Table 1. APA Treatment Selection Guidelines (continued)
Treatment Setting
Presenting Clinical Indications
● Release indicates follow-up recommendations. ● After a suicide attempt or in the presence of suicidal ideation/plan when:
Emergency department release may be possible
○ Suicidality is a reaction to precipitating events (e.g., exam failure, relationship difficulties), particularly if the patient’s view of the situation has changed since coming to the emergency department. ○ Plan/method and intent have low lethality. ○ Patient has a stable and supportive living situation. ○ Patient can cooperate with recommendations for follow-up, with the treater contacted, if possible, if a patient is currently in treatment. ● May be more beneficial than hospitalization. ● A patient has chronic suicidal ideation and/or self-injury without prior medically serious attempts if a safe and supportive living situation is available and outpatient psychiatric care is ongoing.
Outpatient treatment
Once a treatment setting is defined, the medical team can proceed to select a treatment modality. There are two specific
treatment modalities prescribed by the APA guidelines: Somatic therapies and psychotherapy.
SOMATIC THERAPIES
Psychotropic medications found useful in the treatment of suicidal patients are the backbone of somatic therapies as described by the APA guidelines. Also, the early use of supplemental medications, including sedative–anxiolytics and Antidepressants Antidepressants are considered a major therapy option for patients suffering from acute, recurrent, and chronic forms of depression. Administered in an adequate dose, these medications have demonstrated efficacy in the symptomatic management of different anxiety disorders. In suicidal patients, antidepressants have been demonstrated to be effective for substance use disorders and comorbid depression. However, there is not enough evidence to suggest that antidepressants reduce the risk of suicide or reduce the rate of suicide attempts. Currently, the most significant research evidence for the use of antidepressants as a somatic therapy for suicidal ideation and behavior is in the observations collated from countries in which the clinical use of these medications is increasing. Since the late 1990s, the prevalence of suicide risk and the rate of suicide attempts have significantly decreased. Coincidentally, this same period also witnessed a sharp increase in the use of antidepressants in the global population. Nontricyclic antidepressants and non–monoamine oxidase inhibitors (non- MAOI) prescribed in optimal doses perhaps contributed to the reduction in the incidence of suicide globally. This observation has subsequently provided indirect evidence for the role of antidepressants in the treatment of suicidal behavior in adults and adolescents. Selective serotonin reuptake inhibitors (SSRIs) are different from other classes of antidepressants. Initial reports suggested that SSRIs might be associated with increased suicidality and suicide behavior in many patients. These medications reportedly increased the risk of aggression, impulsivity, and command hallucinations in some patients. However, further investigations using large study populations and controlling for factors that Lithium Lithium is another medication that is used in the management of suicide and is recommended by the APA guidelines on the assessment and management of suicide. Since its introduction, there have been multiple research studies reporting consistent and reproducible results on the efficacy of lithium in the management of suicidal ideation. As with antidepressants, the myriad of evidence backing lithium in this regard is from survey evidence and clinical studies on special populations. There is compelling evidence that the use of lithium as long-term therapy in patients with recurring bipolar disorder and major depressive disorder is associated with a reduction in the risk of suicide and the incidence of suicide attempts. Lithium is also commonly used as an option for maintenance therapy in the management
low-dose second-generation antipsychotics, may be useful to address agitation, anxiety, and insomnia. The medication classes recommended under somatic therapy include the following.
might independently affect suicidality score indicated that there is no conclusive evidence that the suicide rate of suicidality is increased by treatment with a specific type of antidepressant. The APA guidelines further advise that as treatment begins, psychiatrists should determine baseline levels of symptoms and then regularly observe patients for symptoms such as anxiety, agitation, insomnia, and aggression. This is important for tracking and monitoring the efficacy of therapy. Since antidepressant therapy also typically involves a substantial delay before the expected clinical response is noticed, a baseline symptom measurement also helps the clinical team make vital decisions about dosage modifications and the withdrawal of any antidepressant if necessary. If an optimal antidepressant dosage is prescribed and a full response is not recorded within the expected timeframe, the APA guidelines recommend adjusting the medication dosage or completely changing to another class of antidepressant. It is important to note the different specificities of the different classes of antidepressants. These specificities in pharmacokinetics may be important if an antidepressant regimen is selected for use in special populations. For instance, non-MAOA antidepressants and nontricyclic are considered relatively safe with no significant risk of lethality and overdose. However, tricyclic antidepressants are more toxic in overdose and are mostly reserved for the treatment of suicidal behaviors in patients showing no significant response to SSRIs and newer antidepressants. Globally, owing to the strong association between clinical depression and suicidality, antidepressants are used as a vital somatic therapy tool for people with suicidal ideation and behavior. of suicidal ideation and behavior (SIB). As maintenance therapy, lithium is liked with a significant reduction in suicide attempts and suicide risk, especially in patients with bipolar disorder comorbidities. However, psychiatrists are warned to consider the potential lethality of lithium overdose before considering this option. Dose adjustment might be important in special populations and people with major organ system dysfunctions. The potential effects of lithium overdose should be discussed with other members of the clinical team to get their input on therapy execution and monitoring.
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