In 2007, the FDA did not advise withholding antidepressants for approved indications, but they did emphasize the following 52 : • Individuals 18 to 24 years old should be informed of the risk of developing suicidality when initiating antidepressant treatment (usually in the first one to two months). • Clinicians should monitor patients closely during antidepressant treatment. • Depression and other psychiatric conditions are themselves associated with an increased risk of suicidality. There is no clear evidence that antidepressant use in patients with depression symptoms increases the risk of suicidality in adults. Some trials show a negative association between antidepressant use and suicide attempts. On the other hand, evidence strongly suggests an age-specific effect of antidepressants and suicidality. Among young adults, adolescents, and children, the onset of suicidality is greater when compared to placebo, especially during the few weeks of psychopharmacological treatment. However, it is important to weigh the small risk of suicidality against the risk of suicidality with untreated depression. 52 Lithium For patients with unipolar depression or bipolar and related disorders, maintenance treatment with lithium has been shown to prevent suicide. The exact mechanism of action through which lithium works to reduce suicidal behaviors remains unknown; however, it has been theorized that it may function by reducing mood disorder episodes or by decreasing impulsive and aggressive behaviors. 2 Evidence-Based Practice: Buprenorphine, the treatment for opioid use disorder, is currently being investigated as a treatment for severe suicidal ideation. A four- week randomized trial compared adjunctive buprenorphine with a placebo in 62 patients with severe suicidal ideation. The patients had various diagnoses (unipolar major depression, borderline personality disorder, adjustment disorder) and were treated with antidepressants and/or benzodiazepines. The study found an improvement in suicidal ideation with adjunctive buprenorphine that was independent of treatment with antidepressants. 2 Overdose Concerns with Medications Of note, tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) may be lethal if taken in high doses and thus should be avoided in patients at risk for suicide. In addition, the SNRI venlafaxine may be dangerous in overdose and should be avoided. By contrast, SSRIs are generally safe in overdose and should be the first-line treatment in patients with thoughts and behaviors of suicide. 2 While acute toxicity is believed to be less severe in the setting of SSRI overdose compared to TCAs and MAOIs, fatal overdose and successful suicide attempts have been reported with SSRIs. 53
Suicide management strategies include non- pharmacologic interventions, such as individual psychotherapy, behavioral therapy, family therapy, and cognitive therapy. The following are proven psychotherapies for treating patients with thoughts and behaviors of suicide: cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), collaborative assessment and management of suicidality (CAMS), and problem-solving therapy (PST), and attachment-based family therapy (ABFT). Many psychotherapies are rooted in the principle that the therapist is an empathic partner who forms a strong alliance with the patient and acknowledges the patient’s suicidal thoughts and behaviors as a response to pain or distress. The following components are necessary for any approach to treating suicidal thoughts or behaviors 54 : •
Its cornerstone is the idea that patients must build a life worth living, even if they have many problems in their life and wish to die. 54 Collaborative Assessment and Management of Suicidality Collaborative Assessment and Management of Suicidality (CAMS) is an evidence-based suicide- focused treatment that quickly reduces suicidal ideation in six sessions, lowers distress and hopelessness, improves hope, and improves clinical retention to care. The therapist and patient work closely to keep the patient stable and identify “drivers” that compel the patient to take their life. 57 Problem-Solving Therapy Problem-Solving Therapy (PST) is a brief, evidence-based approach that teaches and empowers patients to solve their here-and-now problems contributing to their depression and helps increase their self-efficacy. It is effective with a majority of the population, including people from different cultural backgrounds. 58 Attachment-Based Family Therapy Attachment-Based Family Therapy (ABFT) is a family therapy model designed to treat family and individual processes associated with adolescent suicide and depression. 59 Based on interpersonal theories, adolescents’ depressive symptoms and suicidality can be exacerbated or buffered against by the quality of interpersonal relationships with families. Attachment-Based Family Therapy aims to repair attachment relationships or establish a secure base for adolescent development. Other therapies Non-pharmacological interventions for the treatment of suicide include electroconvulsive therapy (ECT). For severely suicidal patients, ECT provides a quick response that may be lifesaving in the short-term. The ECT treatment can be administered in an inpatient or outpatient setting but requires anesthesia and the delivery of an electric current to the brain. 10 Some preliminary evidence has suggested that high doses of repetitive transcranial magnetic stimulation might rapidly decrease suicide ideation and suicidal behaviors. This intervention is potentially useful in emergency or crisis scenarios to expeditiously address a patient’s ideations and intent 44 . Safety Planning Strategies The first National Strategy for Suicide Prevention was put forth in 1999 by then-Surgeon General David Satcher, MD. 60 It was a landmark document that helped officially organize the strategies to prevent suicide across the country. Since then, research and clinical evidence have continued to refine various approaches to protect at-risk individuals. Some well-known interventions are Crisis Hotlines and the use of the Safety Planning Intervention.
Lethal means reduction: This is one of the most important interventions to reduce suicide attempts. It is vital to assess a patient’s access to firearms or other lethal means and to work with them to restrict access to those means. Safety planning: This strategy involves a plan to keep a patient safe until skills can be learned or other solutions put into place. Developing reasons for hope : Many treatments approach patients with thoughts and behaviors of suicide by managing hopelessness. The goal is to connect patients to core values and attachments that inspire them to manage their current pain. Inspiring delay: Generally, the impulse to engage in suicidal behaviors is fleeting. By having the patient delay action on the impulse, it could save their life. One strategy includes having the patient reflect on things they may miss if they die, year by year.
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Psychotherapies
Cognitive Behavioral Therapy Cognitive Behavioral Therapy (CBT) for Suicide Prevention (CT-SP) is an evidence-based cognitive- behavioral treatment for adults with suicidal ideation and behaviors. Although this protocol was initially developed for patients who had recently attempted suicide, it has applications for patients who are more acutely suicidal. The CT-SP treatment is based on the cognitive-behavioral theory that a person’s biopsychosocial vulnerabilities can interact with suicidal thoughts and behaviors to produce a “suicide mode”. 55 By targeting those suicide- related thoughts and behaviors, suicide risk can be decreased. Dialectical Behavior Therapy Dialectical Behavioral Therapy (DBT) was initially developed to treat patients diagnosed with borderline personality disorder who are also chronically suicidal. It is based on the biosocial theory of emotion dysregulation. Dialectical Behavioral Therapy promotes the belief in one’s own ability to succeed, the ability to emotionally self-regulate, and interpersonal effectiveness. 56
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