_____________________________________________________________ Suicide Assessment and Prevention
PSYCHOTHERAPY TO REDUCE SUICIDE RISK In addition to pharmacotherapy, various psychotherapy approaches have been shown to decrease suicide risk in patients at low or intermediate risk for suicide [55]. Post-admission cognitive therapy is a cognitive-behavioral therapy approach designed to help patients who have suicide-related thoughts and/or behaviors. It consists of three phases of therapy for outpatients or inpatients [55]: • The patient is asked to tell a story associated with her or his most recent episode of suicidal thoughts, behavior, or both. • The patient is assisted with modifying underdeveloped or overdeveloped skills that are most closely associated with the risk of triggering a suicidal crisis. • The patient is guided through a relapse-prevention task. Another cognitive-behavioral approach is cognitive-behavioral psychotherapy for suicide prevention, which involves “acute and continuation phases, each lasting about 12 sessions, and includes a chain analysis of the suicidal event, safety plan devel- opment, skill building, psychoeducation, family intervention, and relapse prevention” [53]. Dialectical behavior therapy was originally designed to address the self-harm impulses of patients with borderline personal- ity disorder, but it has good evidence for use in most suicidal individuals. Dialectical behavioral therapy is an adaptation of cognitive-behavioral therapy and is based on the theoretical principle that maladaptive behaviors, including self-injury, are attempts to manage intense overwhelming affect of biosocial origin. It consists of the two key elements of a behavioral, problem-solving approach blended with acceptance-based strategies and an emphasis on dialectical processes. Dialectical behavioral therapy emphasizes balancing behavioral change, problem-solving, and emotional regulation with validation, mindfulness, and acceptance of patients. Therapeutic targets are ranked in hierarchical order, with life-threatening behaviors addressed first, followed by therapy-interfering behaviors, and then behaviors that interfere with quality of life. MENTAL HEALTH REFERRAL Depending on the level of suicide risk, referral to a mental health professional (e.g., psychologist, counselor, therapist), psychiatrist, or hospitalization may be warranted. Long-term treatment and follow-up will be required for many patients, and appropriate referral to outpatient facilities is often necessary. If the person is currently in therapy, the therapist should be called and involved in the management decision. If the patient does not have a therapeutic relationship with a mental health professional, referral to one should be made. Suicidal patients should be referred to a psychiatrist when any of the following are present: psychiatric illness; previous suicide attempt; fam- ily history of suicide, alcoholism, and/or psychiatric disorder; physical illness; or absence of social support [59; 60]. After deciding to refer a patient to a mental health professional,
MANAGEMENT OF SUICIDAL PATIENTS The opportunity for an emotionally disturbed patient with vague suicidal ideation to vent his or her thoughts and feelings to an understanding health or mental health provider may bring a degree of relief such that no further intervention is needed. However, in all cases the encouragement of further contact and follow-up should be conveyed to the patient, espe- cially when inadequate social support is present. Independent of the actual catalyst, most suicidal persons possess feelings of helplessness, hopelessness, and despair and a triad of three cognitive/emotional conditions [59; 60]: • Ambivalence: Most suicidal patients are ambivalent, with alternating wishes to die and to live. The health- care provider can use patient ambivalence to increase the wish to live, thus reducing suicide risk. • Impulsivity: Suicide is usually an impulsive act, and impulse, by its nature, is transient. A suicide crisis can be defused if support is provided at the moment of impulse. • Rigidity: Suicidal people experience constricted thinking, mood, and action and dichotomized black- and-white reasoning to their problems. The provider can help the patient understand alternative options to death through gentle reasoning. Healthcare professionals should assess the strength and avail- ability of emotional support to the patient, help the patient identify a relative, friend, acquaintance, or other person who can provide emotional support, and solicit the person’s help [59; 60]. The engagement of supportive third parties in the patient’s life can be a useful tool in preventing suicide completion. Adherence to established best practices general assures that assessment and care will be ethical and legal. It is important to consider and document informed consent. Underlying key ethical principles include respect for persons, autonomy, and beneficence [121]. PHARMACOTHERAPY TO REDUCE SUICIDE RISK Abundant evidence has demonstrated that lithium reduces the rate of suicidal behavior in patients with bipolar disorder and recurrent major depression and that clozapine reduces suicidal behavior in schizophrenia [97; 98; 99; 100; 101; 102]. Both drugs reduce suicide risk independently of their effect on the primary psychiatric disorder. Although the exact anti-suicide mechanism of both drugs has yet to be identi- fied, lithium enhances serotonergic activity and clozapine is a potent 5-HT2A antagonist. Serotonergic modulation is a likely explanation of the suicide-reducing effects of both medications, because aggression levels and suicide are correlated with pre- frontal cortical 5-HT2A binding [71; 104; 105].
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