In a proper setting to estimate suicide risk, the APA guidelines encourage the psychiatrist to give principal considerations to (Harmer et al., 2022): ● The presence of psychiatric illness ● Specific psychiatric symptoms such as hopelessness, anxiety, agitation, or intense suicidal ideation ● Unique circumstances such as psychosocial stressors and the availability of methods ● Other relevant clinical factors such as genetics and medical, psychological, or psychodynamic issues Although these factors may be present, it is important to understand that they may vary significantly in severity. Other factors may contribute to the risk of suicide only in a particular population of patients, not in others (Soreff et al., 2022). Some factors may also be relevant only when they occur in combination with other specific psychosocial Treatment Modalities Psychiatric management for suicidal ideation and behavior consists of an array of clinical interventions, documentation, and evaluations that should be completed by the medical team. According to the APA guidelines on suicide management, both patient and psychiatrist must collaborate in the process of assessing and monitoring the patient’s clinical status and the corresponding response to therapy. This cooperation should also extend to the stages of selecting specific treatment strategies and the coordination of the treatment components.
stressors and triggers. Once an estimation of suicide risk is made, the psychiatrist is expected to examine the relevant contributing factors and determine if they are modifiable. For instance, risks, triggers, and social stressors linked with demographic characteristics, medical history, and family history are non-modifiable factors. Others - such as financial status, unemployment, and medical illness - may be modifiable. The identification of both the modifiable and the nonmodifiable factors contributing to the estimate of suicide risk helps the psychiatrist plan the first stages of intervention. Preliminary interventions should help the patient mitigate or strengthen risks that can be modified. For instance, the behavioral health therapist may strengthen social support networks, treat associated psychiatric disorders and symptoms, and mitigate any associated social problems and stressors. In summary, the psychiatric management process as specified by the APA includes: ● Establishing and maintaining a therapeutic alliance ● Attending to the patient’s safety ● Determining the patient’s psychiatric status, level of functioning, and clinical needs to arrive at a plan and setting for treatment To select an appropriate treatment strategy, the APA also recommended draft guidelines for psychiatrists. These guidelines enable psychiatrists to understand if there is an urgent need to commence therapy and also to select the best clinical setting for the institution of therapy. Table 1 summarizes the APA guidelines for selecting a treatment setting for patients presenting with clinical indications of suicidal ideation and behavior.
Table 1. APA Treatment Selection Guidelines
Treatment Setting Admission generally indicated
Presenting Clinical Indications
● After a suicide attempt or aborted suicide attempt if: ○ Patient is psychotic
○ An attempt was violent, near lethal, or premeditated ○ Precautions were taken to avoid rescue or discovery ○ Persistent plan and/or intent is present ○ Distress is increased or the patient regrets surviving ○ The patient is male and older than age 45 years, especially with new onset of psychiatric illness or suicidal thinking. ○ The patient has limited family and/or social support, including a lack of a stable living situation. ○ Current impulsive behavior, severe agitation, poor judgment, or refusal of help is evident. ○ A patient has a change in mental status with a metabolic, toxic, infectious, or other etiology requiring further workup in a structured setting. ● In the presence of suicidal ideation with specific plan with high lethality and high suicidal intent. ● After a suicide attempt or aborted suicide attempt, except in circumstances for which admission is generally indicated. ● In the presence of suicidal ideation with: ○ Psychosis ○ Major psychiatric disorder ○ Past attempts, particularly if medically serious ○ Possibly contributing medical condition (e.g., acute neurological disorder, cancer, infection) ○ Lack of response to or inability to cooperate with a partial hospital or outpatient treatment. ○ Need for supervised setting for medication trial or electroconvulsive therapy (ECT). ○ Need for skilled observation, clinical tests, or diagnostic assessments that require a structured setting. ○ Limited family and/or social support, including lack of stable living situation. ○ Lack of an ongoing clinician–patient relationship or lack of access to timely outpatient follow-up. ● In the absence of suicide attempts or reported suicidal ideation/plan/intent but evidence from the psychiatric evaluation and/or history from others suggests a high level of suicide risk and a recent acute increase in risk
Admission may be necessary
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Book Code: PYMA2024
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