Nonpharmacological medical approaches Nonpharmacological interventions for the treatment of suicide include electroconvulsive therapy and transcranial magnetic stimulation. If a case of depression is resistant and does not respond to treatment, it is very severe, or if psychotic symptoms appear, then there are additional treatments that should be used. The oldest and best-studied is electroconvulsive therapy, which is effective but can have side effects. It can be administered as an out- or inpatient treatment, but requires anesthesia and the delivery of a small electric current to the brain (AFSP, 2018). A study of patients with depression at high suicidal risk demonstrated that up to 75% of the patients treated with electroconvulsive therapy had no suicidal ideation or suicidal intentions after nine sessions. A similar treatment is transcranial magnetic stimulation (TMS) which is still in the experimental, research phase and is not approved for general use, but has shown increased promise in treating suicidal ideation (Sonmez, Camasari, Nandakumar, Voort, Kung, et al., 2019). TMS is a form of brain stimulation used to treat patients whose condition has not improved through conventional approaches. During the TMS procedure, a coil device is placed over the patient’s head to deliver magnetic pulses to the brain that cause electrical changes within the underlying brain circuitry. This procedure is non-invasive and relatively painless. Each treatment session takes about 15 to 45 minutes to perform, and patients can resume their regular
activities immediately after each session. To achieve effective results, patients usually will need to be treated five days a week on weekdays for 4 to 8 weeks, depending on the individual condition and response rate (Stubbeman et al., 2018). Some preliminary evidence has suggested that high doses of repetitive transcranial magnetic stimulation applied to the left prefrontal cortex might rapidly decrease suicide ideation and suicidal behaviors. This intervention is potentially useful in emergencies where suicidal ideation and intent must be dealt with expeditiously (Perlis et al., 2016). These results were further supported a recent study by Ozcan, Gica, & Gulec (2020) reporting that accelerated TMS treatment in depressed suicidal patients was found to be safe and well- tolerated and may have the potential to acutely decrease suicidal ideation. In the study, accelerated intermittent TBS was delivered on the left dorsolateral prefrontal cortex of suicidal therapy-resistant depressed patients in a randomized, controlled trial. Patients received 20 sessions spread over 4 days. The change in severity of suicidal ideation was measured by the Beck Scale of Suicidal Ideation (SSI) before and after treatment; findings show a significant decrease of SSI score over time. Furthermore, the attenuation of suicidal thinking was not merely related to depression-severity changes caused by TBS.
PSYCHOTHERAPY
● Having the therapist adopt an active attitude to treatment, including problem solving. ● Planning for coping with suicidal urges as an outpatient. ● Focusing on emotional and cognitive precursors to suicidal behaviors. This section will provide information on: Cognitive Therapy, Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), Mentalization Based Therapy (MBT), Transference Focused Psychotherapy (TBP), and Caring Letter Interventions. Although each therapy will be described with key theoretical underpinnings and basic strategies, readers may refer to the interventions listed in the Resources section for more detailed reading on various treatment models. ● Gain awareness on how thoughts can influence feelings in ways that are sometimes not helpful. ● Learn about thoughts that seem to occur automatically, without even realizing how they may affect emotions. ● Evaluate critically whether these “automatic” thoughts and assumptions are accurate, or perhaps biased. ● Develop the skills to notice, interrupt, and correct biased thoughts independently. Thus, cognitive approaches offer a useful starting point in the therapeutic treatment of suicidal behavior, and many of these cognitive approaches have actually been integrated in one way or another with some of the therapies that will be discussed later in this section. However, few studies have been done actively comparing the treatment effects of cognitive therapy versus these other approaches, so cognitive therapy should not be presumed to be any less effective. concentrate on a person’s views and beliefs about their life, not on personality traits. Behavior therapists and cognitive behavior therapists treat individuals, parents, children, couples and families. Replacing ways of living that do not work well with ways of living that work, and giving people more control over their lives, are common goals of behavior and cognitive behavior therapy (ABCT, 2018).
The treatment and management of suicide is complex, and clinicians must develop a biopsychosocial treatment plan, which is critical for the appropriate management of suicidal ideation. Clinicians must assess the willingness and the availability of family members to participate in a treatment plan crafted to address suicidal ideation. This section reviews several effective psychotherapy approaches for working with patients at risk for suicidal behavior. The psychotherapeutic interventions established as the most efficacious treatments for suicidal behavior share certain common elements, such as (Perlis et al., 2016): ● Exploration to understand the etiology of suicidal behaviors. ● Interventions that encourage positive and discourage negative behaviors. ● Explicitly focusing on suicidal behaviors. Cognitive therapy The basis of cognitive therapy is that thoughts can influence feelings, and that one’s emotional response to a situation comes from one’s interpretation of that situation. Cognitive approaches have been found to be promising approaches for ameliorating suicidal thoughts and behavior (Slesnick, Zhang, Feng, Wu, Walsh, & Granello, 2020). Cognitive therapy suggests that many of our emotions are due to our thinking, including the ways that we have perceived or interpreted our environments. Sometimes these thoughts may be biased or distorted. Some people may set unrealistic expectations for themselves, or harbor pervasive concerns regarding their acceptance among others. These types of thoughts can contribute to distorted or illogical thinking Cognitive behavioral therapy Cognitive and behavioral therapies (CBT) usually are short- term treatments (i.e., often between six and 20 sessions) that focus on teaching patients specific skills. CBT is different from many other therapeutic approaches because it focuses on how a person’s cognitions (i.e., thoughts), emotions, and behaviors are connected and affect one another. Behavior therapists and cognitive-behavior therapists usually focus more on the current situation and its solution, rather than the past. They processes, which then affect feelings. In cognitive therapy, patients learn to: ● Distinguish between thoughts and feelings.
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