Depression and Suicide _ ______________________________________________________________________
TREATMENT OF SUICIDALITY Psychotherapy
at imminent risk for suicide [321]. A study published in 2020 found that esketamine nasal spray demonstrated rapid and robust efficacy in reducing depressive symptoms in severely ill patients with MDD who had active suicidal ideation with intent [492]. ASSESSMENT OF SUICIDE RISK Standard suicide risk assessment intends to gather clinical information sufficient to determine patient risk level for sui- cide, culminating with clinician estimation of risk based on suicide thoughts, intent, behaviors; protective and risk factors, precipitants, warning signs; and behavioral observation during assessment [364; 366; 368]. Patients with any of the following conditions should be assessed for suicide risk, although many are nonspecific factors that do not predict current risk [364; 366; 368]: • Psychiatric (e.g., MDD, bipolar depression, schizo- phrenia, PTSD) and medical (e.g., chronic pain, sleep disturbance, frequent headaches) disorders • Positive depression screening results (e.g., very high scores, suicidality concerns, suicidal thoughts in perina- tal women) • Patients seeking help or self-reporting suicidal thoughts • Referrals from close others over concerns about patient behavior • Clinical judgment Eliciting Information Guidelines recommend an empathetic and direct, yet objective and non-judgmental, approach to eliciting information from patients believed to be at risk for suicide. The gravity of high acute suicide risk and vital need for information suggests an assertive approach. The following recommendations have been made for these situations [364; 493]: • Be clear and use specific, open-ended questions. Be flex- ible to frame questions more clearly. • Avoid assuming patients and families understand clini- cal terms, even if clarification is not requested. • Ask for clarification, and do not accept vague answers. Ask follow-up questions. • Document positive and negative specifics carefully, in narrative form. Clinical suicide assessment guidelines give little attention to dealing with patients suspected of being at acute risk for suicide who are unable or unwilling to cooperate with the risk assess- ment process. Patients evaluated for suicide are often in crisis and may fear that sharing their suicidality will result in loss of autonomy through hospitalization, behavioral restriction, or loss of esteem from a psychiatric diagnosis. In response to these fears, patients can minimize or deny their suicidality when directly asked or make statements to decrease clinician vigilance; clinicians should be aware of these tactics [366].
Highly structured, problem-solving, coping-oriented psycho- therapies have the greatest research support for effectively treating suicidal risk, and include dialectical behavioral therapy, cognitive therapy, and collaborative assessment and management of suicidality [482]. Dialectical behavioral therapy is the most thoroughly studied and effective psychotherapy for suicidal behavior. It has been shown in multiple studies to decrease suicide attempts, self- harm, and other suicide-relevant markers such as suicidal ideation and hopelessness. This psychotherapy emphasizes skills training and mindfulness-based emotion regulation [482]. Cognitive therapy is the next most studied and supported sui- cide-relevant psychotherapy. The initial randomized controlled trial of suicide-specific cognitive therapy in persons presenting to the emergency department with suicide attempt gave con- vincing evidence that 10 sessions decreased follow-up suicide attempts compared to the control group. The primary focus of this modality is identification of patient “suicidal mode,” activated by certain experiences, memories, thoughts, and situations. Patients learn what triggers their suicidal mode and develop and use alternate non-suicidal coping responses [482]. Collaborative assessment and management of suicidality is a therapeutic framework that emphasizes collaborative assess- ment, crisis response planning, and problem-focused interven- tions designed to identify and treat the “drivers” of suicidal risk. In one study, it was shown to effectively treat suicidal ideation, overall symptom distress, hopelessness, and reasons for living at 12-month follow-up compared to enhanced usual care [482]. Pharmacotherapy Effective pharmacotherapy for suicidality has been elusive. Antidepressants are standard treatment for acutely suicidal patients, but delayed onset imposes unacceptable distress and elevates risk of lethal self-harm [47]. In MDD and bipolar disorder, lithium is protective against suicidal behavior and has extensive evidence support, but it is underprescribed for this purpose. In schizophrenia, clozapine is superior to other antipsychotic agents in lowering suicide rates. However, the need for close toxicity monitoring has limited its use in pre- venting suicide. In severe MDD with high suicide risk, ECT is established as rapid, effective treatment, but practical issues and stigma constrain its use [47; 483; 484]. Aside from clozapine and lithium, pharmacotherapy approaches have traditionally been based on the belief that sui- cidality is an extension of MDD [485]. However, breakthroughs have been made in rapid-active drug interventions for suicidal individuals, with ketamine, esketamine, and buprenorphine now being explored for this use [485; 486; 487; 488; 489; 490; 491]. In 2016, the FDA granted breakthrough therapy designation for intranasal esketamine in patients with MDD
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