The leading mechanistic explanation is an activation syndrome: SSRIs restore psychomotor energy before improving mood (a 4-6 week lag), creating a window in which patients have increased capacity to act on distress but have not yet experienced emotional relief. This can be compounded by SSRI-induced akathisia, agitation, and anxiety.

Evidence (2)

Age-Dependent Analysis of Suicidal Ideation, Suicide Attempts, and Suicides Associated with SSRI and SNRI Drugs

2024 pharmacovigilance analysis describing the psychomotor activation / mood lag mechanism.

https://pmc.ncbi.nlm.nih.gov/articles/PMC11677404/

The Risk of Suicide With Selective Serotonin Reuptake Inhibitors in the Elderly

Identifies akathisia and treatment-emergent agitation as rare idiosyncratic triggers of suicidal ideation, possibly pharmacogenetic in basis.

https://psychiatryonline.org/doi/10.1176/ajp.2006.163.5.813

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