If it's bipolar, don't forget lithium. If they're appropriate for clozapine, Don't forget clozapine in schizophrenia”
39:53Suicide Risk Assessment: Acute vs Chronic Risk, Formulation, and Suicidal Ideation TypesJun 2026 Also said in 1 more episode
“Those are the two medications that have shown to have evidence in reducing suicidality. Lithium for bipolar and clozapine for schizophrenic patients has shown to actually reduce suicidality”
40:35Suicide Risk Assessment: Acute vs Chronic Risk, Formulation, and Suicidal Ideation TypesJun 2026
Pitfalls and myths
Do not think "suicidal or depressed, give an SSRI." None of these varieties respond primarily to an antidepressant. Have a formulation, diagnosis and treatment plan before you prescribe.
“none of these respond to an SSRI. None of these respond to an antidepressant, primarily. So do not just think someone is suicidal or depressed, give an SSRI. You need to have a formulation, diagnosis, and treatment plan before you prescribe things”
37:44Suicide Risk Assessment: Acute vs Chronic Risk, Formulation, and Suicidal Ideation TypesJun 2026 SSRIs have not been shown to specifically reduce suicidality, though they have far fewer side effects and are much safer than older antidepressants.
“SSRIs have not been shown to specifically reduce suicidality. Though, of course, they have far less side effects and are much safer than older antidepressants”
40:48Suicide Risk Assessment: Acute vs Chronic Risk, Formulation, and Suicidal Ideation TypesJun 2026 People who get worse on antidepressants mostly have a more bipolar-type condition and develop antidepressant-related agitation and sleep problems. That is probably why we see more suicidal ideation in people under 25 on antidepressants.
“Why do some people get worse than antidepressants? In my opinion, it's mostly because they have some kind of a more bipolar disorder type condition and experience antidepressant-related agitation and sleep problems. That's probably, in my opinion, why we see the increased risk for suicidal ideation in people under the age of 25 on antidepressants”
1:06:35Treating Depression: Practical Tips & Pearls for Anti-Depressant MedicationsJan 2025
It also comes up on
- Case formulationThe right response to suicidality depends on the patient. For suicidality driven by an adjustment disorder, hospitalization can be the best treatment.
- Suicide risk assessmentThe majority of completed suicides are not from patients reporting suicidality. Most people who complete suicide have never seen a psychiatrist and usually have never mentioned suicidality at all.
- SSRIsAdvise patients about the risk of suicidal ideation and agitation. It is probably mainly a bipolarity problem, but it is a risk.
- Suicide risk assessmentExample: a surgeon asked for a suicidality assessment after a patient, following a painful waking procedure, said something like 'if I have to go through that again, I'm going to kill myself.'
- Bipolar disorderBipolar disorder and agitated depressions are the most dangerous treatable medical conditions for suicidality, because of the hyperarousal: irritability and being really activated.
- Borderline personality disorderA subset looks like OCD but does not respond well to ERP and SSRIs, because the underlying problem is self and other relating. Suicidality better formulated through borderline is now being recast as ego-dystonic OCD obsessions.
From these episodes
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.