Primary care physicians, nurse practitioners, and other healthcare providers play an important role in the assessment and management of suicide risk. It is estimated that 75% of individuals who die by suicide are in contact with a primary care physician in the year before their death, and that 45% do so within one month of their death. In contrast, only 20% of these patients saw a mental health professional in the preceding month (HHS, 2012).
Improving clinician skills to recognize and manage risk factors for suicide has been shown to reduce rates of suicidal ideations in patients. The Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) found that primary care intervention reduced suicidal ideations. Studies have found that 70% of the elderly who committed suicide saw a primary care physician within a month of their death. These data underscore the potential impact of primary care–based screening and intervention strategies (Hassamal et al., 2015).
Pharmacologic intervention may be markedly helpful in managing underlying mental disorders and the danger of repeated or more dangerous self-directed violence. All medications (prescription drugs, over-the-counter medications, and supplements) used by patients at risk for suicide should be reviewed to ensure effective and safe treatment without adverse drug interactions. When prescribing drugs to people who self-harm, consider the toxicity of prescribed drugs in overdose and limit the quantity dispensed or available, and/or identify another person to be responsible for securing access to medications. The need for followup and monitoring for adverse events should be addressed (DVA/DOD, 2013).
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). Individuals who have psychiatric and substance use problems should receive psychosocial interventions along with medication.
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 the individual is deemed to be under the influence of alcohol, illicit substances, or other medication in prescribed or overdose amounts.
Lithium, which is an effective mood stabilizer, is approved for the treatment of mania and the maintenance treatment of bipolar disorder. A number of cohort studies have described the anti-suicide benefits of lithium for individuals on long-term maintenance. Mood stabilizers are 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 (NIMH, 2016).
A possible explanation for its anti-suicidal effects of lithium is that it reduces the relapse of mood disorders. However, lithium is not as potent in acute phase therapy as other antidepressants, which do not seem to have similar anti-suicidal efficacy. Possible mechanisms include an effect on aggression or impulsivity, both of which are associated with an increased risk of suicide. 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).
Lithium Used to Treat Suicidal Ideation and Behavior
- Lithium should be considered for patients diagnosed with unipolar depressive disorder who have had a partial response to an antidepressant and for those with recurrent episodes who are at high risk for suicidal behavior, provided they do not have a contraindication to lithium use and the potential benefits outweigh the risks.
- Lithium should be considered for patients diagnosed with bipolar disorder who do not have contraindications to its use.
- Lithium should be avoided or used in caution in patients with impaired renal function, those taking concurrent medications that increase or decrease lithium concentrations or those with other risk factors for lithium toxicity.
- When prescribing lithium to patients at risk for suicide, it is important to pay attention to the risk of overdose by limiting the amount of lithium dispensed and the form in which it is provided.
Source: DVA/DOD, 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. 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, with some authors suggesting that these medications are at best no better than placebo and others that antidepressants may actually increase the risk of suicidal behavior, particularly in young people. In contrast, still other authors contend that there is a bias in these findings and that the benefits are in fact greater than the risk. For instance, one meta-analysis of 27 RCTs 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 risk for suicide, no antidepressant medication has yet to be shown to lower suicide risk in depressed patients. However, because of the relationship between low CSF 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. However, 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 FDA has recently created a black box warning when prescribing SSRIs for persons under the age of 25.
Antidepressants Used to Treat Suicidal Ideation and Behavior
- Antidepressants may benefit suicidal behavior in patients with mood disorders. Treatment for the underlying cause should be optimized according to evidence-based guidelines for the respective disorder.
- 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.
Source: DVA/DOD, 2013.
Clozapine is an atypical antipsychotic medication used primarily to treat individuals with schizophrenia. However, it is the only medication with a specific U.S. Food and Drug Administration (FDA) indication for reducing the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder who are at risk for ongoing suicidal behavior (NIH, 2017).
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, 2016).
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.
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. Treatment for the psychiatric disorder should be optimized according to evidence-based guidelines for the respective disorder.
- 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 (eg, clonazepam, a benzodiazepine) are candidate pharmaceutics for use in emergency psychopharmacology for anxiety reduction 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 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).
Care of Patients with Substance Use Disorders
Every year about 650,000 people receive treatment in emergency departments following a suicide attempt. In 2011 approximately 230,000 ED visits resulted from drug-related suicide attempts, and almost all involved a prescription drug or over-the-counter medication (SAMHSA, 2016).
Did You Know. . .
The number of ED visits for drug-related suicide attempts increased 51% overall from 2005 to 2011 and more than doubled among people age 45 to 64 (SAMHSA, 2016).
Substance use disorders are a prevalent and strong risk factor for suicide attempts and suicide. Three key issues to bear in mind in working with this population are assessing intoxicated patients, differentiating unintentional and intentional overdose events, and special assessment considerations (DVA/DOD, 2013).
Individuals at acute risk for suicidal behavior who appear to be under the influence of alcohol or other drugs, either based on clinical presentation or objective data (breath or laboratory tests), should be maintained in a secure setting until intoxication has resolved. Risk assessment needs to be repeated once the patient is sober in order to determine appropriate next steps. Risk management options include, but are not limited to, admitting the patient for inpatient hospital care, making a referral for residential care, detoxification, ambulatory care, or scheduling outpatient followup in the near future (DVA/DOD, 2013).
Individuals with substance use disorders are particularly susceptible to suicide ideation and suicide attempts. Indeed, suicide is a leading cause of death among people who misuse alcohol and drugs. A significant percentage of deaths by suicide involve alcohol intoxication or opiates (SAMHSA, 2016).
Number of Substances Used
The number of substances used seems to be more predictive of suicide than the types of substances used.
Alcohol misuse or dependence is associated with a suicide risk that is 10 times greater than the suicide risk in the general population, and individuals who inject drugs are at about 14 times greater risk for suicide. Acute alcohol intoxication is present in about 30% to 40% of suicide attempts (SAMHSA, 2016).
One of the reasons alcohol and drug misuse significantly affects suicide rates is the disinhibition that occurs when a person is intoxicated. Although less is known about the relationship between suicide risk and other drug use, as noted above, the number of substances used seems to be more predictive of suicide than the types of substances used. More research is needed on the association between different drugs, drug combinations, and self-medication on suicidal behavior (SAMHSA, 2016).
For suicide prevention to be effective, providers of mental health and substance abuse services must coordinate services with each other and with other service providers in the community. It is generally recognized that mental health and substance abuse services can have a greater impact when community gatekeepers refer at-risk patients to these specialized providers. The effects of mental and substance use services can also be enhanced when specialized providers refer patients to community programs that can augment care (HHS, 2012).
Cooperation, collaboration, and communication between mental health and substance use providers, as well as community support, are critical components of patient safety and recovery. Mental health and substance abuse providers should link with community agencies for suicide prevention, mental health advocacy organizations, aging services organizations, veterans support organizations, and programs providing peer support services. These programs foster a sense of connection and belonging and provide critically needed services, including employment and vocational help, housing assistance, peer support, and social interactions that are not focused on illness (HHS, 2012).
All patients at acute risk for suicide who are under the influence (intoxicated by drugs or alcohol) should be evaluated in an urgent care setting and be kept under observation until they are sober. Patients who are under the influence should be reassessed for risk for suicide when the patient is no longer acutely intoxicated, demonstrating signs or symptoms of intoxication, or acute withdrawal (DVA/DOD, 2013).
Obtaining additional information from sources such as family members, treatment providers, and medical records, can be invaluable in making the determination between intentional and unintentional overdose. Intoxicated or psychotic patients who are unknown to the clinician and who are suspected to be at acute risk for suicide should be transported securely to the nearest crisis center or ED for evaluation and management. These patients can be dangerous and impulsive; assistance in transfer from law enforcement may be considered (DVA/DOD, 2013).
Intoxication with drugs or alcohol impairs judgment and increases the risk of suicide attempt. Use of drugs or alcohol should routinely be assessed with all persons at any risk for suicide. Psychiatric and behavioral comorbidities (mood, anxiety disorder, aggression) should be assessed in patients with substance use disorder at risk for suicide. Also take into account social risk factors such as disruptions in relationships and legal and financial difficulties, which are important in individuals with substance use disorders (DVA/DOD, 2013).
Discerning Unintentional vs. Intentional Overdose
Intentional overdose is the most common method of attempted suicide and the possibility that an overdose was an intentional act of suicide should always be considered. Differentiating between unintentional and intentional overdose is generally straightforward in patients who are forthcoming. However, many patients will insist an overdose was not intentional even if it was, and the differentiation is especially challenging in patients with a history of substance abuse (DVA/DOD, 2013).
Unfortunately, there is limited data on the differentiation between unintentional overdose and suicidal behavior in substance abusers. Available data indicate that risk factors for suicide attempt (compared to unintentional overdose) include female sex, comorbid depression, interpersonal distress or disruption, and use of substances other than one’s drug of choice. Prior suicide attempts also increase the likelihood that a recent overdose event was intentional (DVA/DOD, 2013).
A risk factor for unintentional overdose is a recent loss of tolerance, for example due to incarceration or detoxification. Individuals using recreational drugs with high potential for miscalculation (eg, intoxicants sold in head shops as “bath salts”) were more likely to experience unintentional overdose (DVA/DOD, 2013).
Although not typical, there are instances when intentionality is unclear or ambiguous even among substance abusers who are forthcoming, for example a case where the individual was experiencing suicidal ideation when she overdosed but appeared not to have intended to attempt suicide, or when a distressed person knowingly pushed the limits of dosage and stated “I didn’t care if I lived or died” but seemed to have no clear agenda for suicide (DVA/DOD, 2013).
Developing and Monitoring a Safety Plan
Safety planning is a provider-patient collaborative process—a prevention tool designed to help an individual manage suicidal thoughts. The safety planning process produces a written plan that restricts access to means for completing suicide, encourages problem-solving and coping strategies, enhances social supports, and identifies a network of emergency contacts. Safety plans should be tailored to the individual, identifying specific warning signs as well as coping strategies that have been effective in the past (DVA/DOD, 2013).
Developing the Plan
Although no universally accepted safety planning method exists, the Safety Planning Intervention has gained widespread acceptance in the suicide prevention community and has been incorporated into numerous treatment guidelines and interventions. The plan is collaboratively built by a clinician with a patient and encourages individuals to engage in six sequential steps when feeling suicidal:
- Identify early warning signs
- Employ internal coping strategies
- Distract with social engagement or change of environment
- Access suicide-protective social support
- Seek help through crisis resources
- Restrict access to lethal means (Boudreaux et al., 2017)
The Safety Planning Intervention has a strong empirical foundation supporting each of its six steps, as well as evidence that it improves the average number of outpatient mental health visits for suicidal patients during the 6 months following the index ED visit, when compared with treatment as usual (Boudreaux et al., 2017).
The plan and the process of developing it should be included in the medical record, and the patient should receive a copy. The safety plan should be specific and should list situations, stressors, thoughts, feelings, behaviors, and symptoms that suggest periods of increased risk, as well as a step-by-step description of coping strategies and help seeking behaviors (DVA/DOD, 2013).
Monitoring the Plan
A common misconception is that suicide risk is an acute problem that, once dealt with, ends. Unfortunately, individuals who are suicidal commonly experience a return of suicide risk following any number of setbacks, including relapse to substance use, a distressing life event, increased depression, or any number of other situations. Sometimes suicidal behavior even occurs in the context of substantial improvement in mood and energy. Therefore, monitoring for signs of a return of suicidal thoughts or behavior is essential (CSAT, 2015).
There is a tendency to refer a patient experiencing suicidal thoughts and behaviors to another provider and then assume that the issue has been taken care of. This is a mistake. It is essential to follow up with the provider to determine that the person kept the appointment. It is also critical to coordinate ongoing care and to alert other providers when a patient has relapsed and may be vulnerable to suicidal thoughts. Monitoring emphasizes the importance of watching for a return of suicidal thoughts and behaviors, following up with referrals, and continual coordinating with providers who are addressing the patient’s suicidal thoughts and behaviors (CSAT, 2015).
Monitoring can include following up with the ED when a patient has been referred for acute assessment as well as continual coordinating with mental health providers, case managers, or other professionals. The client’s condition and your responses should be documented, including referrals and the outcomes of the referrals. Other monitoring actions include:
- Confirming that the client still has a safety plan in effect.
- Monitoring and updating the treatment plan.
- Confirming that a client has kept referral appointments.
- Following up if a recurrence of suicidal thoughts or attempts is observed.
- Keeping family members engaged in the treatment process.
- Confirming that the client and the family have an emergency phone number to call.
- Confirming that the client does not have access to a method of suicide.
- Completing a formal treatment termination summary when this stage of care is reached. (CSAT, 2015)
These approaches typically include followup contact and use diverse modalities (home visits, mail, telephone, e-mail) to engage recent suicide attempt survivors in continued treatment to prevent re-attempts. Treatment may focus on improved coping skills, mindfulness, and other emotional regulation skills, and may include case management home visits to increase adherence to treatment and continuity of care; and one-on-one interpersonal therapy and/or group therapy. Approaches that engage and connect people to peers and providers are especially important because many attempters do not present to aftercare; 12% to 25% re-attempt within a year, and 3% to 9% of attempt survivors die by suicide within 1 to 5 years of their initial attempt (Stone et al., 2017).