Suicide risk management Summary

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					Suicide risk management
ID: 1016
Type: Monograph Standard [en-us]

Topic Synonyms
  •       Suicide
  •       Self-harm
  •       Deliberate self-harm
  •       Suicide attempt
  •       Suicidal thoughts
  •       Self-destructive acts

Related Topics
  •       Depression
  •       Bipolar disorder in adults
  •       Schizophrenia
  •       Seasonal affective disorder (SAD)
  •       Substance abuse
  •       Post-traumatic stress disorder
  •       Anxiety disorders

Summary
Key Highlights
  •       Suicide is the 13th leading cause of death worldwide, with about 1 million deaths every year due to
          self-inflicted violence.
  •       In people ages 15 to 44 years, self-inflicted injury is the fourth leading cause of death and the sixth
          leading cause of ill health and disability worldwide, making suicide a significant public health concern.
  •       There are 5 components to suicide: ideation, intent, plan, access to lethal means, and history of past
          suicide attempts.
  •       Suicide risk management refers to the identification, assessment, and treatment of a person exhibiting
          suicidal behavior (includes death by suicide, suicide attempt, and suicidal ideation).
  •       Key risk factors for suicide include previous suicide attempt, current suicidal plan or ideation, and
          history of mental illness (most commonly major depressive disorder and substance abuse).
  •       Effective treatment of mental disorder plays an important role in suicide prevention. Other important
          prevention strategies are suicide risk screening, mental health education for primary care physicians
          and gatekeepers, school-based interventions, means restriction, and media interventions.

 History and Exam,                               Tests               Treatment Options
 Diagnostic Factors                               1st Tests To       Acute
  Key Diagnostic Factors                          Order                 •   patients with suicidal risk or
      •     previous suicide attempt                •   Tool for            behavior
      •     current suicide plan                        Assessment            • hospitalization or outpatient
      •     access to lethal means                      of                       monitoring
      •     hx of psychiatric disease,                  Suicide               • with bipolar disorder
            including substance abuse                   Risk                        • mood stabilizer
      •     FHx of suicide or mental illness            (TASR)                • with schizoaffective disorder
                                                                                    • antipsychotic and/or
  Other Diagnostic Factors                                                             mood stabilizer




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   •   chronic medical illness,                 •  with depression
       disability, or disfigurement                   • selective
   •   significant psychosocial factors                  serotonin-reuptake
   •   personality and/or maladaptive                    inhibitor (SSRI)
       traits                                   • with personality disorder
                                                      • selective
                                                         serotonin-reuptake
                                                         inhibitor (SSRI)
                                                • with substance abuse
                                                      • detoxification and
                                                         monitoring
                                          •   patients with suicidal risk or
                                              behavior
                                                • psychotherapy
                                                • with bipolar disorder
                                                      • mood stabilizer
                                                • with schizoaffective disorder
                                                      • antipsychotic and/or
                                                         mood stabilizer
                                                • with depression
                                                      • selective
                                                         serotonin-reuptake
                                                         inhibitor (SSRI)
                                                • with personality disorder
                                                      • selective
                                                         serotonin-reuptake
                                                         inhibitor (SSRI)
                                                • with substance abuse
                                                      • detoxification and
                                                         monitoring
                                          •   patients with suicidal risk or
                                              behavior
                                                • psychosocial interventions
                                                • with bipolar disorder
                                                      • mood stabilizer
                                                • with schizoaffective disorder
                                                      • antipsychotic and/or
                                                         mood stabilizer
                                                • with depression
                                                      • selective
                                                         serotonin-reuptake
                                                         inhibitor (SSRI)
                                                • with personality disorder
                                                      • selective
                                                         serotonin-reuptake
                                                         inhibitor (SSRI)
                                                • with substance abuse
                                                      • detoxification and
                                                         monitoring
                                          •   patients with suicidal risk or
                                              behavior




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                                                                         •   treatment of physical injury if
                                                                             suicidal attempt
                                                                         •   with bipolar disorder
                                                                                • mood stabilizer
                                                                         •   with schizoaffective disorder
                                                                                • antipsychotic and/or
                                                                                   mood stabilizer
                                                                         •   with depression
                                                                                • selective
                                                                                   serotonin-reuptake
                                                                                   inhibitor (SSRI)
                                                                         •   with personality disorder
                                                                                • selective
                                                                                   serotonin-reuptake
                                                                                   inhibitor (SSRI)
                                                                         •   with substance abuse
                                                                                • detoxification and
                                                                                   monitoring

                                                                 Ongoing
                                                                   •   those left behind after a death by
                                                                       suicide
                                                                         • grief counseling

Basics
Basics: Definition
Suicide risk management refers to the identification, assessment, and treatment of a person exhibiting
suicidal behavior. Suicidal behavior includes death by suicide, suicide attempt, and suicidal ideation. The
literature also sometimes includes nonsuicidal self-harm as a component of suicidal behavior. There are
5 components to suicide: ideation, intent, plan, access to lethal means, and history of past suicide attempts.

Basics: Classifications
 Suicidality
Refers to any thoughts or actions associated with an implicit or explicit intent to die. However, this word is
sometimes used in a manner that includes self-harm events that may not be associated with the intent to
die. This term is of limited value, because it covers such a wide range of concepts that it provides little if
any clinical or public health specificity.

 Suicidal ideation
Includes thoughts and fantasies about, or ruminations and preoccupations with, death in general, and
self-inflicted death in particular. The greater the magnitude, clarity, and persistence of suicidal thoughts a
person experiences, the greater is thought to be the risk for death by suicide.

 Suicidal intent
A person's commitment to and expectation of death by suicide. The strength of the person's intent to die
may be reflected in his or her belief in the lethality of the chosen method of suicide. This belief may be
more relevant to the person's commitment to suicide than the actual lethality of the chosen method. The
stronger the suicidal intent a person experiences, the greater is thought to be the risk for death by suicide.




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 Suicide plan
Refers to the specific ideas a person has about an impending suicide attempt. May include the choice of
a method, plans to access the method, belief about the lethality of the method, a time or setting for the
event, and any other actions taken to prepare for death (e.g., writing a suicide note, preparing a will, giving
away personal belongings or property).
In general, suicide plans that are premeditated and well thought out involve the choice of a highly lethal
method (e.g., firearm or hanging) and are planned for a setting and time when discovery is unlikely. Such
plans usually indicate a high suicide risk.

 Suicide attempt
Sometimes referred to as parasuicide, a suicide attempt is any purposeful action taken by a person
associated with an implicit or explicit intent to die, regardless of the objective lethality of the method. History
of a previous suicide attempt increases a person's risk for death by suicide.

 Self-harm
Any self-inflicted injury that is not associated with an implicit or explicit intent to die. Examples of self-harm
behaviors include burning/cutting after an emotionally upsetting event or burning/cutting as a method of
manipulation or threat. Data collection in some jurisdictions may not differentiate self-harm events from
suicide attempts, although clinical approaches to patients with persistent self-harm behaviors may be
specific to that group.

Basics: Vignette
Common Vignette
A 48-year-old respected business owner residing in a large urban area visits his family physician. He is
concerned because of a loss of weight over the previous 6 weeks and worries that he may have cancer.
He has no substantive medical or psychiatric history and notes that he has been seeing his religious leader
due to a loss of faith, self-doubt, and worries about the future of the world. Routine physical exam is
unremarkable. He is booked for a CT scan of his abdomen, and a stool sample analysis is requested
because of vague complaints about bowel problems. Three days later the coroner informs the physician
that this patient has committed suicide by hanging. A postmortem case review concludes that the patient
has had a major depressive disorder for about 3 to 4 months. His work colleagues had noticed that something
was wrong but were concerned about approaching him because they did not want to pry. His wife had
been very concerned about his lack of interest, brooding, sleep problems, and weight loss but had attributed
these changes to difficulties at work.
Common Vignette
A 79-year-old man residing in a rural village presents to his family doctor with complaints of a 3-week
history of constipation, backache, headaches, and constant fatigue. He has a pre-existing cardiac condition
and is taking occasional nitrogylcerin for exercise-induced chest pain. He also has insulin-requiring diabetes
with reasonable control of his diabetic indices. He is the primary caretaker for his wife, who has recently
been diagnosed with Alzheimer disease. A systems review elicits feelings of depression, hopelessness,
and persistent suicidal ideation. He feels overwhelmed by the severity of his wife's condition and the burden
of her caretaking. He has made vague suicide plans but is worried about how his death would affect his
wife's care.

Basics: Epidemiology
Suicide is one of the leading causes of death in the US, Canada, UK, Australia, and New Zealand. In people
ages 15 to 44 years, self-inflicted injury is the fourth leading cause of death and the sixth leading cause of
ill health and disability worldwide, making suicide a significant public health concern.



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Suicide is usually more common among males than females, but the opposite is true for suicide attempts.[1]
[2] In 2005, the suicide rate among males in the US was 4 times the rate among females.[1] However, the
rate of lifetime suicide attempts among females outnumbers the rate for males.[2] In Canada, the suicide
rate among men peaks in the 30- to 44-years age group, falling thereafter until past age 75 years, when
there is another increase. Among women, the suicide rate is highest in the 45- to 59-years age group.[2]
The discrepancy between men and women with respect to death by suicide may result from the method
choice, because men tend to choose more lethal methods such as firearms and hanging rather than
poisoning or cutting, which are favored by women.[2] In addition, the higher rate of female suicide attempts
may in part be due to self-harm behaviors (more common among females) being coded as suicide attempts.
Suicide is frequently reported as the most common cause of death in correctional settings. As a group,
inmates have higher suicide rates than their community counterparts.[3]
While comparison of suicide prevalence rates across countries is difficult due to differences in nature,
quality, and availability of reporting, as well as collection and analysis of data related to suicide, the WHO
provides some comparative international data.[4] Male suicide rates are highest in postcommunist countries
such as Lithuania (68.1/100,000), Belarus (63.3/100,000), and Russia (58.1/100,000), whereas female
suicide rates are highest in Asian countries such as China (14.8/100,000), Korea (14.1/100,000), and
Japan (13.1/100,000).[4] Rate variations are similarly substantial in different regions of the same country,
even in Western states. For example, in Canada suicide rates range from a high of 364.4/100,000 to a low
of 6.5/100,000 across the administrative regions of provinces and territories.[5]
In developed countries, the suicide rate is high for people in midlife and in older people, whereas in
developing countries it is highest in people <30 years of age.[6] The male-to-female suicide ratio also
differs, with more females committing suicide in some developing countries (e.g., ratio of 3:1 in Canada
versus 1.4:1 in China).[6]
Therefore, while suicide is a global concern, it must be understood within the local or regional context so
that appropriate public health and clinical responses can be developed and effectively implemented.
It should also be noted that suicide affects a web of people connected with the deceased, including spouses,
parents, siblings, friends and acquaintances, coworkers, and healthcare providers. A conservative estimate
counts 6 survivors for every suicide death.[7] In one US study, 7% of the 5000 participants had experienced
a suicide of someone they cared about in the past year; for 3% the deceased was an immediate family
member.[8]

Basics: Etiology
Suicide results from a constellation of psychological, biologic, genetic, social, and environmental factors.
A major component of suicide is mental illness, and studies report that up to 90% of people who commit
suicide have a diagnosed psychiatric disorder.[9]
The 2 most prevalent mental disorders associated with suicide are major depressive disorder and substance
abuse.[10] [11] [12] However, different psychiatric disorders bring different levels of risk for suicide.




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             Comparison of risk for suicide in the presence of selected psychiatric disorders
               Source: Adapted from Harris EC, et al. Br J Psychiatry 1997;170:205-228

Physical disorders have also been studied in relation to increased suicide risk. Increased rates of suicide
have been reported in Huntington disease, epilepsy, and after neurosurgery.[13] Other medical illnesses
associated with increased suicide risk include HIV/AIDS, cancer (especially of lung and upper airway, GI
tract, CNS, lymphoreticular system, pancreas, and kidney), multiple sclerosis, peptic ulcer disease, renal
disease, spinal cord injury, and SLE.[13]




         Comparison of risk for suicide with and without presence of selected medical illnesses




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 Source: Data adapted from Harris EC, et al. Br J Psychiatry 1997;170:205-228; McGirr A, et al. J Clin
        Psychiatry 2008;69:966-970; Harris EC, et al. Medicine (Baltimore) 1994;73:281-296

Medical illness and increased risk of suicide are thought to be associated in part through the presence of
a concurrent mental illness. For example, brain injury may result from substance abuse or suicide attempt;
a change in brain function due to a CNS disorder may lead to mood disturbance or personality disorder;
and disability, disfigurement, and social alienation may lead to mood disturbance.[13] In addition, terminal
illness diagnosis may induce patients to wish to preempt the inevitable on their own terms.[14] Other
research regarding the role of physical illness on suicide has found an independent link between physical
illness and suicide attempts even after controlling for a variety of mental disorders.[15] [16]
Social disadvantage, nonintact family of origin, parental psychopathology, family history of suicidal behavior,
and history of childhood physical or sexual abuse have also been studied as risk factors for suicide,
especially in youth.[17] [18] Sexual orientation has been implicated as a risk factor for suicide attempt but
not death by suicide.[19]
Suicide is frequently reported as the most common cause of death in correctional settings. As a group,
inmates have higher suicide rates than their community counterparts. A systematic review of risk factors
for suicide in prisoners identified occupation of a single cell, recent suicidal ideation, history of attempted
suicide, psychiatric diagnosis, and history of alcohol use problems as most important.[3] In addition, the
International Association for Suicide Prevention Task Force on Suicide in Prisons has developed profiles
of high-risk groups within the prisoner population.[20] Risk for suicide among pretrial inmates is associated
with male gender, young age (20-25 years), unmarried status, and being a first-time offender arrested for
a minor, usually substance-related, offense.[20] They are typically intoxicated at the time of their arrest
and commit suicide at an early stage of their confinement, or near the time of a court appearance, especially
if a favorable outcome is not expected.[20] Compared with pretrial inmates, among sentenced prisoners
factors associated with suicide include older age (30-35 years), being a violent offender, and having served
considerable time in custody (often 4 or 5 years).[20] Among this group, suicide may be precipitated by a
conflict within the institution with other inmates or with the administration, a family conflict or breakup, or
a negative outcome relating to their legal status.[20]
Certain occupations carry a greater risk for suicide than others (e.g., medical and dental professionals in
the UK).[21] However, unemployed people tend to have a higher suicide rate than those in the work
force.[22]
Risk factors for suicide in developing countries may be different from those in developed countries. For
example, married women are at highest risk for suicide in some developing countries, whereas in developed
countries suicide risk is higher for divorced, widowed, or separated men.[6] Other risk factors for suicide
in non-Western countries may include social dislocation, economic instability, widespread availability of
lethal means (such as pesticides), sociocultural factors, and lack of availability of effective mental health
care.
Access to lethal means significantly increases risk for death by suicide.The US national mortality follow-back
survey showed that the odds of suicide increased 28-fold given the presence of a firearm in the home
(odds ratio 27.9, 95% CI 18.7 to 41.4).[23] The most lethal means of suicide are firearms, with case-fatality
rates of about 90%, followed by hanging, strangling, and suffocation.[24] Drug overdose and cutting are 2
less-lethal methods, with case-fatality rates of 2% and 3%, respectively.[24] Other methods of suicide are
drowning; poisoning by gas, liquid, or solid; burning; jumping in front of moving objects or from a height;
and motor vehicle collisions.

Basics: Pathophysiology
Genetic and neuroendocrine studies point to factors involved in serotonin pathways as relevant to suicidal
behaviors.[25] These observations seem to be independent of the serotonin abnormalities found in
depression. Genetic studies have focused on serotonin-related genes, including tryptophan hydroxylase,
serotonin transporter, 3 serotonin receptors (HTR1A, HTR2A, HTR1B), and the monoamine oxidase



Page 7
promoter.[25] Other factors with putative involvement in suicidal behavior include the noradrenergic system
(alpha-2-adrenergic receptors, tyrosine hydroxylase, catechol-O-methyltransferase), the dopaminergic
system (cerebrospinal fluid homovanillic acid, dopamine receptors), and the hypothalamic-pituitary-adrenal
axis stress response function.[26]

Basics: Risk Factors
Strong
 current suicidal plan
  •   In general, suicide plans that are premeditated and well thought out usually indicate a high suicide
      risk. In a sample of British psychiatric hospital inpatients, the odds of death by suicide increased
      11-fold given presence of a suicide plan (odds ratio 11.8, 95% CI 1.3 to 111.3).[27]
 previous suicide attempt
  •   Odds of suicide increased 16-fold given greater-than or equal to2 previous suicide attempts (odds
      ratio 16.39, 95% CI 2.11 to 125.00).[28]
 hx of mental disorder, including substance abuse
  •   Mental illness is a major component of suicide, with up to 90% of people committing suicide having
      a psychiatric diagnosis.[9] The 2 most prevalent mental disorders associated with suicide are major
      depressive disorder and substance abuse.[10] [11] [12] [e2]
 availability of lethal means
  •   The most lethal means of suicide are firearms (case-fatality rate about 90%), followed by hanging,
      strangling, and suffocation.[24]
  •   Studies in different countries have consistently found a gender difference with respect to choice of
      method used to commit suicide.[24] [29] [30]
  •   For males, the most common methods are hanging, strangling, or suffocation, followed by firearms
      and poisoning. For females, hanging is used with equal frequency but poisoning is more common
      than use of firearms. Males tend to use more-lethal methods, resulting in higher rates of death by
      suicide.
 hx of childhood sexual or physical abuse
  •   A retrospective cohort study found that the odds of a lifetime history of attempted suicide tripled
      among patients who reported childhood sexual or physical abuse (odds ratio 3.4, 95% CI 2.9 to
      4.0).[31]
 FHx of death by suicide
  •   A Danish case-control study demonstrated increased suicide risk for patients with a family history of
      death by suicide (odds ratio 2.58, 95% CI 1.84 to 3.61).[32]
 male gender
  •   Death by suicide is usually more common among males than females. In 2005, the suicide rate among
      males in the US was 4 times the rate for females.[1] However, the rate of lifetime suicide attempts
      among females outnumbers the rate among males.[2]
  •   The discrepancy between males and females with respect to death by suicide may result from method
      choice because males tend to choose more lethal methods such as firearms and hanging rather than
      poisoning or cutting, which are favored by females.[2] In addition, the higher rate of female suicide
      attempts may in part be due to self-harm behaviors (more common among females) being coded as
      suicide attempts.
 prison inmate



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 •   Suicide is frequently reported as the most common cause of death in correctional settings. As a group,
     inmates have higher suicide rates than their community counterparts.
 •   A systematic review of risk factors for suicide in prisoners identified occupation of a single cell, recent
     suicidal ideation, history of attempted suicide, psychiatric diagnosis, and history of alcohol use problems
     as most important.[3]
 •   In addition, the International Association for Suicide Prevention Task Force on Suicide in Prisons has
     developed profiles of high-risk groups within the prisoner population.[20] Risk for suicide among
     pretrial inmates is associated with male gender, young age (20-25 years), unmarried status, and
     being a first-time offender arrested for a minor, usually substance-related, offense.[20] They are
     typically intoxicated at the time of their arrest and commit suicide at an early stage of their confinement,
     or near the time of a court appearance, especially if a favorable outcome is not expected.[20] Compared
     with pretrial inmates, among sentenced prisoners factors associated with suicide include older age
     (30-35 years), being a violent offender, and having served considerable time in custody (often 4 or
     5 years).[20] Among this group, suicide may be precipitated by a conflict within the institution with
     other inmates or with the administration, a family conflict or breakup, or a negative outcome relating
     to their legal status.[20]

Weak
FHx of psychiatric illness
 •   A Danish case control study demonstrated increased suicide risk for patients with a family history of
     psychiatric illness. This increased risk was restricted to patients with a personal history of psychiatric
     illness (odds ratio 1.31, 95% CI 1.19 to 1.45).[32]
physical illness (especially of CNS) and/or physical impairment
 •   Increased rates of suicide have been reported in Huntington disease, epilepsy, after neurosurgery,
     and in the presence of unspecified organic mental disorders.[11] [12] [13] Risk for suicide may also
     increase in the presence of terminal illness, chronic disease, pain, functional impairment, cognitive
     impairment, loss of sight or hearing, disfigurement, and loss of independence or increased dependency
     on others.
marital status (divorced, single, widowed)
 •   A Danish national register-based study showed single marital status to be a significant risk factor for
     suicide (odds ratio 3.17, 95% CI 3.08 to 3.27).[33] A US-based national longitudinal mortality study
     demonstrated an increased risk for suicide among divorcees, especially males (relative risk 2.47,
     95% CI 1.84 to 3.30).[34] An Italian study of the relationship between suicide and marital status
     concluded that being single, divorced, or separated was associated with a higher rate of suicide (odds
     ratio 2.00, 95% CI 1.87 to 2.16).[35]
professions/occupations (unemployed, self-employed, agricultural workers,
medical and dental professionals)
 •   Certain occupations carry a greater risk for suicide than others.
 •   A New Zealand study found that people working in farming, fisheries, forestry, and trades had higher
     suicide rates than people in other occupations.[22] Studies from England and Wales also point to
     medical and dental professionals in addition to agricultural occupation.[21] A Lithuanian study found
     that self-employed people had much higher suicide risk than employees.[36] In contrast, a Danish
     study found that suicide risk was reduced in all occupations after adjustment for history of psychiatric
     admission and socioeconomic factors (employment status, marital status, gross income) with the
     exception of medical doctors and nurses.[37]
 •   Unemployed people tend to have a higher suicide rate than employed people.[22]
psychosocial stressors



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  •   Suicide risk factors associated with psychosocial history include actual/perceived interpersonal loss
      or bereavement, perceived humiliation, legal difficulties, financial difficulties, changes in socioeconomic
      status (e.g., job loss), housing problems, work/school issues, family problems, marital/relationship
      troubles, interpersonal/peer group problems, and domestic violence.
  •   None of the above factors is a substantial predictor of suicide, but they may contribute to the overall
      risk profile through their effect on the person's ability to cope and on the support systems available
      to the person.

Basics: Prevention
Primary care physician training
  • One promising approach to suicide prevention is the training of primary care physicians to recognize,
     treat, and, if necessary, refer patients with mental illness, especially depression.[38] Effective early
     treatment of depression is associated with decreased suicide rates and suicide attempts.This approach
     therefore targets a causal as well as modifiable risk factor.[39] [40] [41] This is especially important
     given that people who commit suicide often see primary healthcare professionals within a month
     before death.[42] Unfortunately, knowledge of suicide risk factors and application of risk assessment
     and management is low among many primary care providers.[43] [44] The success of depression
     and suicide training programs in reducing suicide rates and increasing care for depression has
     underscored the need for improved mental health training for primary care physicians as a
     suicide-prevention strategy.[9] [45] [46] Ideally, these strategies should be integrated into models of
     enhancing mental healthcare delivery in primary health care.[47]
Provision of enhanced primary care
  • The Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) evaluated the
     impact of a care management intervention (including use of pharmacologic and/or psychological
     therapies) on suicidal ideation and depression in primary care patients who were greater-than or
     equal to60 years old.[48] Depressed patients in the primary care practices that used the PROSPECT
     intervention had a higher likelihood of receiving treatment for depression, a greater decline in suicidal
     ideation, lower severity of depressive symptoms, and a higher response rate over 24 months than
     patients in practices providing usual care.[48]
Gatekeeper training
 • Gatekeepers are people in contact with high-risk people or populations and include clergy, first
    responders, pharmacists, geriatric caregivers, personnel staff, and people employed in institutional
    settings, including schools, prisons, and the military.[9] The purpose of gatekeeper training is to
    facilitate recognition of risk for suicide, mental illness, or high levels of distress, and to improve links
    between the person in distress and mental health services. Gatekeeper training has been successful
    in improving knowledge, attitudes, and skills of trainees, and programs implemented in the Norwegian
    army and the US Air Force have been successful in lowering suicide rates.[9] [49] [50]
School-based suicide-prevention programs
  • Suicide awareness curricula are widely employed in schools in many countries. However, there is
    little substantial evidence to support their implementation.[51] [18] [52] Promising programs include
    screening for and subsequent referral of students with mental health problems, gatekeeper training
    for educational professionals with respect to recognizing depression and other mental illnesses, and
    seamless procedures for referral to mental health services.
  • SOS (Signs of Suicide), a program that includes a self-screening and curriculum component, is the
    only school-based suicide-prevention program that has been shown to be effective in the short term
    (3 months postintervention) in reducing suicide attempts, without an associated increase in help-seeking
    behavior.[53] However, its impact on suicide rates is not reported, making its effectiveness as a
    suicide-prevention program unclear. Two other school-based suicide-prevention strategies - peer



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     helper programs and postintervention/crisis debriefing interventions - are not supported by sufficient
     evidence to substantiate their widespread use.[54] [55]
Community-based prevention programs
  • Suicide risk factors within the community setting may be used to identify populations, groups, or
    people in populations who are at higher risk for suicide. However, population-based risk-factor
    modification as a public health strategy for decreasing suicide rates may not be effective if the factors
    chosen for modification are not causal. Furthermore, targeting of risk factors considered to be proxy
    measures of death by suicide (e.g., suicidal ideation) using population-based interventions may not
    lead to the desired outcome (decreased rates of death by suicide).
  • Other community-based suicide-prevention programs, such as those built on the ideology of enhancing
    protective factors or strengthening community cohesion, have not been shown to be effective in
    significantly decreasing and maintaining a decrease in suicide rates. Often, neither the potential risks
    (e.g., a rise in suicide after the implementation of a program) nor the cost effectiveness of these
    approaches has been adequately evaluated.[56]
  • Another community-based suicide-prevention program involves education of media regarding
    responsible reporting of suicide, which has been implicated in reducing suicide rates in Austria.[57]
  • Although crisis hotlines are widely available, there is little substantial evidence for their effectiveness
    in suicide prevention.[9] [51] [58]
Restricting access to lethal methods of self-harm
  • Access to methods for self-harm is a modifiable risk factor, and restricting access to methods is one
     strategy that may be successful in preventing suicides. For example, constructing bridge safety
     barriers, detoxifying cooking gas and car exhausts, limiting amounts of acetaminophen, and restricting
     firearms have all been cited as possible effective suicide-prevention strategies.[9] [51] [18] [59]
     Difficulties in measuring direct effects of means-restriction strategies in the presence of secular trends
     in suicide rates, coupled with the potential for method substitution, contribute to controversy surrounding
     their effectiveness.
Secondary Prevention
Informed consent should be obtained from patients to allow physicians and family members to contact
each other if suicide risk is a concern.
Family members need to be educated about suicide risk. Lethal means such as guns should be removed
from the home. Family members should be instructed to contact the patient's physician if they suspect
adherence to treatments has been compromised; the patient begins to discuss suicide ideas or plans; or
the patient's clinical condition worsens.
Among adolescents, fostering family alliance and increasing the availability of external supports may be
important in reducing the risk of a suicide attempt among patients who self-harm.[113]

Diagnosis
Diagnosis: Diagnosis Approach
When establishing the presence of suicidal ideation, the overall goal is to determine the risk for death by
suicide. Therefore, history taking and a thorough psychological assessment, especially addressing suicide
risk factors, are key.
Risk factors for suicide cover a broad range of variables, from personal history (e.g., history of past suicide
attempt) to indicators of current emotional or psychological functioning (e.g., major depressive episode).
In the case of the clinical assessment for suicide risk, risk factors are used to estimate the probability of
the occurrence of suicide in the immediate future. They do not predict which person will or will not commit
suicide or when they might do it. Clinical interventions are guided by the clinician's estimation of the



Page 11
probability of imminent suicide using risk factors as a guide. The most predictive factors for imminent suicide
are the presence of a suicide plan and immediate access to lethal means.
Most published suicide research comes from Western countries, and most public health intervention studies
have been conducted in resource-rich settings. Similarly, clinical interventions have most often been
developed from Western perspectives, although non-Western and resource-poor regions are increasingly
reporting on clinical and public health interventions. Much of the information used to address the clinical
approach to suicide in this monograph has been gleaned from systematic reviews of Western-based studies
in which mental health and primary care systems are relatively well developed. Where reasonable evidence
for other approaches in different settings is available, this has been included. Overall, it is necessary for
the clinician to be aware that, while mental disorders contribute in large part to suicide, in some settings,
other factors related to sociocultural or political-economic issues may also be at play.

Clinical assessment of suicide risk
Suicide risk must be evaluated under the following circumstances:[60]
  • When a patient presents in crisis to mental health or emergency services
  •   During all initial psychiatric inpatient or outpatient clinical evaluations
  •   When a change in patient observation status or treatment setting is considered
  •   When clinical presentation of previously known mental status changes suddenly, including sudden
      worsening or improvement in symptoms
  •   When patients do not improve, or experience worsening of symptoms despite treatment
  •   When a patient has experienced a significant psychosocial stressor, such as perceived or actual loss,
      shame, or humiliation.
Suicide risk assessment has 4 steps:[60]
  • Assessment of the 5 components of suicide: ideation, intent, plan, access to lethal means, and history
     of past suicide attempts
  • Evaluation of suicide risk factors
  •   Evaluation of current experience (What's going on?)
  •   Identification of targets for intervention.
The Tool for Assessment of Suicide Risk (TASR) can be used by the assessing clinician in the clinical
setting to determine the probability of imminent suicide risk. It has no numeric scoring system or cutoff
score that predicts suicide. The TASR, however, helps ensure consideration of the most important issues
pertaining to suicide risk so that the best-informed decision as to how to proceed can be made. This tool
also provides a good record of the details of the suicide assessment and can be appended to a patient's
chart or record in any setting.[60]




Page 12
                               Tool for Assessment of Suicide Risk
Source: From Kutcher S, Chehil S. Suicide risk managment: a manual for health professionals. Malden,
                                        MA: Blackwell; 2007

The following observable signs and symptoms in a person indicate the need for immediate medical
intervention:[61]
   • Threatening to hurt or kill himself or herself




Page 13
  •   Looking for ways to kill himself or herself
  •   Seeking access to pills, weapons, or other means
  •   Talking or writing about death, dying, or suicide.

Assessment of the 5 components of suicide
When assessing suicidal intent, plan, access to lethal means, and history of suicide attempts the following
questions are recommended:
Asking about suicidal ideation
  • Have you thought that your life is not worth living?
  •   Have you thought about ending your life?
  •   Do you feel that your reasons for living outweigh your reasons for dying?
  •   If you had a way, would you try to take your own life?
  •   If you thought you were going to die, would you take steps to save yourself?
  •   How often do you think about dying?
        • How long does it usually take for the thoughts to go away?
  •   Are thoughts about dying or taking your life overpowering to you?
Asking about suicidal intent and plan
  • How do you feel when you start thinking about taking your own life?
  •   Have you ever thought of ways to take your own life?
  •   Have you ever had specific thoughts or plans about taking your own life?
        • Have you set a time or place?
        •   What are those plans?
  •   Do you have access to method (e.g., pills, poisons, medication, weapon)?
        • Do you think you could get (method) if you needed to?
  •   Do you think you would die if you used (method)?
  •   Have you done anything or taken steps to prepare to take your own life (e.g., writing suicide note or
      will, arranging method, giving away possessions)?
  •   Do you think that you could take your own life?
  •   Do you feel ready to die?
Frequency, context (e.g., time, setting, planning, substance use, impulsivity, witnesses), method (lethality
of method, insight into lethality), consequences (medical severity, resulting treatment, psychosocial
consequences), and intent (expectation of lethality of method, attitude toward life, feeling about discovery
and survival) are important characteristics of past suicidal behaviors that should be identified during the
initial assessment.

Evaluation of other suicide risk factors
Having dealt with the presence of any current or past suicidal behaviors, as well as access to lethal means,
it is essential to collect information on the patient's psychiatric history and to conduct a careful psychiatric
mental status exam to establish current psychiatric symptoms. Mental illness is a major component of
suicide, with up to 90% of people who commit suicide having a psychiatric diagnosis.[9] Greater risk of
suicide is associated with mood disorders, anxiety disorders, substance abuse, and psychotic disorders.
Psychiatric disorders should be diagnosed using standard international diagnostic criteria (DSM or ICD).




Page 14
Details of the patient's medical, psychosocial, and family history (particularly of mental illness or suicide)
should also be discussed.
The purpose of obtaining a medical history is to identify the presence of current medical diagnoses or
physical challenges that may increase suicide risk, such as terminal illness, chronic disease, pain, functional
impairment, cognitive impairment, loss of sight or hearing, disfigurement, and loss of independence or
increased dependency on others.
Family history of suicide and psychiatric disorders is associated with increased suicide risk. Information
should be obtained about the patient's age, degree of relatedness to, and involvement with family member(s)
who committed suicide or had a psychiatric disorder. Information about history of family conflict, separation
or divorce, legal troubles, substance use, domestic violence, and physical or sexual abuse should also be
collected.
The purpose of the psychosocial history is to gain insight into the patient's current living situation and level
of functioning, and to investigate the presence of acute or chronic stressors that may be overwhelming the
patient's coping capabilities. The psychosocial history also allows for determination of external supports
available to the patient, investigation of the presence of protective factors present in the patient's
environment, and exploration of cultural or religious beliefs relating to death or suicide.
It is also necessary to assess personality strengths and weaknesses. Aspects of the patient's personality,
such as personality traits or thinking styles, affect how he or she tolerates emotional or psychological stress
and what type of coping strategies he or she uses to deal with these stressors. Although these factors do
not predict suicide, they may contribute to the overall risk profile through their effect on the patient's ability
to cope, and on the support systems available to the person.

Evaluation of current experience (What's going on?)
The patient's current experience may be influenced by an underlying psychiatric disorder and/or severe
psychosocial stressors (acute or chronic). Personality disorders or maladaptive traits (no disorder) can
also play a role. The following questions are important to consider:
  • Why is the patient considering suicide as an option?
  •   Why now? Has anything changed in the patient's environment?
  •   What exactly is happening now? How is it affecting the patient?

Identification of targets for intervention
Information gathered in the previous steps should be used to identify specific targets for intervention.These
include the presence of an underlying psychiatric diagnosis or symptoms, distressing psychosocial situations,
and personality difficulties.

Assessment of suicide risk: practical suggestions
When initiating the suicide assessment, the following SHOULD be done:
 • Establish rapport.
  •   Use a calm, patient, nonjudgmental, and empathic approach.
  •   Begin with supportive statements and open-ended inquiries.
  •   Start with general and then move toward more specific questions in a sensitive and nonjudgmental
      way that creates an opportunity for dialogue; do ask specific questions about self-harm, suicidal
      thoughts, plans, attitudes toward suicide, history of suicidal behavior, thoughts of death, and feelings
      of hopelessness.
The following SHOULD NOT be done:
  • Allow your personal feelings and reactions to influence assessment and treatment.
  •   Rush the patient or ask leading questions.



Page 15
  •   Interrogate the patient or force the patient to defend his or her actions.
  •   Minimize the patient's distress.
  •   Undermine the seriousness of the suicidal thought or action.
Acquiring collateral information
  • A patient may not explicitly admit to suicidal thoughts, behaviors, or history (passive suicidality).
     Family, friends, health professionals, teachers, coworkers, or others may also provide valuable
     information to support the assessment.
  • If no informants are able to provide collateral information and the patient does not directly answer
     questions, clinical judgment based on apparent risks, possible warning signs for hidden suicidal
     ideation, intent or plan (e.g., presence of psychosis, despondence, anger, agitation; inability to develop
     rapport, make eye contact, answer direct questions about suicide), and subjective impressions may
     need to be called upon. Furthermore, the clinician may need to review hospital or clinic records for
     evidence of past self-harm behaviors, and pay close attention during the physical exam for signs of
     suspicious injuries.

Diagnosis: History and Exam, Diagnostic Factors
Key Diagnostic Factors
 previous suicide attempt (common)
  •   Significant risk factor for suicide.
  •   Frequency, context (e.g., time, setting, planning, substance use, impulsivity, witnesses), method
      (lethality of method, insight into lethality), consequences (medical severity, resulting treatment,
      psychosocial consequences), and intent (expectation of lethality of method, attitude toward life, feeling
      about discovery and survival) are important characteristics of past suicidal behaviors that should be
      identified during the initial assessment.
 current suicide plan (common)
  •   In general, suicide plans that are premeditated and well thought out involve the choice of a highly
      lethal method (e.g., firearm or hanging) and are planned for a setting and time when discovery is
      unlikely. Such plans usually indicate a high suicide risk.
 access to lethal means (common)
  •   The most predictive factors for imminent suicide are the presence of a suicide plan and immediate
      access to lethal means.
  •   The most lethal means of suicide are firearms (case-fatality rate about 90%), followed by hanging,
      strangling, and suffocation.[24]
 hx of psychiatric disease, including substance abuse (common)
  •   It is essential to collect information on the patient's psychiatric history and to conduct a careful
      psychiatric mental status exam to establish current psychiatric symptoms.
  •   Mental illness is a major component of suicide, with up to 90% of people committing suicide having
      a psychiatric diagnosis.[9] The 2 most prevalent mental disorders associated with suicide are major
      depressive disorder and substance abuse.[10] [11] [12] [e2]
  •   Greater risk of suicide is also associated with other mood disorders (e.g., bipolar disorder,
      schizoaffective disorder), anxiety disorders, and psychotic disorders.
 FHx of suicide or mental illness (common)
  •   Suicide risk factors include suicide or suicide attempt in first-degree relative, psychiatric disorder in
      first-degree relative, substance use disorder in family, domestic violence/abuse, and/or high level of
      family conflict.



Page 16
Other Diagnostic Factors
 chronic medical illness, disability, or disfigurement (common)
  •   A medical history identifies the presence of current medical diagnoses or physical challenges that
      may increase suicide risk, such as terminal illness, chronic disease, pain, functional impairment,
      cognitive impairment, loss of sight or hearing, disfigurement, and loss of independence/increased
      dependency on others.
 significant psychosocial factors (common)
  •   Suicide risk factors include actual/perceived interpersonal loss or bereavement, perceived humiliation,
      legal difficulties, financial difficulties, changes in socioeconomic status (e.g., job loss), housing
      problems, work/school issues, family problems, marital/relationship troubles, interpersonal/peer group
      problems, and domestic violence.
  •   None of these is a substantial predictor of suicide, but they may contribute to the overall risk profile
      through their effect on the patient's ability to cope and on the support systems available to the person.
 personality and/or maladaptive traits (common)
  •   These include poor problem solving skills, impulsivity, poor insight, poor affective control, rigid thinking,
      dependency, and manipulation.
  •   None of these predict suicide but may contribute to overall risk profile through their effect on the
      patient's ability to cope and on the support systems available to the person.

Diagnosis: Tests
1st Tests To Order
                                         Test                                                             Result
Tool for Assessment of Suicide Risk (TASR)                                                                variable
  •   Can be used by the assessing clinician in the clinical setting to determine the probability of
      imminent suicide risk.[image] It has no numeric scoring system or cutoff score that predicts
      suicide but helps ensure the most important issues pertaining to suicide risk are considered,
      allowing the best-informed decision as to how to proceed to be made. Also provides a good
      record of details of suicide assessment and can be appended to patient's chart/record in any
      setting.[60]

Diagnosis: Differentials
Condition                                  Sign/Symptoms                                    Differentiating tests
Self-harm     •   Self-inflicted injury that is not associated with an implicit or explicit   • Clinical
                  intent to die.                                                                 diagnosis.
              •   Examples of self-harm behaviors include burning/cutting after an
                  emotionally upsetting event or burning/cutting as a method of
                  manipulation or threat.

Diagnosis: Screening
If suicide risk screening is employed as a public health intervention in the adult[62] [63] [64] or older[65]
[66] population, as well as the adolescent population (such as in a school setting),[67] [68] [69] [70] it is
essential to ensure clarity about the threshold at which a case will be assessed, and that appropriate and
effective clinical interventions are readily available to people screened as being at high risk.
A summary of the evidence for suicide risk screening in adult primary care patients was produced for the
US Preventive Services Task Force in 2004.[71] The task force found no studies that addressed whether
screening for suicide risk in primary care patients improved morbidity or mortality, and only 1 that assessed



Page 17
an instrument's operating characteristics for identifying suicide risk in primary care. This study compared
3 items from the Symptom-Driven Diagnostic System for Primary Care (thoughts of death, wishing to be
dead, feeling suicidal) with a structured interview for identifying a plan to commit suicide. The ranges for
sensitivity were 83% to 100%, specificity 81% to 98%, and positive predictive value 5.9% to 30%.[71] With
little evidence for effectiveness of screening for suicide risk in adult primary care patients, the task force
instead recommended routine screening for suicide risk among depressed primary care patients, for which
evidence of effectiveness does exist.[71]

Diagnosis: Diagnosis Guidelines
 Assessment and treatment of patients with suicidal behaviors[72]
View Guidelines
Published by: American Psychiatric Association
Last Published: 2003
Summary
  •   Comprehensive recommendations for assessing and treating patients exhibiting suicidal behavior.
 The assessment and management of people at risk of suicide[73]
View Guidelines
Published by: New Zealand Guidelines Group
Last Published: 2003
Summary
  •   Comprehensive report aimed at those working in emergency departments or acute mental health
      services on how to assess and begin treating suicidal patients.
 Practice parameter for the assessment and treatment of children and adolescents
with suicidal behavior[74]
View Guidelines
Published by: American Academy of Child and Adolescent Psychiatry
Last Published: 2001
Summary
  •   Recommendations for assessment and management of children and adolescents presenting with
      suicidal behavior.
 Guidelines for identification, assessment and treatment planning for suicidality[75]
View Guidelines
Published by: Risk Management Foundation, Harvard Medical Institutions
Last Published: 1996
Summary
  •   Comprehensive recommendations on identifying and assessing the patient with suicidal intent.
      Management is also addressed.




Page 18
Treatment
Treatment: Treatment Approach
Treatment planning is determined by several factors, including the degree of suicide risk, presence of an
associated psychiatric condition, and level of social support available for the affected patient.

First steps
Once the presence of suicide risk is established, immediate action should include removing the means for
suicide and ensuring the safety of the patient and others, as well as treating any existing psychiatric
disorders.[76] [77]
Patients who indicate a high degree of suicidal intent, have specific plans, or choose methods with high
lethality should be assigned a higher level of risk. Admission to the hospital, or observation in a safe place
is generally indicated, though it may not reduce subsequent attempts at self-harm.[e9] Patients who present
with psychosis and/or lack adequate social support should also be admitted to the hospital for continued
monitoring.[72] If the patient refuses admission, he or she can be admitted on an involuntary basis following
the legal procedures present in the location of practice. Physicians should be familiar with the legal issues
pertaining to involuntary admission in their jurisdiction.
Outpatient treatment may be more appropriate for those patients with chronic suicidal ideation but no
history of prior significant suicide attempts. For outpatient treatment to succeed, a strong support network
and easy access to outpatient facilities are required.[72] [e3]
Any physical injury associated with a current suicide attempt should be treated appropriately.

Psychotherapy and psychosocial interventions
Psychotherapy is considered an important part of the recovery process for most patients with a high risk
of suicidal intent. However, an effectiveness study of a suicide treatment intervention would require a very
large patient population and a very long follow-up period. One study found that no specific intervention had
been shown to reduce suicide.[78] Therefore, most suicide intervention therapies are tested for their
effectiveness on preventing suicide attempt.[79] However, this is a proxy measure for suicide. Most people
who attempt it do not die by suicide, and some may be successful on their first attempt.
In RCTs, cognitive behavioral therapy (CBT) interventions have been shown to be effective in reducing
repeated suicide attempts.[79] [80] [e7] [e6] Of particular interest is dialectical behavioral therapy (DBT),
an intensive and long-term intervention featuring a combination of behavioral, cognitive, and supportive
elements developed to treat patients with borderline personality disorder. DBT has been extensively
documented and has been found to reduce suicide attempts among patients with recent suicidal and
self-harm behaviors and borderline personality disorder.[81] DBT has also been shown as promising for
use among suicidal adolescents with borderline personality features.[82] It is not known whether DBT has
a similar suicide-sparing effect in other mental disorders such as depression, bipolar disorder, substance
abuse, and schizophrenia. While DBT is reserved for those patients with an underlying personality disorder
or features thereof, candidates for CBT include patients with a psychiatric disorder that is responsive to
CBT (e.g., depression).
A review of RCTs of psychological and psychosocial interventions after attempted suicide found that
psychodynamic interpersonal therapy may also be effective in reducing suicidal ideation, habitual
self-harming behavior, and suicide attempts among patients with borderline personality disorder.[79] This
review also stressed the importance of the therapeutic alliance as a key factor in the success of a program,
and the need for outreach to improve attendance and compliance among patients, which in routine care
settings rarely exceeds 40%.[80] In fact, one study found significantly lower suicide rates among a group
of patients refusing further treatment pursuant to termination of psychiatric inpatient treatment for a
depressive or suicidal state when regular personal written contact was maintained for 5 years.[83]




Page 19
Additional interventions may include a focus on developing long-term personal goals, identifying positive
expectations, and broadening perspectives beyond immediate distress. Social supports and group
interventions may also help reduce the risk of suicide.
There is no empiric evidence for the effectiveness of no-harm contracts (agreements between a patient
and a clinician in which the patient pledges, usually in writing, not to harm him- or herself) in reducing death
by suicide or suicide attempts.[84] Furthermore, some evidence suggests that these contracts may actually
have a negative impact.[84]

With existing mental disorders
Eliminating or reducing the degree of illness associated with mental disorders should theoretically decrease
suicide rates. This has been shown true in practice. For example, better detection of major depression and
increased prescription of antidepressants have been associated with declining suicide rates in Hungary
and Sweden.[85] [86] [87] Similarly, the reduction in prescription of selective serotonin-reuptake inhibitors
(SSRIs) to treat depression in youths was associated with an increased suicide rate in the US, Canada,
and the Netherlands.[88] [89]
Identified psychiatric disorders should be treated using the best available evidence-based interventions,
pharmacologic or psychological. A study found that, regardless of intervention used, suicide attempts
decreased after the onset of treatment for depression compared with the month before initiating
treatment.[39]
The following discussion outlines treatments that have been found to reduce suicidal behaviors among
patients with psychiatric disorders.
The long-term effectiveness of lithium therapy in reducing completed and attempted suicide among patients
with bipolar and other mood disorders (it may also be helpful in schizoaffective disorder) is well
established.[e4] Withdrawal of lithium treatment may be associated with an increased rate of suicide.[90]
Patients who attempt suicide while taking lithium may require a change in their medication due to the high
lethality of lithium taken in overdose. Patients should be admitted to the hospital and their medications
reviewed with consideration for the use of antipsychotic medicines such as clozapine or an alternative
mood stabilizer such as divalproex (also known as valproate semisodium). Reports on the relative efficacy
of divalproex in preventing suicide attempts or complete suicide compared with lithium are mixed.[91] [92]
Treatment with the atypical antipsychotic clozapine has been shown to be significantly more effective than
olanzapine in preventing suicide attempts in patients with schizophrenia and schizoaffective disorder at
high risk for suicide.[93] In 2003, the FDA approved clozapine for the reduction of suicide risk in
schizophrenia.
Antidepressant treatment for major depressive disorder is associated with a substantial decrease in suicide
risk.[94] [e1] Commonly used antidepressants include fluoxetine, citalopram, and sertraline (all SSRIs).
These 3 have the best postmarketing surveillance data and are all generic. There is no substantial added
therapeutic benefit in using the newer more costly SSRIs. Both fluoxetine and paroxetine have also been
studied in relation to suicidal behavior in borderline and other personality disorders, with generally positive
results.[94] SSRIs are a popular choice (particularly as they are considered safe in overdose). However,
other studies demonstrate that antidepressants as a group reduce the risk for suicide.[95]
While controversy remains about the potential for suicide-promoting effects of antidepressants in some
vulnerable youth, most recent analyses support the finding that, while a few patients may develop new
suicidal ideation or self-harm with SSRI treatment, overall, SSRI treatment substantively decreases suicide
rates and suicide attempts in youth.[96] [97] [e5] According to a consensus statement released by the
World Psychiatric Association Section on Pharmacopsychiatry in 2008, "antidepressants, including SSRIs,
carry a small risk of inducing suicidal thoughts and suicide attempts in age groups below 25 years." However,
they note that "this risk has to be balanced against the well-known beneficial effects of antidepressants on
depressive and other symptoms including suicidality and suicidal behaviour."[95]




Page 20
A review of the acute treatment of anxiety in depressed patients with sedatives/hypnotics did not reveal
any evidence that using sedatives/hypnotics as an early adjunct to antidepressant treatment decreases
suicide risk.[98] Since there is considerable evidence that sedatives/hypnotics produce depressant and/or
disinhibitory effects in a small proportion of people, the potential risks of prescribing this type of medication
for depressed patients who may be suicidal are serious.[98] Consequently, sedatives/hypnotics are best
avoided in suicidal patients.

With substance abuse
A review found no empirically based criteria for admission to the hospital of suicidal, alcohol-dependent
people.[99] Patients with alcohol or substance dependence or abuse who are experiencing suicidal ideation,
or who have exhibited suicidal behavior, should be provided with immediate attention, specific treatments
for the chemical dependence, and/or specific treatments for any comorbid disorders.[99] This may include
detoxification treatments, or treatments that target symptoms such as anxiety, agitation, insomnia, and
panic attacks.[99] This may also include treatment of comorbid mood disorders with antidepressants such
as fluoxetine.[100]
Referral to an appropriate rehabilitation facility should be considered. Usual environmental precautions
(e.g., removing lethal means, monitoring by patient's family and friends) are also recommended.

Those left behind after a death by suicide
Suicide affects a web of people connected with the deceased, including spouses, parents, siblings, friends
and acquaintances, coworkers, and healthcare providers. These individuals should be offered grief
counseling.
Suicide postvention services target individuals personally affected by a recent suicide. The intention of
postvention programs is to aid the grieving process and reduce the incidence of suicide contagion through
bereavement counseling and education among survivors. (defined as all individuals, including family,
friends, class-mates, etc., who are affected by the death).
Provision of outreach at the time of suicide to family member survivors has been shown to increase use
of services designed to assist in the grieving process when compared to no outreach.[101] Furthermore,
bereavement support group interventions conducted by trained facilitators have been shown to result in
positive reductions in measures of psychological distress, such as depression symptoms, anxiety symptoms,
and grief experiences.[102] [103] [104] [105] [106] [107] [108] However, this area requires further study
since effects differ among individuals and survivor populations, and programs may have different impacts
based on gender (mothers versus fathers), and severity of distress.[104]

Treatment: Treatment Options
Acute
                   Treatment
Patient Group         Line                                      Treatment
patients with         1st    hospitalization or outpatient monitoring
suicidal risk or               • Immediate action should include removing means for suicide, ensuring the
behavior                          safety of the patient and others, and treating existing psychiatric
                                  disorders.[76] [77]
                               • Patients who indicate a high degree of suicidal intent, have specific plans,
                                  or choose methods with high lethality should be assigned a higher level of
                                  risk.
                               • Determining the appropriate treatment setting is essential. Admission to
                                  the hospital, or observation in a safe place is generally indicated, though
                                  it may not reduce subsequent attempts at self-harm.[e9] Patients who
                                  present with psychosis and/or lack adequate social support should also be
                                  admitted to the hospital for continued monitoring.[72]


Page 21
                           •   On admission the patient should be monitored according to established
                               suicide protocol with appropriate levels of supervision and should not have
                               access to means of self-harm.
                           •   If patient refuses admission, he or she can be admitted on an involuntary
                               basis following the legal procedures in the location of practice. Physicians
                               should be familiar with legal issues pertaining to involuntary admission in
                               their jurisdiction.
                           •   Outpatient treatment may be more appropriate for patients with chronic
                               suicidal ideation but no history of prior significant suicide attempts. For
                               outpatient treatment to succeed, a strong support network and easy access
                               to outpatient facilities are required.[72] [e3]
                           •   If ability of the patient to be safe outside admission to a treatment facility
                               is in doubt, admission is prudent for assessment or until patient's
                               environment can be more comprehensively evaluated.

   with bipolar   plus   mood stabilizer
      disorder            • The long-term effectiveness of lithium in reducing completed and attempted
                             suicide among patients with bipolar and other mood disorders is well
                             established. [e4]
                          • Withdrawal of lithium treatment may be associated with an increased rate
                             of suicide.[90]
                          • Patients who attempt suicide while taking lithium may require a change in
                             their medication due to the high lethality of lithium taken in overdose.
                          • Patients should be admitted to the hospital and their medications reviewed
                             with consideration for the use of antipsychotic medicines such as clozapine
                             or an alternative mood stabilizer such as divalproex (also known as valproate
                             semisodium). Reports on the relative efficacy of divalproex in preventing
                             suicide attempts or complete suicide compared with lithium are mixed.[91]
                             [92]
                          • While there is no absolute contraindication for combining selective
                             serotonin-reuptake inhibitors (SSRIs) with lithium (e.g., if the patient is
                             bipolar with acute depression), there may be a slightly increased risk for
                             adverse effects including serotonin syndrome. Those clinicians who do
                             combine these medications need to inform their patient of the risks and
                             benefits, and should provide additional monitoring.

                         Primary Options
                           • lithium: 300 mg orally twice daily initially, increase dose according to
                             response, maximum 1800 mg/day given in 3-4 divided doses
                         Secondary Options
                           • clozapine : 12.5 mg orally once or twice daily initially, increase by 25-50
                             mg/day increments every 3-7 days according to response, maximum 900
                             mg/day
                           • divalproex sodium: 20 mg/kg orally (extended-release) once daily initially,
                             increase according to response and serum drug level, maximum 60
                             mg/kg/day
                                 • Serum level target: 80-100 micrograms/mL.




Page 22
           with   plus   antipsychotic and/or mood stabilizer
schizoaffective            • The long-term effectiveness of lithium in reducing completed and attempted
      disorder                suicide among patients with bipolar and other mood disorders, including
                              schizoaffective disorder, is well established.[e4]
                           • Withdrawal of lithium treatment may be associated with an increased rate
                              of suicide.[90]
                           • One study found that treatment with the atypical antipsychotic clozapine is
                              significantly more effective than olanzapine in preventing suicide attempts
                              in patients with schizophrenia and schizoaffective disorder at high risk for
                              suicide.[93]

                         Primary Options
                           • clozapine : 12.5 mg orally once or twice daily initially, increase by 25-50
                              mg/day increments every 3-7 days according to response, maximum 900
                              mg/day and/or
                           • lithium: 300 mg orally twice daily initially, increase dose according to
                              response, maximum 1800 mg/day given in 3-4 divided doses
          with    plus   selective serotonin-reuptake inhibitor (SSRI)
   depression              • Antidepressant treatment for major depressive disorder is associated with
                              a substantial decrease in suicide risk.[94] [e1]
                           • Commonly used antidepressants include fluoxetine, citalopram, and
                              sertraline (all SSRIs). These 3 have the best postmarketing surveillance
                              data and are all generic. There is no substantial added therapeutic benefit
                              in using the newer more costly SSRIs. SSRIs are a popular choice
                              (particularly as they are considered safe in overdose). However,
                              antidepressants as a group reduce the risk for suicide.[95]
                           • While controversy remains about the potential for suicide-promoting effects
                              of antidepressants in some vulnerable youth, most recent analyses support
                              the finding that, while a few patients may develop new suicidal ideation or
                              self-harm with SSRI treatment, overall, SSRI treatment substantively
                              decreases suicide rates and suicide attempts in youth.[96] [97] [e5]
                           • The antidepressants discussed have been limited to those found to reduce
                              suicidal behaviors among patients with depression.
                           • There is considerable evidence that sedatives/hypnotics produce depressant
                              and/or disinhibitory effects in a small proportion of people.[98] Therefore,
                              sedatives/hypnotics are best avoided in suicidal patients.

                         Primary Options
                           • fluoxetine: 10 mg orally once daily initially, increase by 10 mg/day
                              increments at weekly intervals according to response, maximum 80 mg/day
                           • citalopram : 20 mg orally once daily initially, increase according to response,
                              maximum 60 mg/day
                           • sertraline: 50 mg orally once daily initially, increase according to response,
                              maximum 200 mg/day
          with    plus   selective serotonin-reuptake inhibitor (SSRI)
   personality             • Both fluoxetine and paroxetine have been studied in relation to suicidal
     disorder                 behavior in borderline and other personality disorders with generally positive
                              results.[94]

                         Primary Options



Page 23
                            •  fluoxetine: 10 mg orally once daily initially, increase by 10 mg/day
                               increments at weekly intervals according to response, maximum 80 mg/day
                            • paroxetine : 20 mg orally (regular-release) once daily initially, increase
                               according to response, maximum 50 mg/day
          with     plus   detoxification and monitoring
    substance               • There are no empirically based criteria for admission to the hospital of
       abuse                   suicidal, alcohol-dependent patients.[99]
                            • Patients with alcohol or substance dependence or abuse who are
                               experiencing suicidal ideation or who have exhibited suicidal behavior
                               should be provided with immediate attention, specific treatments for the
                               chemical dependence, and/or specific treatments for any comorbid
                               disorders.[99] This may include detoxification treatments or treatments that
                               target symptoms such as anxiety, agitation, insomnia, and panic attacks.[99]
                               This may also include treatment of comorbid mood disorders with
                               antidepressants such as fluoxetine.[100]
                            • Referral to an appropriate rehabilitation facility should be considered.
                            • Usual environmental precautions (e.g., removing lethal means, monitoring
                               by patient's family and friends) are also recommended.

patients with    adjunct psychotherapy
suicidal risk or           • Psychotherapy is considered an important part of the recovery process for
behavior                      most patients with high-risk suicidal intent. No specific intervention has
                              been shown to reduce suicide,[78] and most suicide intervention therapies
                              are tested for effectiveness in preventing suicide attempt.[79]
                           • In RCTs, cognitive behavioral therapy (CBT) has been effective in reducing
                              repeated suicide attempts.[79] [80] [e7] [e6] Candidates for CBT include
                              patients with a psychiatric disorder that is responsive to CBT (e.g.,
                              depression).
                           • Dialectical behavioral therapy (DBT) is an intensive and long-term
                              intervention featuring a combination of behavioral, cognitive, and supportive
                              elements developed to treat patients with borderline personality disorder.
                           • DBT reduces suicide attempts among patients with recent suicidal and
                              self-harm behaviors and borderline personality disorder.[81] DBT is also
                              promising for use among suicidal adolescents with borderline personality
                              features.[82]

    with bipolar   plus   mood stabilizer
       disorder            • The long-term effectiveness of lithium in reducing completed and attempted
                              suicide among patients with bipolar and other mood disorders is well
                              established. [e4]
                           • Withdrawal of lithium treatment may be associated with an increased rate
                              of suicide.[90]
                           • Patients who attempt suicide while taking lithium may require a change in
                              their medication due to the high lethality of lithium taken in overdose.
                           • Patients should be admitted to the hospital and their medications reviewed
                              with consideration for the use of antipsychotic medicines such as clozapine
                              or an alternative mood stabilizer such as divalproex (also known as valproate
                              semisodium). Reports on the relative efficacy of divalproex in preventing
                              suicide attempts or complete suicide compared with lithium are mixed.[91]
                              [92]




Page 24
                           •   While there is no absolute contraindication for combining selective
                               serotonin-reuptake inhibitors (SSRIs) with lithium (e.g., if the patient is
                               bipolar with acute depression), there may be a slightly increased risk for
                               adverse effects including serotonin syndrome. Those clinicians who do
                               combine these medications need to inform their patient of the risks and
                               benefits, and should provide additional monitoring.

                         Primary Options
                           • lithium: 300 mg orally twice daily initially, increase dose according to
                             response, maximum 1800 mg/day given in 3-4 divided doses
                         Secondary Options
                           • clozapine : 12.5 mg orally once or twice daily initially, increase by 25-50
                             mg/day increments every 3-7 days according to response, maximum 900
                             mg/day
                           • divalproex sodium: 20 mg/kg orally (extended-release) once daily initially,
                             increase according to response and serum drug level, maximum 60
                             mg/kg/day
                                 • Serum level target: 80-100 micrograms/mL.

           with   plus   antipsychotic and/or mood stabilizer
schizoaffective            • The long-term effectiveness of lithium in reducing completed and attempted
      disorder                suicide among patients with bipolar and other mood disorders, including
                              schizoaffective disorder, is well established.[e4]
                           • Withdrawal of lithium treatment may be associated with an increased rate
                              of suicide.[90]
                           • One study found that treatment with the atypical antipsychotic clozapine is
                              significantly more effective than olanzapine in preventing suicide attempts
                              in patients with schizophrenia and schizoaffective disorder at high risk for
                              suicide.[93]

                         Primary Options
                           • clozapine : 12.5 mg orally once or twice daily initially, increase by 25-50
                              mg/day increments every 3-7 days according to response, maximum 900
                              mg/day and/or
                           • lithium: 300 mg orally twice daily initially, increase dose according to
                              response, maximum 1800 mg/day given in 3-4 divided doses
          with    plus   selective serotonin-reuptake inhibitor (SSRI)
   depression              • Antidepressant treatment for major depressive disorder is associated with
                              a substantial decrease in suicide risk.[94] [e1]
                           • Commonly used antidepressants include fluoxetine, citalopram, and
                              sertraline (all SSRIs). These 3 have the best postmarketing surveillance
                              data and are all generic. There is no substantial added therapeutic benefit
                              in using the newer more costly SSRIs. SSRIs are a popular choice
                              (particularly as they are considered safe in overdose). However,
                              antidepressants as a group reduce the risk for suicide.[95]
                           • While controversy remains about the potential for suicide-promoting effects
                              of antidepressants in some vulnerable youth, most recent analyses support
                              the finding that, while a few patients may develop new suicidal ideation or
                              self-harm with SSRI treatment, overall, SSRI treatment substantively
                              decreases suicide rates and suicide attempts in youth.[96] [97] [e5]



Page 25
                             •   The antidepressants discussed have been limited to those found to reduce
                                 suicidal behaviors among patients with depression.
                             •   There is considerable evidence that sedatives/hypnotics produce depressant
                                 and/or disinhibitory effects in a small proportion of people.[98] Therefore,
                                 sedatives/hypnotics are best avoided in suicidal patients.

                           Primary Options
                             • fluoxetine: 10 mg orally once daily initially, increase by 10 mg/day
                                increments at weekly intervals according to response, maximum 80 mg/day
                             • citalopram : 20 mg orally once daily initially, increase according to response,
                                maximum 60 mg/day
                             • sertraline: 50 mg orally once daily initially, increase according to response,
                                maximum 200 mg/day
           with   plus     selective serotonin-reuptake inhibitor (SSRI)
    personality              • Both fluoxetine and paroxetine have been studied in relation to suicidal
      disorder                  behavior in borderline and other personality disorders with generally positive
                                results.[94]

                           Primary Options
                             • fluoxetine: 10 mg orally once daily initially, increase by 10 mg/day
                                increments at weekly intervals according to response, maximum 80 mg/day
                             • paroxetine : 20 mg orally (regular-release) once daily initially, increase
                                according to response, maximum 50 mg/day
          with    plus     detoxification and monitoring
    substance                • There are no empirically based criteria for admission to the hospital of
       abuse                    suicidal, alcohol-dependent patients.[99]
                             • Patients with alcohol or substance dependence or abuse who are
                                experiencing suicidal ideation or who have exhibited suicidal behavior
                                should be provided with immediate attention, specific treatments for the
                                chemical dependence, and/or specific treatments for any comorbid
                                disorders.[99] This may include detoxification treatments or treatments that
                                target symptoms such as anxiety, agitation, insomnia, and panic attacks.[99]
                                This may also include treatment of comorbid mood disorders with
                                antidepressants such as fluoxetine.[100]
                             • Referral to an appropriate rehabilitation facility should be considered.
                             • Usual environmental precautions (e.g., removing lethal means, monitoring
                                by patient's family and friends) are also recommended.

patients with    adjunct psychosocial interventions
suicidal risk or           • A review of RCTs of psychological and psychosocial interventions after
behavior                      attempted suicide found that psychodynamic interpersonal therapy may
                              also be effective in reducing suicidal ideation, habitual self-harming behavior,
                              and suicide attempts among patients with borderline personality disorder.[79]
                              This review also stressed the importance of the therapeutic alliance as a
                              key factor in the success of a program, and the need for outreach to improve
                              attendance and compliance among patients, which in routine care settings
                              rarely exceeds 40%.[80]
                           • Additional interventions may include focus on developing long-term personal
                              goals, identifying positive expectations, and broadening perspectives beyond
                              immediate distress.



Page 26
                            •   Social supports and group interventions may also help reduce risk of suicide.

    with bipolar   plus   mood stabilizer
       disorder            • The long-term effectiveness of lithium in reducing completed and attempted
                              suicide among patients with bipolar and other mood disorders is well
                              established. [e4]
                           • Withdrawal of lithium treatment may be associated with an increased rate
                              of suicide.[90]
                           • Patients who attempt suicide while taking lithium may require a change in
                              their medication due to the high lethality of lithium taken in overdose.
                           • Patients should be admitted to the hospital and their medications reviewed
                              with consideration for the use of antipsychotic medicines such as clozapine
                              or an alternative mood stabilizer such as divalproex (also known as valproate
                              semisodium). Reports on the relative efficacy of divalproex in preventing
                              suicide attempts or complete suicide compared with lithium are mixed.[91]
                              [92]
                           • While there is no absolute contraindication for combining selective
                              serotonin-reuptake inhibitors (SSRIs) with lithium (e.g., if the patient is
                              bipolar with acute depression), there may be a slightly increased risk for
                              adverse effects including serotonin syndrome. Those clinicians who do
                              combine these medications need to inform their patient of the risks and
                              benefits, and should provide additional monitoring.

                          Primary Options
                            • lithium: 300 mg orally twice daily initially, increase dose according to
                              response, maximum 1800 mg/day given in 3-4 divided doses
                          Secondary Options
                            • clozapine : 12.5 mg orally once or twice daily initially, increase by 25-50
                              mg/day increments every 3-7 days according to response, maximum 900
                              mg/day
                            • divalproex sodium: 20 mg/kg orally (extended-release) once daily initially,
                              increase according to response and serum drug level, maximum 60
                              mg/kg/day
                                  • Serum level target: 80-100 micrograms/mL.

           with    plus   antipsychotic and/or mood stabilizer
schizoaffective             • The long-term effectiveness of lithium in reducing completed and attempted
      disorder                 suicide among patients with bipolar and other mood disorders, including
                               schizoaffective disorder, is well established.[e4]
                            • Withdrawal of lithium treatment may be associated with an increased rate
                               of suicide.[90]
                            • One study found that treatment with the atypical antipsychotic clozapine is
                               significantly more effective than olanzapine in preventing suicide attempts
                               in patients with schizophrenia and schizoaffective disorder at high risk for
                               suicide.[93]

                          Primary Options
                            • clozapine : 12.5 mg orally once or twice daily initially, increase by 25-50
                              mg/day increments every 3-7 days according to response, maximum 900
                              mg/day and/or



Page 27
                         •  lithium: 300 mg orally twice daily initially, increase dose according to
                            response, maximum 1800 mg/day given in 3-4 divided doses
         with   plus   selective serotonin-reuptake inhibitor (SSRI)
  depression             • Antidepressant treatment for major depressive disorder is associated with
                            a substantial decrease in suicide risk.[94] [e1]
                         • Commonly used antidepressants include fluoxetine, citalopram, and
                            sertraline (all SSRIs). These 3 have the best postmarketing surveillance
                            data and are all generic. There is no substantial added therapeutic benefit
                            in using the newer more costly SSRIs. SSRIs are a popular choice
                            (particularly as they are considered safe in overdose). However,
                            antidepressants as a group reduce the risk for suicide.[95]
                         • While controversy remains about the potential for suicide-promoting effects
                            of antidepressants in some vulnerable youth, most recent analyses support
                            the finding that, while a few patients may develop new suicidal ideation or
                            self-harm with SSRI treatment, overall, SSRI treatment substantively
                            decreases suicide rates and suicide attempts in youth.[96] [97] [e5]
                         • The antidepressants discussed have been limited to those found to reduce
                            suicidal behaviors among patients with depression.
                         • There is considerable evidence that sedatives/hypnotics produce depressant
                            and/or disinhibitory effects in a small proportion of people.[98] Therefore,
                            sedatives/hypnotics are best avoided in suicidal patients.

                       Primary Options
                         • fluoxetine: 10 mg orally once daily initially, increase by 10 mg/day
                            increments at weekly intervals according to response, maximum 80 mg/day
                         • citalopram : 20 mg orally once daily initially, increase according to response,
                            maximum 60 mg/day
                         • sertraline: 50 mg orally once daily initially, increase according to response,
                            maximum 200 mg/day
         with   plus   selective serotonin-reuptake inhibitor (SSRI)
  personality            • Both fluoxetine and paroxetine have been studied in relation to suicidal
    disorder                behavior in borderline and other personality disorders with generally positive
                            results.[94]

                       Primary Options
                         • fluoxetine: 10 mg orally once daily initially, increase by 10 mg/day
                            increments at weekly intervals according to response, maximum 80 mg/day
                         • paroxetine : 20 mg orally (regular-release) once daily initially, increase
                            according to response, maximum 50 mg/day
         with   plus   detoxification and monitoring
   substance             • There are no empirically based criteria for admission to the hospital of
      abuse                 suicidal, alcohol-dependent patients.[99]
                         • Patients with alcohol or substance dependence or abuse who are
                            experiencing suicidal ideation or who have exhibited suicidal behavior
                            should be provided with immediate attention, specific treatments for the
                            chemical dependence, and/or specific treatments for any comorbid
                            disorders.[99] This may include detoxification treatments or treatments that
                            target symptoms such as anxiety, agitation, insomnia, and panic attacks.[99]
                            This may also include treatment of comorbid mood disorders with
                            antidepressants such as fluoxetine.[100]




Page 28
                            •   Referral to an appropriate rehabilitation facility should be considered.
                            •   Usual environmental precautions (e.g., removing lethal means, monitoring
                                by patient's family and friends) are also recommended.

patients with    adjunct treatment of physical injury if suicidal attempt
suicidal risk or            • Any physical injury associated with a current suicide attempt should be
behavior                      treated appropriately.

    with bipolar   plus   mood stabilizer
       disorder            • The long-term effectiveness of lithium in reducing completed and attempted
                              suicide among patients with bipolar and other mood disorders is well
                              established. [e4]
                           • Withdrawal of lithium treatment may be associated with an increased rate
                              of suicide.[90]
                           • Patients who attempt suicide while taking lithium may require a change in
                              their medication due to the high lethality of lithium taken in overdose.
                           • Patients should be admitted to the hospital and their medications reviewed
                              with consideration for the use of antipsychotic medicines such as clozapine
                              or an alternative mood stabilizer such as divalproex (also known as valproate
                              semisodium). Reports on the relative efficacy of divalproex in preventing
                              suicide attempts or complete suicide compared with lithium are mixed.[91]
                              [92]
                           • While there is no absolute contraindication for combining selective
                              serotonin-reuptake inhibitors (SSRIs) with lithium (e.g., if the patient is
                              bipolar with acute depression), there may be a slightly increased risk for
                              adverse effects including serotonin syndrome. Those clinicians who do
                              combine these medications need to inform their patient of the risks and
                              benefits, and should provide additional monitoring.

                          Primary Options
                            • lithium: 300 mg orally twice daily initially, increase dose according to
                              response, maximum 1800 mg/day given in 3-4 divided doses
                          Secondary Options
                            • clozapine : 12.5 mg orally once or twice daily initially, increase by 25-50
                              mg/day increments every 3-7 days according to response, maximum 900
                              mg/day
                            • divalproex sodium: 20 mg/kg orally (extended-release) once daily initially,
                              increase according to response and serum drug level, maximum 60
                              mg/kg/day
                                  • Serum level target: 80-100 micrograms/mL.

           with    plus   antipsychotic and/or mood stabilizer
schizoaffective             • The long-term effectiveness of lithium in reducing completed and attempted
      disorder                 suicide among patients with bipolar and other mood disorders, including
                               schizoaffective disorder, is well established.[e4]
                            • Withdrawal of lithium treatment may be associated with an increased rate
                               of suicide.[90]
                            • One study found that treatment with the atypical antipsychotic clozapine is
                               significantly more effective than olanzapine in preventing suicide attempts




Page 29
                            in patients with schizophrenia and schizoaffective disorder at high risk for
                            suicide.[93]

                       Primary Options
                         • clozapine : 12.5 mg orally once or twice daily initially, increase by 25-50
                            mg/day increments every 3-7 days according to response, maximum 900
                            mg/day and/or
                         • lithium: 300 mg orally twice daily initially, increase dose according to
                            response, maximum 1800 mg/day given in 3-4 divided doses
         with   plus   selective serotonin-reuptake inhibitor (SSRI)
  depression             • Antidepressant treatment for major depressive disorder is associated with
                            a substantial decrease in suicide risk.[94] [e1]
                         • Commonly used antidepressants include fluoxetine, citalopram, and
                            sertraline (all SSRIs). These 3 have the best postmarketing surveillance
                            data and are all generic. There is no substantial added therapeutic benefit
                            in using the newer more costly SSRIs. SSRIs are a popular choice
                            (particularly as they are considered safe in overdose). However,
                            antidepressants as a group reduce the risk for suicide.[95]
                         • While controversy remains about the potential for suicide-promoting effects
                            of antidepressants in some vulnerable youth, most recent analyses support
                            the finding that, while a few patients may develop new suicidal ideation or
                            self-harm with SSRI treatment, overall, SSRI treatment substantively
                            decreases suicide rates and suicide attempts in youth.[96] [97] [e5]
                         • The antidepressants discussed have been limited to those found to reduce
                            suicidal behaviors among patients with depression.
                         • There is considerable evidence that sedatives/hypnotics produce depressant
                            and/or disinhibitory effects in a small proportion of people.[98] Therefore,
                            sedatives/hypnotics are best avoided in suicidal patients.

                       Primary Options
                         • fluoxetine: 10 mg orally once daily initially, increase by 10 mg/day
                            increments at weekly intervals according to response, maximum 80 mg/day
                         • citalopram : 20 mg orally once daily initially, increase according to response,
                            maximum 60 mg/day
                         • sertraline: 50 mg orally once daily initially, increase according to response,
                            maximum 200 mg/day
         with   plus   selective serotonin-reuptake inhibitor (SSRI)
  personality            • Both fluoxetine and paroxetine have been studied in relation to suicidal
    disorder                behavior in borderline and other personality disorders with generally positive
                            results.[94]

                       Primary Options
                         • fluoxetine: 10 mg orally once daily initially, increase by 10 mg/day
                            increments at weekly intervals according to response, maximum 80 mg/day
                         • paroxetine : 20 mg orally (regular-release) once daily initially, increase
                            according to response, maximum 50 mg/day
         with   plus   detoxification and monitoring
   substance             • There are no empirically based criteria for admission to the hospital of
      abuse                 suicidal, alcohol-dependent patients.[99]




Page 30
                               •   Patients with alcohol or substance dependence or abuse who are
                                   experiencing suicidal ideation or who have exhibited suicidal behavior
                                   should be provided with immediate attention, specific treatments for the
                                   chemical dependence, and/or specific treatments for any comorbid
                                   disorders.[99] This may include detoxification treatments or treatments that
                                   target symptoms such as anxiety, agitation, insomnia, and panic attacks.[99]
                                   This may also include treatment of comorbid mood disorders with
                                   antidepressants such as fluoxetine.[100]
                               •   Referral to an appropriate rehabilitation facility should be considered.
                               •   Usual environmental precautions (e.g., removing lethal means, monitoring
                                   by patient's family and friends) are also recommended.


Ongoing
                    Treatment
 Patient Group         Line                                       Treatment
those left behind      1st    grief counseling
after a death by                • Suicide postvention services target individuals personally affected by a
suicide                             recent suicide. The intention of postvention programs is to aid the grieving
                                    process and reduce the incidence of suicide contagion through
                                    bereavement counseling and education among survivors. (defined as all
                                    individuals, including family, friends, class-mates, etc., who are affected
                                    by the death).
                                • Provision of outreach at the time of suicide to family member survivors
                                    has been shown to increase use of services designed to assist in the
                                    grieving process when compared to no outreach.[101] Furthermore,
                                    bereavement support group interventions conducted by trained facilitators
                                    have been shown to result in positive reductions in measures of
                                    psychological distress, such as depression symptoms, anxiety symptoms,
                                    and grief experiences.[102] [103] [104] [105] [106] [107] [108] However,
                                    this area requires further study since effects differ among individuals and
                                    survivor populations, and programs may have different impacts based
                                    on gender (mothers versus fathers), and severity of distress.[104]


Treatment: Treatment Guidelines
 Self-harm: the short-term physical and psychological management and secondary
prevention of self-harm in primary and secondary care[109]
View Guidelines
Published by: National Collaborating Centre for Mental Health
Last Published: 2004
Summary
  •   Recommendations for acute management of patients who self-harm within the first 48 hours of the
      event.
 Assessment and treatment of patients with suicidal behaviors[72]
View Guidelines
Published by: American Psychiatric Association
Last Published: 2003



Page 31
Summary
  •   Recommendations for diagnosis and treatment of suicidal patients.
 The assessment and management of people at risk of suicide[73]
View Guidelines
Published by: New Zealand Guidelines Group
Last Published: 2003
Summary
  •   Recommendations on the assessment and early management of suicidal patients, particularly for
      those working in emergency departments or providing acute psychiatric services.
 Practice parameter for the assessment and treatment of children and adolescents
with suicidal behavior[74]
View Guidelines
Published by: American Academy of Child and Adolescent Psychiatry
Last Published: 2001
Summary
  •   Comprehensive report on the emergency management of children and adolescents who exhibit
      suicidal behavior. Assessment is also addressed.
 Guidelines for identification, assessment and treatment planning for suicidality[75]
View Guidelines
Published by: Risk Management Foundation, Harvard Medical Institutions
Last Published: 1996
Summary
  •   Treatment planning for the suicidal patient, as well as identification and assessment of these patients.

Followup
Followup: Outlook
A significant proportion of those who attempt suicide will eventually die by suicide, usually in the same
year as the initial attempt.[110] Furthermore, the greater the number of lifetime suicide attempts, the
increased likelihood of death by suicide. Overall, though, statistics show that most people who attempt
suicide do not eventually die in this manner.[110] However, this fact should not distract the physician from
the seriousness of a patient exhibiting suicidal behavior.

Followup: Complications
                                   Complication                                       LikelihoodTimeframe
death by suicide                                                                      medium short term
  •   Although statistics show that most patients who attempt suicide survive the
      attempt, a significant percentage will die by suicide.[110] A good outcome
      depends on early identification of suicidal behavior and appropriate therapeutic
      and supportive measures.
  •   Suicide affects a web of people connected with the deceased, including
      spouses, parents, siblings, friends and acquaintances, coworkers, and
      healthcare providers.



Page 32
  •   While the grief experienced by those left behind after suicide has many features
      similar to the grief experienced by other bereaved people, it has a few unique
      characteristics, including feelings of shame, self-recrimination, and a perpetual
      search for meaning.[7] [e10]
  •   Mental health professionals who lose a patient to suicide may experience grief,
      anger, guilt, shock, self-doubt, and fear of blame.[111] After the initial reaction,
      they may experience a period of feeling profound loss, sadness, isolation, and
      shame.[111]
  •   In a study of therapists whose patients had died by suicide, one third
      experienced severe distress, found to be associated with 4 factors: failure to
      admit to the hospital an imminently suicidal patient who then died; a treatment
      decision the therapist felt contributed to the suicide; negative reactions from
      the therapist's institution; and fear of a lawsuit by the patient's relatives.[112]
      Trainees' experiences are often especially traumatic, particularly if they feel
      they have not been adequately trained to deal with a patient suicide or feel
      they have not been sufficiently supported by their institution.[7]
  •   Suicide postvention services target individuals personally affected by a recent
      suicide. The intention of postvention programs is to aid the grieving process
      and reduce the incidence of suicide contagion through bereavement counseling
      and education among survivors. (defined as all individuals, including family,
      friends, class-mates, etc., who are affected by the death).

Followup: Recommendations
Monitoring
Patients who have attempted suicide should be monitored at regular visits for increased risk.[e8] Use of
the Tool for Assessment of Suicide Risk (TASR; a tool used, in the clinical setting, by the clinician to
determine the probability of imminent suicide risk) is one clinically appropriate approach to this issue.




Page 33
                               Tool for Assessment of Suicide Risk
Source: From Kutcher S, Chehil S. Suicide risk managment: a manual for health professionals. Malden,
                                        MA: Blackwell; 2007
Adherence to treatments (medication, psychotherapy) is essential and should also be closely monitored.
The research on nonsuicidal self-harm and its relationship to suicide attempts highlights some areas of
clinical importance for providers working with patients who self-harm. These include the need for monitoring




Page 34
suicidal ideation, levels of depressive symptoms, and feelings of apathy, because these may be markers
of increased risk of suicide attempt.
Patient Instructions
Patients who are sent home with responsible support should be provided with contact cards carrying the
name and phone number of a crisis worker that they can call should the situation worsen. A similar contact
card should be provided to the person supporting the patient at home. In addition, the patient and his or
her supports should be advised to secure the home environment with regard to limiting access to potentially
lethal means (e.g., guns should be removed from the home, pills should be locked up).
Patients should also be encouraged to actively participate in establishing and achieving treatment goals.
Death by suicide affects a web of people connected with the deceased, including spouses, parents, siblings,
friends and acquaintances, coworkers, and healthcare providers. These individuals should be advised to
attend grief counseling.

Evidence Scores
e1.   Suicide risk reduction: there is good-quality evidence suggesting that the use of selective
      serotonin-reuptake inhibitor (SSRIs) to treat patients with depression and suicidal features leads to
      a reduction in suicidal ideation and mortality when compared with placebo or active comparator.[94]
      Score: A
e2.   Risk of death by suicide: medium-quality evidence in the form of a meta-analysis of psychological
      autopsy studies showed that substance-related disorders (odds ratio 5.24, 95% CI 3.30 to 8.31) and
      mood disorders (odds ratio 13.42, 95% CI 8.05 to 22.37) were strongly associated with an increased
      risk of death by suicide. [114] Score: B
e3.   Symptom improvement: medium-quality evidence suggests that day hospital treatment can result in
      greater symptom reduction among patients with high levels of suicidal ideation than overnight care
      at discharge.[109] Score: B
e4.   Risk reduction of suicide and suicide attempt: medium-quality evidence in the form of a meta-analysis
      showed that the reduction of risk for suicide and suicide attempt was about 80% over an average of
      18 months among patients treated with lithium for bipolar disorder or other major affective disorder.[115]
      Score: B
e5.   Safety of antidepressants in adolescents: there is good-quality evidence that most suicidal events
      among adolescents occur in the context of persistent depression and insufficient symptom
      improvement, without evidence of medication-induced behavioral activation as a precursor. [116]
      Score: A
e6.   Reduction in suicidal behavior: medium-quality evidence in the form of a systematic review and
      meta-analysis showed that cognitive behavioral therapy (CBT) had a highly significant effect in
      reducing suicidal behavior.[117] In addition, the evidence shows that CBT appears effective with adult
      populations but not as much with adolescents, is effective if provided to individual patients but not to
      groups, and is effective when directly focused on reducing some aspect of suicide behavior but not
      when focused on other symptoms (such as depression or distress).[117] Score: B
e7.   Repetition of deliberate self-harm: there is medium-quality evidence that cognitive therapy plus usual
      care (care from clinicians in the community, tracking and referral services from the study case
      managers) compared with usual care alone seems more effective at reducing the incidence of
      deliberate self-harm and at reducing suicide attempts at 6-18 months in adults with a recent history
      of self-harm.Clinical Evidence: [link] Score: B
e8.   Reduction in death by suicide: good-quality evidence in the form of a multisite RCT of a brief information
      session combined with systematic long-term contact among people attending emergency units for
      attempted suicide showed significantly fewer subsequent deaths from suicide in the treatment group
      than in the usual-care group at 18 months' follow-up.[118] Score: A
e9.   Repetition of deliberate self-harm: medium-quality evidence suggests that hospital admission for
      about 17 hours when compared with immediate discharge seems no more effective at reducing the



Page 35
     proportion of people who repeat deliberate self-harm at 16 weeks.Clinical Evidence: [link] Score:
     B
e10. Effect of suicide on those left behind: good-quality evidence in the form of a systematic review of
     controlled studies showed no significant differences between people bereaved by suicide and those
     bereaved in other ways with respect to general mental health, depression, PTSD symptoms, anxiety,
     or suicidal behavior.[119] Score: A

Key Articles
     •   Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies: a systematic review. JAMA.
         2005;294:2064-2074.[Abstract]
     •   Gould MS, Greenberg T, Velting DM, et al. Youth suicide risk and preventive interventions: a review
         of the past 10 years. J Am Acad Child Adolesc Psychiatry. 2003;42:386-405.[Abstract]
     •   Beautrais A, Fergusson D, Coggan C, et al. Effective strategies for suicide prevention in New Zealand:
         a review of the evidence. N Z Med J. 2007;120:U2459.[Abstract]
     •   Gibbons RD, Hur K, Bhaumik DK, et al. The relationship between antidepressant medication use and
         rate of suicide. Arch Gen Psychiatry. 2005;62:165-172.[Abstract]
     •   Kutcher S, Chehil S. Suicide risk management: a manual for health professionals. Malden, MA:
         Blackwell; 2007.
     •   Mann JJ. A current perspective of suicide and attempted suicide. Ann Intern Med.
         2002;136:302-311.[Abstract]
     •   Hepp U, Wittmann L, Schnyder U, et al. Psychological and psychosocial interventions after attempted
         suicide: an overview of treatment studies. Crisis. 2004;25:108-117.[Abstract]
     •   van der Sande R, Buskens E, Allart E, et al. Psychosocial intervention following suicide attempt: a
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Image Library




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            Comparison of risk for suicide in the presence of selected psychiatric disorders
              Source: Adapted from Harris EC, et al. Br J Psychiatry 1997;170:205-228




       Comparison of risk for suicide with and without presence of selected medical illnesses
 Source: Data adapted from Harris EC, et al. Br J Psychiatry 1997;170:205-228; McGirr A, et al. J Clin
        Psychiatry 2008;69:966-970; Harris EC, et al. Medicine (Baltimore) 1994;73:281-296




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                               Tool for Assessment of Suicide Risk
Source: From Kutcher S, Chehil S. Suicide risk managment: a manual for health professionals. Malden,
                                        MA: Blackwell; 2007




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                               Tool for Assessment of Suicide Risk
Source: From Kutcher S, Chehil S. Suicide risk managment: a manual for health professionals. Malden,
                                        MA: Blackwell; 2007

Credits
Authors
Stan Kutcher


Page 44
Professor
Department of Psychiatry
Dalhousie University and
Sun Life Financial Chair in Adolescent Mental Health
IWK Health Centre and Dalhousie University and
Director
WHO Collaborating Center for Mental Health Training and Policy
Dalhousie University
Halifax
Nova Scotia
Canada
Magdalena Szumilas
Sun Life Financial Chair in Adolescent Mental Health Team
IWK Health Centre and Dalhousie University
Halifax
Nova Scotia
Canada
SK is the coauthor of some references in this article. SK has been reimbursed by the Lundbeck Institute
for the development of the monograph Suicide risk management: a manual for health professionals.
MS is a coauthor of a reference in this article.

Peer Reviewers
Ricardo Gusmão
Professor of Psychiatry and Mental Health
Departamento de Saude Mental
Faculdade de Ciencias Medicas
Universidade Nova de Lisboa
Lisbon
Portugal
Sanjai Rao
Assistant Clinical Professor of Psychiatry
University of California
San Diego
Veterans Hospital
La Jolla
CA
RG declares that he has no competing interests.
SR declares that he has no competing interests.




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