Approach

Treatment planning is determined by several factors, including the strength of concern on the part of the clinician about the patient’s safety, presence of any mental illness, and level of social support available for the affected patient.

First steps

Once a significant concern is raised by an appropriate clinician about a patient’s safety, immediate action should include removing the means for suicide, ensuring the safety of the patient and others, and treating any existing psychiatric disorders.​

Considerations relevant to patients who self-harm

  • If the function of self-harm is to cope with a stressful life event, deal with overwhelming feelings, or stave off thoughts of suicide, it may not be appropriate to expect someone to stop self-harming immediately. For some people, self-harm is a coping strategy that they are unable to just "stop". However, you can still attempt to mitigate any risk factors and underlying issues contributing to the self-harm.

  • Address any underlying psychosocial issues, share coping strategies, and improve psychological health by attempting to:

    • Engage the individual in seeking and accepting help for their underlying problems

    • Promote resilience and resourcefulness by co-producing a safety plan, discussing alternative coping strategies (such as problem solving), and addressing any social issues.

If there is concern for suicidal ideation or attempt in pediatric psychiatric patients presenting to the emergency department, it is recommended that the patient has a personal and belongings search, is changed into hospital attire, and placed in as safe a setting as possible (e.g., a room without easy access to medical equipment) with close staff supervision.[88]

Decide on site of care

  • Psychosis, diagnostic uncertainty, imminent suicide risk, and/or lack of adequate social support may suggest the need for admission to the hospital for detailed assessment and continued monitoring. Unfortunately, there is little evidence that admission to the hospital alone prevents suicide, and other interventions will be required.

  • One study showed that patients who are hospitalized are at highest risk for death by suicide early in admission, with the slowest decline in risk noted in patients with schizophrenia.[146] Inpatient suicide has been associated with admission numbers, previous suicidal behavior, absence of support, absence of supervision, hopelessness, a family history of suicide, and presence of family conflict.[146][147]

  • Although commonly employed, no qualitative or randomized controlled trials exist to support formal observation in the inpatient psychiatric setting for the prevention of suicide and self-harm among inpatients.[148] One systematic review of qualitative studies demonstrated that from the perspective of the patient with suicidal thoughts, feeling safe may depend on the fulfillment of three specific needs: feeling of connection, protection, and control.[149]

  • If admission is necessary, it is important to minimize any restrictions to autonomy and connections with friends or family, and to help the patient to feel safe. Legal procedures may be used to admit involuntarily a patient who refuses admission, or lacks capacity to agree to admission. Clinicians should be familiar with legal issues relevant to involuntary admission in their jurisdiction.

  • Admission to an inpatient psychiatric facility is recommended for any pediatric psychiatric patient presenting to the emergency department if they continue to show a desire to die, remain agitated or severely hopeless, or cannot engage in a discussion around safety planning. Admission is also recommended if the patient lacks adequate social support, cannot be adequately monitored or receive follow-up care, or had a high-lethality suicide attempt or an attempt with clear expectation of death.[88]

  • Outpatient treatment may be more appropriate for patients with chronic suicidal ideation but no history of significant prior suicide attempts; a strong support network and easy access to outpatient facilities are required.

Treat physical injuries

  • Treat any physical injury associated with a current suicide attempt appropriately.

Make a safety plan

  • A collaborative discussion with the patient can produce a personalized safety plan that includes strategies for dealing with distress, removal of access to means, and a list of people and organizations to contact should they become distressed or suicidal in the future. This safety plan belongs to the patient, ideally with the clinician (and key others) having a copy. A safety plan can be reviewed regularly as part of routine discussions and at change/transition points. Patients who indicate a high degree of suicidal intent, have specific plans, or choose methods with high lethality should raise more concern and will need more intensive support and/or referral to specialist mental health services.

Psychotherapy and psychosocial interventions

Psychotherapy is an important part of the recovery process for most patients with high suicidal intent. However, the feasibility of suicide intervention effectiveness studies that are sufficiently large and have an adequate follow-up period is limited. Most suicide intervention therapies are tested for effectiveness on a proxy measure: preventing an episode of self-harm.[150]

Psychosocial interventions that directly address suicidal thoughts and self-harm (“direct”) appear to be effective at reducing suicidal ideation immediately post-therapy and in the longer-term, whereas psychosocial treatments that tackle these issues indirectly appear to be effective only in the longer-term.[151]

In randomized controlled trials, cognitive behavioral therapy interventions for individuals who have attempted suicide have been shown to reduce repeated attempts.[150]​​[152]​​[153]​ There was some evidence that psychotherapy reduced subsequent suicide attempts in high-risk adults, but not in adolescents.[154]

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. While patients with personality disorder may have been considered particularly difficult to treat in the past, DBT may be effective in reducing self-harm in adults and adolescents with borderline personality disorder, or features of borderline personality.​[153][155][156]

Case management and remote contact interventions were not shown, in one study, to reduce repetition of self-harm.​[153]​ Despite this, the American Academy of Pediatrics recommends that depression in children or adolescents is treated with a referral to a psychotherapist when indicated, as depression increases the risk of suicide.[126]

Research using a particular psychosocial intervention called Youth-Nominated Support Team Intervention for Suicidal Adolescents-Version II to reduce suicide is encouraging.[157]

Other therapies are being trialed. One randomized controlled trial looking at a brief psychotherapeutic intervention specifically designed for application in specialty mental health services with individuals exhibiting ultra-high risk for suicide demonstrated positive results in a small cohort of patients followed over a 2-year period.[158] A review of randomized controlled trials of psychological and psychosocial interventions after attempted suicide found that psychodynamic interpersonal therapy may be effective in reducing suicidal ideation, habitual self-harming behavior, and suicide attempts in patients with borderline personality disorder.[150] This review stressed the importance of the therapeutic alliance in the success of a program, and the need for outreach to improve patient attendance and adherence.​[159]

Evidence supports psychological interventions for suicidal patients with the following features: clear treatment framework; defined strategy for managing suicide crises; close attention to affect; active, participatory therapist style; and use of exploratory and change-oriented interventions.[160] Additional interventions may include a focus on developing long-term personal goals, identifying positive expectations, and broadening perspectives beyond immediate distress.  

Uncertainty exists about the safety and effectiveness of no-harm contracts (agreements between the patient and the clinician in which the patient pledges, usually in writing, not to harm him- or herself), postcard mailed interventions, assertive outreach (including case management with crisis intervention, problem-solving training, motivational support, and assistance to attend scheduled appointments), systematic therapeutic contact, and a variety of brief contact interventions in reducing death by suicide or suicide attempts.[161][162][163][164][165][166] There is putative evidence that a gender difference in response to psychosocial therapy for self-harm may exist.[167]

Identify target factors for intervention

Use information gathered in the history to identify specific target factors requiring intervention, including any underlying psychiatric diagnoses or symptoms, distressing psychosocial situations, and personality difficulties.

Current mental illness

Treat identified psychiatric disorders using the best available pharmacologic or psychological evidence-based interventions. Data show that discontinuation of mental health treatment increases suicide risk.[168][169] Eliminating or reducing the degree of illness associated with mental disorders decreases suicide rates. 

Bipolar disorder and other mood disorders

The long-term effectiveness of lithium therapy in reducing death by suicide and attempted suicide in patients with bipolar and other mood disorders (schizoaffective disorder) is well established.[170][171] Withdrawal of lithium treatment may be associated with an increased rate of suicide.[171]​ Patients who attempt suicide while taking lithium may require a change in medication due to the high lethality of lithium when taken in overdose. Reports on the relative efficacy of divalproex (a combination of valproate sodium and valproic acid in a 1:1 molar ratio) in preventing suicide attempts or death by suicide compared with lithium are mixed.[172][173] Treatment with divalproex was shown not to increase suicidal thoughts or behavior.[174]

Schizophrenia spectrum disorders

A second-generation antipsychotic is common acute first-line therapy for schizophrenia and schizoaffective disorder. A mood stabilizer is often needed for long-term management of schizoaffective disorder. The long-term effectiveness of lithium in reducing death by suicide and attempted suicide in patients with schizoaffective disorder is well established.[170] Withdrawal of lithium treatment may be associated with an increased rate of suicide.​[171]

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.[175] In 2003, the Food and Drug Administration (FDA) approved clozapine for the reduction of suicide risk in schizophrenia. Antipsychotic medications that treat hostility, impulsivity, and depression while not creating unacceptable adverse effects may be important in decreasing suicide-related risk.[176]

Depression

Antidepressant treatment for major depressive disorder is associated with a substantial decrease in suicide risk.[177][178] Better detection of major depression and increased prescription of antidepressants have been associated with declining suicide rates in Hungary and Sweden.[179][180][181] Similarly, reduction in prescription of selective serotonin-reuptake inhibitors (SSRIs) to treat depression in youths in the US, Canada, and the Netherlands was associated with an increased suicide rate.[182][183] Commonly-used first-line antidepressants include SSRIs. They are relatively safe in overdose.[184]

In 2004, the FDA issued a black box warning for suicidality associated with pediatric use of antidepressants. Controversy remains about the proportional impact of, and potential for, suicide-promoting effects of antidepressants in children, adolescents, and young adults under the age of 25 years.[185][186] It is worth noting that the aim of this warning was not meant to discourage use of antidepressants in youth, but rather to encourage close follow-up/monitoring of youth who are prescribed these medications, especially within the first few months of use and after dose changes.[126]​​ While analyses suggest a small number of young patients may develop new suicidal ideation or self-harm with SSRI treatment, overall, SSRI treatment substantially decreases suicide rates and suicide attempts;[187][188]​ SSRIs may have less suicide-sparing impact in children and young people than in adults.[189] 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, the association notes that "this risk has to be balanced against the well-known beneficial effects of antidepressants on depressive and other symptoms, including suicidality and suicidal behavior".[190] Several meta-analyses and other studies have come to the same conclusion, as well as commenting on the focus of regulators on suicidal thoughts rather than death by suicide.[189][191][192][193][194]​ When present, this risk appears to relate to the initial weeks of treatment, suggesting a need for close monitoring for worsening of depressive symptoms and emergence or worsening of suicidal thoughts during the initial phase of treatment.[195][196][197]​ The results of one large meta-analysis suggest that in adults under the age of 25, the risk of both emergence and worsening of suicidality may be raised in weeks 3 to 6 of treatment (but not in weeks 1 and 2), which is later than has been suggested by other studies.[198] Initiating SSRI treatment at higher doses may heighten risk of self-harm, so the authors of this topic recommend a “start low” and “go slow” approach.[195]

One study found that regardless of intervention used, suicide attempts decreased after the onset of treatment for depression compared with the month before initiating treatment.[89]

Anxiety disorders

One review of the acute treatment of anxiety with sedatives/hypnotics in patients with depression did not support using sedatives/hypnotics as an early adjunct to antidepressant treatment to decrease suicide risk.[199] Because there is considerable evidence that sedatives/hypnotics produce depressant and/or disinhibitory effects in a small proportion of people, sedatives/hypnotics may be best avoided in suicidal patients.

Borderline personality disorder

One 2011 meta-analysis concluded that no drug regimen improves the overall symptoms of borderline personality disorder. It concluded that antipsychotics may improve paranoia, dissociation, mood lability, anger, and global functioning, and that antipsychotics and divalproex can decrease anger, anxiety, depression, and impulsivity.[200]

The UK National Institute for Health and Care Excellence does not recommend using drug treatment specifically for borderline personality disorder or symptoms associated with the disorder, such as repeated self-harm. Short-term sedative medications may be appropriate for a crisis, which may involve an escalation of self-harm thoughts and acts. Drug treatment may also be appropriate for any comorbid conditions, such as depression or anxiety.[201]

Substance misuse

One review found no guidelines for admission to the hospital of suicidal, alcohol-dependent people.[202] Provide patients with alcohol or substance dependence or misuse who are experiencing suicidal ideation, or who have self-harmed, with immediate attention, specific treatments for the chemical dependence, and/or specific treatments for any comorbid disorders.[202] This may include detoxification treatments, or treatments that target symptoms such as anxiety, agitation, insomnia, and panic attacks.[202] Consider treating comorbid mood disorders with antidepressants such as fluoxetine.[203] Consider referring the patient to an appropriate rehabilitation facility. Advise the family and friends to remove lethal means and monitor the patient’s progress.

Attention deficit hyperactivity disorder

One large Swedish longitudinal, register-based pharmaco-etiology study using a within-patient design showed that pharmacologic treatment of ADHD decreased suicidal behavior.[204] Psychological therapy should be available in all clinical adult ADHD settings as a viable treatment option.

If there has been any substance abuse in the last year, stimulant medication can be used with caution. It is advisable to use longer-acting stimulants, as they have less potential to be abused.[205]

Obtain a careful cardiac history and, in cases where there are symptoms or a history of concern, an ECG and cardiology consultation prior to starting a stimulant.

Those left behind after a death by suicide

Suicide affects a web of people connected with the deceased, including spouses, parents, siblings, friends, acquaintances, coworkers, and healthcare providers. Offer these individuals grief counseling, even though grief counseling does not decrease risk of suicide in those bereaved.[206][207]

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 survivor education.[86]

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 with no outreach.[208] Bereavement support group interventions conducted by trained facilitators have been shown to reduce the intensity of complicated grief.[209] Unfortunately, not all of those who might benefit can necessarily access this support.[210] Weak evidence shows support groups for children and adolescents bereaved by suicide may reduce subsequent depression and anxiety.[211]

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