This is a case report highlighting the side effect of suicidal ideation with lemborexant, a novel agent approved for the treatment of insomnia. A 22-year-old man received care at an outpatient psychiatrist for the treatment of major depressive disorder, persistent depressive disorder, generalized anxiety disorder, social phobia, and insomnia. The patient also has a diagnosis of Loeys-Dietz syndrome, a connective tissue disorder. Following numerous medication trials for both depression and insomnia that resulted in partial remission of mood symptoms without improvement in sleep, he was initiated on lemborexant to address insomnia. He was noted to be denying suicidal ideation at the appointment when lemborexant was prescribed. The patient did not take lemborexant until three days after the appointment, at which time he took the recommended dose of 5 mg at bedtime for insomnia. The patient experienced drowsiness immediately following taking this dose; however, he woke up two hours later with new-onset suicidal ideation. The patient was brought to the hospital for this complaint, and the following evening had attempted suicide by hanging in his hospital room. Laboratory investigations showed normal findings in blood chemistries, complete blood count, thyroid stimulating hormone, vitamin B12 level, vitamin D level, and urine illicit drug screening. Differential diagnosis includes acute reaction to insomnia, medication-induced side effect, and major depressive disorder. He had completed trials for insomnia with zolpidem, hydroxyzine, quetiapine, nortriptyline, and trazodone prior to beginning lemborexant. The patient had no history of suicide attempts in the past, but did experience suicidal ideation following a trial of nortriptyline. In the hospital, the lemborexant was discontinued, and clonidine and clonazepam were initiated at bedtime to address insomnia and ruminative thoughts. The patient was discharged with follow-up at his outpatient psychiatrist after his suicidal ideation was in remission, as well as noted improvement in insomnia. This case highlights new-onset suicidal ideation with subsequent suicide attempt after first use of lemborexant in a patient with major depressive disorder. This case is important given lemborexant is a new medication with limited information about its efficacy and safety in major psychiatric disorders.
