○ Train all staff . Staff members can influence a patient’s impression of the outpatient office. Greeting patients with compassion and warmth will help the patient feel more comfortable and can influence the patient’s willingness to engage in treatment. 2. Reach out to their family members or other supports. Psychopharmacotherapy Each patient should be individually assessed to evaluate the discharge environment for safety. In these circumstances, psychopharmacologic interventions are often employed. If psychopharmacologic interventions are used for patients discharged home, the patient and family members must understand the possible side effects associated with the drugs being administered, especially the use of antidepressants in patients who are depressed and suicidal (Kazim, 2017). Antidepressants Several studies using randomized controlled trials have shown that the treatment of depression using drug therapy, such as antidepressants, has been associated with decreased suicidal ideation in individuals age 25 years and older (Kazim, 2017). Some studies suggest that the use of selective serotonin reuptake inhibitors (SSRIs) (e.g., Lexapro, Prozac) results in a more significant reduction of suicidal ideation compared to selective serotonin and norepinephrine reuptake inhibitors (SNRIs) (e.g., Cymbalta, PRISTIQ) or norepinephrine–dopamine reuptake inhibitors (NRDIs) (e.g., Wellbutrin) (Kazim, 2017). Interestingly, in patients younger than 25 years, antidepressant therapy has not been shown to decrease suicidal ideation and behaviors, although it does reduce signs and symptoms of depression (Kazim, 2017). Black box warning of increased SI on antidepressants In 1999, concerns were raised about patients developing intense suicidal ideation while taking fluoxetine (Prozac) as prescribed (Rush, 2021). In response, the manufacturer conducted a meta-analysis of 3,065 patients and found no significant difference in suicidal behavior in patients taking fluoxetine versus placebo (Rush, 2021). In 2003, concerns reemerged as the U.S. Food and Drug Administration (FDA) issued a warning regarding the risk of increased suicidality associated with antidepressant use in young people under 26 years of age seen in clinical trials. In 2005, The FDA issued another warning about suicidality in adults being treated with antidepressants (Rush, 2021). In 2007, the FDA did not advise withholding antidepressants for approved indications, but they did emphasize the following (Rush, 2021): ● Individuals age 18 to 24 years 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. Psychotherapies The following components are necessary for any approach to treating suicidal thoughts or behaviors (Sudak & Rajalakshmi, 2018): ● 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
○ Meet the patient and family members at the inpatient psychiatric setting . If an in-person meeting with the patient is not feasible, consider connecting through telemedicine. At a minimum, call the patient prior to discharge to begin fostering a therapeutic alliance. Lithium For patients with unipolar depression or bipolar and related disorders, maintenance treatment with lithium has been shown to prevent suicide (Schreiber & Culpepper, 2021). 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 (Schreiber & Culpepper, 2021). 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 (Schreiber & Culpepper, 2021). In addition, the SNRI venlafaxine may be dangerous in overdose and should be avoided (Schreiber & Culpepper, 2021). By contrast, SSRIs are generally safe in overdose and should be the first-line treatment in patients with thoughts and behaviors of suicide (Schreiber & Culpepper, 2021). Evidence-based practice! Buprenorphine, a 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 (Schreiber & Culpepper, 2021). The patients had various diagnoses (unipolar major depression, borderline personality disorder, adjustment disorder) and were treated with antidepressants and/or benzodiazepines (Schreiber & Culpepper, 2021). The study found an improvement in suicidal ideation with adjunctive buprenorphine that was independent of treatment with antidepressants (Schreiber & Culpepper, 2021).
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: The goal is to manage hopelessness by connecting patients to core
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Book Code: SWPA1525
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