Suicidal thoughts, if unchecked, evolve into a wish to die, an intention to act, and a plan to end one’s life. The evolution of these steps can occur over minutes or years and each step presents an opportunity to intervene. Often, a patient’s intentions are identified only after a suicide attempt is made, which makes the management particularly difficult.
Easy access to mental health services—especially during high-risk periods—is a key component of management, as is the management of major depression. Unfortunately, geography, transportation, insurance, and income challenges often limit access to healthcare services.
Improving a provider’s ability to identify and manage risk factors, understanding the role of therapeutic interventions and psychiatric medications, restricting access to lethal means, and ensuring continuity of care have been shown to reduce rates of suicide and suicidal ideations in patients.
To the degree possible, care decisions should be made in a team environment with shared decision making and shared responsibility for care. The team must include the patient and his or her family, whenever possible and appropriate.
National Action Alliance for Suicide Prevention
Psychosocial interventions are intended to help people learn new ways of dealing with stressful experiences, identify patterns of thinking, and practice alternative actions when thoughts of suicide arise (NIH, 2017). Psychotherapy is a type of therapeutic intervention that takes place in a one-on-one or group format and can vary in duration from several weeks to several months or longer. Treatment that employs collaborative and integrated care engages and motivates patients, increases retention in therapy, and decreases suicide risk (Stone et al., 2017).
On the morning of December 25, 2000, Terry Wise tried to kill herself. She awoke two days later in the intensive care unit. The death of Terry’s husband from Lou Gehrig’s disease was a trigger for her suicide attempt; but in reality her attempt was the culmination of years of depression and other problems that started in her childhood. Terry was overwhelmed by an intense emotional pain that had been building for years, and when her husband died the pain became unbearable.
Right after Terry tried to kill herself, she felt lost. She didn’t know what to do. She found no joy in living. Terry went to therapy, and ultimately it changed her life. By working with a counselor, Terry realized that the trauma she experienced when she was younger still affected her emotions as an adult. Her counselor helped her find ways to cope with her feelings. Therapy also allowed her to see how others would have reacted to her death by suicide. Most important, Terry’s therapist trusted her and respected her and, for Terry, her therapist’s compassion made a huge difference.
Terry’s recovery was a process. It took time and hard work. She recalls: “And that is really the first step, to go from feeling that life is an endurance test to being able to tolerate being alive. And then you hope that the unendurable becomes bearable. Then you hope the bearable becomes manageable. Then you hope the manageable becomes pleasurable. And so it’s a process. It evolved over time.”
Source: SAMHSA, 2015.
Cognitive Behavior Therapy for Suicide Prevention (CBT-SP) uses a risk-reduction, relapse-prevention approach that includes an analysis of risk factors and stressors leading up to and following the suicide attempt. This is followed by the development of a safety plan, skill building, and psycho-education. CBT-SP includes family skill modules focused on family support and communication patterns as well as on improving the family’s problem-solving skills. In a randomized controlled trial utilizing outpatient cognitive therapy, there was a 50% reduction in the likelihood of a suicide re-attempt relative to treatment as usual among adults who had been admitted to an ED for a suicide attempt (Stone et al., 2017).
Dialectical Behavioral Therapy (DBT) is a multi-component therapy for individuals at high risk for suicide and who may struggle with impulsivity and emotional regulation issues. DBT includes individual therapy, group skills training, telephone coaching, and a therapist consultation team. In a randomized controlled trial of women with recent suicidal or self-injurious behavior, those receiving DBT were half as likely to make a suicide attempt at the two-year followup than women receiving community treatment. The women also required less hospitalization for suicide ideation, and had lower medical risk across all suicide attempts and self-injurious acts combined (Stone et al., 2017). DBT has also been shown to reduce the rate of suicide among people with borderline personality disorder (NIH, 2017).
The Improving Mood—Promoting Access to Collaborative Treatment (IMPACT) program aims to prevent suicide among older primary care patients by reducing suicide ideation and depression. IMPACT facilitates the development of a therapeutic alliance, a personalized treatment plan that includes patient preferences, as well as proactive followup by a depression care manager. The program has been shown to significantly improve quality of life, and to reduce functional impairment, depression and suicidal ideation over 24 months of followup relative to patients who received care as usual (Stone et al., 2017).
Collaborative Assessment and Management of Suicidality (CAMS), is a therapeutic suicide-specific assessment and treatment approach. The program’s flexible approach includes the clinician and patient, who work together to develop patient-specific treatment plans. Sessions involve constant patient input about what is (and is not) working with the goal of enhancing the therapeutic alliance and increasing treatment motivation in the suicidal patient (Stone et al., 2017).
CAMS has been tested in several studies, in a variety of inpatient and outpatient settings. A community-based sample of suicidal outpatients randomly assigned to CAMS or enhanced care as usual (psychiatric care, medication, and case management) found better treatment retention among the CAMS group and significant improvements in suicidal ideation, overall symptom distress, and feelings of hopelessness at the 12-month followup (Stone et al., 2017).
Attachment-Based Family Therapy (ABFT) is a program for adolescents aged 12 to 18 designed to treat clinically diagnosed major depressive disorder, eliminate suicidal ideation, and reduce dispositional anxiety. A trial using ABFT found that suicidal adolescents receiving ABFT experienced significantly greater improvement in suicidal ideation over 24 weeks of followup than did adolescents assigned to enhanced usual care. Significantly, a higher percentage of ABFT participants reported no suicidal ideation in the week prior to assessment, at 12 weeks, and again at 24 weeks than did adolescents receiving enhanced usual care (Stone et al., 2017).
Pharmacologic intervention can be helpful in managing underlying mental disorders and decreasing self-directed violence.
Although there is limited evidence that psychiatric medications reduce suicidal thoughts and behaviors, a decrease in the long-term suicide rate for patients with mood disorders treated with lithium, neuroleptics, and antidepressants has been reported (Pompili & Goldblatt, 2012).
All medications used by patients at risk for suicide should be reviewed to prevent adverse drug interactions. When prescribing drugs to people who self-harm, consider the toxicity and limit the quantity dispensed or available. If possible, ask another person to be responsible for securing access to medications. Followup and monitoring for adverse events is crucial.
The only two evidence-based medications that have been shown to lower suicidal behaviors are lithium and clozapine. However, these medications do not reach therapeutic levels immediately. Anxiolytics, sedative/hypnotics, and short-acting antipsychotic medications may be used to directly address agitation, irritability, psychic anxiety, insomnia, and acute psychosis, until such time as a behavioral health assessment can be made. The amount and type of medication must be carefully chosen and titrated when an individual is under the influence of alcohol, illicit substances, or other medications.
Lithium, a mood stabilizer, is used primarily to treat bipolar disorder, mood swings associated with other mental disorders, and, in some cases, to augment the effect of other medications used to treat depression. A number of studies have described the anti-suicide benefits of lithium for individuals on long-term maintenance (NIMH, 2016), possibly because it reduces the relapse of mood disorders. Other possible mechanisms include an effect on aggression or impulsivity, both of which are associated with an increased risk of suicide (Cipriani et al., 2013).
People treated for an affective disorder have a 30 times greater risk of suicide than the general population, and the evidence that lithium reduces the risk of suicide and possibly deliberate self-harm in people with bipolar disorder and recurrent unipolar depression indicates that lithium should continue to have an important clinical role (Cipriani et al., 2013).
Clozapine (marketed as Clozaril, Fazaclo ODT, Versacloz and generics) is an antipsychotic medicine used to treat schizophrenia in patients whose symptoms are not controlled with standard antipsychotic drugs. Clozapine is also used in patients with recurrent suicidal behavior associated with schizophrenia or schizoaffective disorder (FDA, 2019).
While clozapine is beneficial for some patients, there are risks associated with this drug. Specifically, clozapine can decrease the number of neutrophils, a type of white blood cell, that function in the body to fight off infections. When neutrophils are significantly decreased, severe neutropenia may result and the body may become prone to infections. For this reason, patients taking clozapine need to have their absolute neutrophil count (ANC) monitored on a regular basis (FDA, 2019).
Key Point about Clozapine
Clozapine should be considered for patients diagnosed with schizophrenia at high risk for suicide, who do not have contraindications to clozapine, and will be compliant with all required monitoring.
Source: DVA/DOD, 2013.
Antidepressant, Antipsychotic, Antiepileptic, and Antianxiety Agents
[Unless otherwise cited material in this section is from Gusmão et al., 2013.]
Suicide is strongly associated with poor mental health, especially mood disorders. Antidepressants are the most common treatment for mood disorders, but effective use of these medications requires administration to patients who have been properly diagnosed and then adequately followed up (Gusmão et al., 2013).
There is a consensus as to the importance of primary care doctors’ education programs for improving the management of depression with antidepressants in order to reduce the risk of suicide. Furthermore, a number of multi-component suicide prevention programs emphasize the crucial importance of primary care education programs to facilitate optimal antidepressant prescribing (Gusmão et al., 2013).
However, there are concerns about the efficacy and safety of antidepressants. Some researchers have suggested that antidepressants are no better than placebo and that antidepressants may actually increase the risk of suicidal behavior, particularly in young people. Others contend that there is a bias in these findings and that the benefits are in fact greater than the risk. For instance, an analysis of nearly 30 randomized controlled trials examined antidepressant prescribing in children and adolescents to age 18 with a diagnosis of major depressive disorder and showed that benefits appeared to far outweigh a small increased risk of suicidal behavior (Gusmão et al., 2013).
Although depressive symptoms are often associated with suicide risk, no antidepressant medication has been shown to lower suicide risk in depressed patients. However, because of the relationship between low cerebrospinal fluid serotonin levels and the emergence of aggression and impulsivity, the selective serotonin reuptake inhibitors (SSRIs) have been recommended for the treatment of depressive disorders when suicidal risk is present. Treatment with SSRIs must be carefully monitored and managed during the initial treatment phase because of the potential for the possible emergence of suicidal ideation and behaviors during this time. The Food and Drug Administration has recently created a black box warning when prescribing SSRIs for persons under the age of 25.
- Antidepressants may benefit suicidal behavior in patients with mood disorders.
- Young adults (18–24) started on an antidepressant for treatment of depression or another psychiatric disorder should be monitored and observed closely for emergence or worsening of suicidal thoughts or behaviors during the initiation phase of treatment.
- Patients of all age groups who are managed with antidepressants should be monitored for emergence or worsening of suicidal thoughts or behaviors after any change in dosage.
- When prescribing antidepressants for patients at risk for suicide, pay attention to the risk of overdose and limit the amount of medication dispensed and refilled.
Atypical antipsychotics may be used as treatment augmentation in the management of major depressive disorder and treatment of bipolar depressive disorders. Aripiprazole, quetiapine, and olanzapine in combination with fluoxetine include depressive disorders in their label indications. Their labels also include the same box warning as antidepressants for an increased risk of suicidal thinking and behaviors. There is no evidence to support this increased risk in adults, albeit atypical antipsychotics have not been as extensively studied as antidepressants (DVA/DOD, 2013).
Key Points About Antipsychotics
- There is no evidence that antipsychotics provide additional benefits in reducing the risk of suicidal thinking or behavior in patients with co-occurring psychiatric disorders.
- Patients who are treated with antipsychotics should be monitored for changes in behavior and emergence of suicidal thoughts during the initiation phase of treatment or after any change in dosage.
- When prescribing antipsychotics in patients at risk for suicide pay attention to the risk of overdose and limit the amount of mediation dispensed and refilled.
Source: DVA/DOD, 2013.
Patients started, or who are managed with, antiepileptics should be monitored for changes in behavior and the emergence of suicidal thoughts. There is no evidence that antiepileptics are effective in reducing the risk of suicide in patients with a mental disorder (DVA/DOD, 2013).
Anxiety is a significant and modifiable risk factor for suicide and the use of anti-anxiety agents may have the potential to decrease this risk. Any one of several rapidly acting, anti-anxiety agents can be used in an emergency to reduce anxiety in patients who exhibit suicidal behaviors. The use of any medications for this purpose must consider the risk of death from suicide versus the risk of serious adverse effects from psychopharmacology (to include disinhibition that could lead to suicide) versus the utility of various psychosocial interventions versus doing nothing (DVA/DOD, 2013).
Benzodiazepines can be effective in treating symptoms of anxiety, insomnia, hypervigilance, and other anxiety symptoms. In general, benzodiazepines are not recommended for long-term use in chronic aggression because of the potential for dependence and tolerance, resulting in an increase in impulsivity and aggression. Benzodiazepines can occasionally disinhibit aggressive and dangerous behaviors and enhance impulsivity. Benzodiazepines taken in excessive amounts can cause dangerous deep unconsciousness. In combination with other central nervous system depressants, such as alcohol and opiates, the potential for toxicity increases exponentially (DVA/DOD, 2013).
Continuity of Care
Continuity of care is critical when dealing with a patient who has attempted suicide. Continuity of care is affected by the many healthcare providers, friends, and family members who are involved with the care of a person at risk for suicide. Shared electronic medical records may help healthcare providers; however, not everyone has access to these records, partly because mental health information has a higher level of consent than other medical records.
Maintaining continuity of care is particularly important when a patient transitions between care settings. Even a transfer within the same organization present risks for discontinuities. Transitions may include:
- Transfers or referrals upon discharge from the emergency department
- Referrals from primary care to behavioral health
- Transfers from inpatient care to a residential treatment settings
- Discharge residential care units to ambulatory services
Continuity of care is enhanced when a provider directly contacts another provider and followup appointments are scheduled. Transition support services—such as telephone contact with behavioral health providers—are strongly recommended. Best practices include telephone reminders of appointments, providing a “crisis card” with emergency phone numbers and safety measures, and sending a letter of support. Counseling and case management also provide support and promote adherence to the recommended treatment.
Patients leaving the emergency department or hospital inpatient unit after a suicide attempt require rapid proactive outreach and followup. The risk is particularly high in the weeks and months following the attempt, including the period after discharge.
For patients who are transferred from the emergency department to medical-surgical services for the treatment of injuries related to a suicide attempt, followup mental health evaluations should be conducted before discharge.
Evaluations should assess the support available from family and friends. Before discharge, followup appointments for mental healthcare should be made and patients, families, or friends should be coached about the importance of keeping these appointments.
Adults who receive medical care immediately after a suicide attempt are more likely to receive mental health treatment compared to those who did not receive medical care. The emergency department provides an important opportunity to assess the patient's mental health needs and provide followup resources at a particularly critical juncture (Crane, 2016).
Having survived a suicide attempt is one of the most significant risk factors for later death by suicide. Continuity of care following a suicide attempt is critically important and should be a collaborative effort between patient and provider that gives the patient a feeling of connectedness.
Julio Faces a Divorce
Julio is a 50-year-old police/firefighter who is facing an unwanted divorce from his wife of 25 years. He has been a client of ABC Dental Services for more than 10 years and is well-known to everyone who works in the office. He has an appointment with Manolo, the dental hygienist, for a cleaning. Keisha, the office manager has asked Julio to fill out a short questionnaire while he is waiting for Manolo.
After a short wait, Manolo escorts Julio into his treatment room. Manolo notices that Julio is very quiet and asks him how he’s doing. Julio tells him that he’s a little depressed because he was recently arrested for drunk driving and he’s been suspended without pay from his job. He says his wife (also a client of ABC Dental) has asked him for a divorce.
As Manolo is prepping for the cleaning, Julio thanks Manolo for the excellent dental care he’s received over the years and asks Manolo to tell the dentist how much he appreciates everyone at the clinic. He tells Manolo that he’s planning a hunting trip and isn’t sure when he’ll be back.
The ABC Clinic uses the PHQ 2 to screen all clients at each visit and employees have received specialized training in screening and referral for suicidal ideation and behaviors. The clinic maintains a list of pre-screened referral services in the event that a referral is needed for one of their clients.
Manolo excuses himself and asks the office assistant for the results of Julio’s waiting room screen. Keisha lets Manolo know that Julio marked “3” on both of the questions on the waiting room questionnaire (little interest or pleasure in doing things and feeling down, depressed, or hopeless). Because of Julio’s screening answers, Manolo decides to discuss the results with Julio.
Manolo: You mentioned that you feel depressed. On the waiting room questionnaire you indicated that you also feel hopeless and have little interest in anything anymore. Is this true?
Julio: Yes, I’m losing everything that’s important to me—my wife, my job, my driver’s license—even my kids are mad at me.
Manolo: You sound pretty unhappy.
Julio: I am. I just want to get away from all this pressure and try to get my head straight.
Manolo: Sometimes, when people feel hopeless and depressed, they don’t see any reason to go on living. Have you thought about suicide?
Julio: Well, sometimes I do. I have guns, and sometimes think it isn’t worth it anymore. But I don’t think I could really pull the trigger—I’m not that kind of guy.
Manolo: Have you ever tried to hurt yourself in the past?
Julio: Well, about 10 years ago, when I failed the firefighter training exam I was so depressed I downed a bottle of Vicodin and passed out. My roommate at the time called an ambulance and I had to have my stomach pumped. I didn’t really want to die—I just wanted to turn off my brain for a while.
Manolo: I want to thank you for sharing all of this with me. Right now, I’m concerned that you might try to hurt yourself when you leave the office. Are you planning to go back home before you go on your trip?
Julio: Yes, I want to say goodbye to my wife and kids.
Manolo: Would it be okay with you if I called your wife and let her know what’s going on? I’d like to have her to remove your guns and medications from the house. Is that okay with you? I’d also like to have you talk to some people who can help you with your depression and thoughts of suicide. Is that okay? I can ask someone to come over to the clinic right now to talk to you.
Julio: Yes, I would appreciate that.
Manolo stays with Julio in a private room while the office manager contacts social services. She also informs the dentist. The office assistant also calls Julio’s wife to let her know the situation and to ask her to remove any guns and narcotic medication from the house. Julio’s wife agrees to do this but refuses to come to the clinic.
The fact that Julio tried to harm himself 10 years ago by overdosing on a narcotic pain medication is a red flag. Manolo discusses the situation with the dentist and they decide that Julio should be seen immediately for a more thorough assessment. The clinic has a list of pre-screened mental health providers who are willing to come to the clinic and talk to Julio. Manolo reaches a social worker who agrees to meet with Julio. Manolo stays with Julio in a private room until the social worker arrives.
When Manolo follows up the next day he learns that Julio has voluntarily admitted himself to the local hospital’s mental health ward.