psychiatric disorders
Suicidal Behavior
Treatment for Risk of Suicide
Brief interventions Brief interventionsare effective for reducing risk for suicide and are considered best practice. These interventions can be performed in primary care, outpatient behavioral health care, and inpatient care settings. These interventions include Performing a suicide risk screening Performing a suicide risk assessment Performing safety planning intervention Providing lethal means safety counseling Providing supportive follow-up phone calls, texts, or messages (which have been shown to decrease suicide risk in at-risk patients) Providing education to the patient and family when possible Providing crisis resources Treatment that decreases suicide risk includes several types of psychotherapy: Cognitive-behavioral therapy for suicide prevention Dialectical behavior therapy Certain types of family therapy Collaborative assessment and management of suicidality Incognitive-behavioral therapy for suicide prevention, suicidal behavior is viewed as a problematic coping behavior and as the primary problem and target of treatment, rather than as a symptom of a disorder. Treatment is focused on preventing future suicidal crises. Personal change is intended to occur by helping people modify their responses to their automatic thoughts, and by unlinking negative thought-behavior-mood patterns. Dialectical behavior therapyfocuses on increasing distress tolerance, identifying and trying to change negative thinking patterns, and promoting positive changes. It aims to help patients find more constructive ways of responding to stress (eg, resist urges to behave self-destructively). have been developed to specifically reduce suicidal behavior and help families support their loved one. For example, the SAFETY Program is a cognitive-behavioral family intervention designed to increase safety and reduce suicidal behavior ( Treatment references ). Attachment-based family therapy has also shown promise as an intervention for suicidal adolescents and their parents ( Incollaborative assessment and management of suicidality (or CAMS), a person's risk for acting on suicidal thoughts is decreased by improving their understanding of their drivers for suicidal impulses, relationship issues, and problem solving. The person who has suicidal ideation and/or behavior collaborates with a clinician to jointly develop and track a plan for staying alive and enhancing their motivation to live. (See theAmerican Foundation for Suicide Prevention web sitefor a full discussion of prevention interventions and treatment options.) A change to the clinical approach to addressing suicide risk is the recommendation not only to focus on the patient's primary psychiatric condition(s), but also to consider suicide risk its own clinical focus ( Treatment references ). People with depression and other mental health conditions have a significant risk of suicide and should be carefully monitored for suicidal behaviors and ideation. Risk of suicide may be increased early in the treatment of depression, when psychomotor retardation and indecisiveness have been ameliorated but the depressed mood is only partially lifted. When Public health warnings about the possible association between use of antidepressants and suicidal thoughts and attempts in children, adolescents, and young adults led to a significant reduction (>30%) in antidepressant prescriptions to these populations. However, youth suicide rates increased by 14% during the same period. Thus, by discouraging pharmacologic treatment of depression, these warnings may have temporarily resulted in more, not fewer, deaths by suicide. Together, these findings suggest that the best approach is to encourage treatment, but with appropriate precautions such as Dispensing antidepressants in sublethal amounts Preferentially using antidepressants that are not lethal if taken in overdose Providing more frequent monitoring and visits early in treatment Giving a clear warning to patients and to family members and significant others to be alert for symptoms such as agitation, insomnia, or suicidal ideation Instructing patients, family members, and significant others to immediately call the prescribing clinician or seek care elsewhere if symptoms worsen or suicidal ideation occurs Evidence from randomized trials has shown that Lithium , when given alone or as adjunctive therapy with antidepressants or second-generation antipsychotics (also known as atypical antipsychotics), reduces the number of deaths by suicide in patients with major depression or bipolar disorder ( There are multiple treatments under investigation for the depressed suicidal patient, including psychological interventions and medical interventions withbuprenorphine(a medication used for treatment of alcohol and opioid withdrawal). Electroconvulsive therapy (ECT) (ECT) is still effective for the treatment of severe depression and for suicidal depression. ECT and transcranial magnetic stimulation (rTMS) have been approved for treatment-resistant depression and can be considered for patients with severe treatment-refractory depression, psychotic depression, or bipolar disorder. Both of these forms of treatment may also be helpful in reducing suicide risk ( 1.Asarnow JR, Berk M, Hughes JL, et al: The SAFETY Program: A treatment-development trial of a cognitive-behavioral family treatment for adolescent suicide attempters.J Clin Child Adolesc Psychol44(1):194-203, 2015. doi: 10.1080/15374416.2014.94062 2.Krauthamer Ewing ES, Diamond G, Levy S: Attachment-based family therapy for depressed and suicidal adolescents: Theory, clinical model and empirical support.Attach Hum Dev17(2):136-156, 2015. doi: 10.1080/14616734.2015.1006384 3. Moutier C, Pisani A, Stahl S: Stahl’s Handbooks: Suicide Prevention. Cambridge University Press, 2021. 4.Cipriani A , Hawton K, Stockton A, et al:Lithiumin the prevention of suicide in mood disorders: Updated systematic review and meta-analysis.BMJ346:f3646, 2013. doi: 10.1136/bmj.f3646 5.Kellner CH, Fink M, Knapp R, et al:Relief of expressed suicidal intent by ECT: A consortium for research in ECT study.Am J Psychiatry162(5):977-982, 2005. doi: 10.1176/appi.ajp.162.5.977 doi:10.1176/appi.ajp.162.5.977 6.George MS, Raman R, Benedek DM, et al: A two-site pilot randomized 3 day trial of high dose left prefrontal repetitive transcranial magnetic stimulation (rTMS) for suicidal inpatients.Brain Stimul7(3):421-431, 2014. doi: 10.1016/j.brs.2014.03.006 