The need to cooperate with the patient on the module of cognitive therapy also appears to have a bearing on the efficiency of therapy. Many patients and providers appreciate the structured nature of CBT and generally find it to be acceptable. However, some patients also find homework to be challenging and burdensome, and some decline to participate. Methods considered effective by the patient should be selected to make sure the effect of therapy can be accurately measured and reviewed over time. In summary, the VA/DoD guidelines indicate that the benefits of instituting an effective cognitive therapy module for suicide prevention and management far outweigh the potential harm of adverse events, of which there was no evidence in the included studies, and which have not been observed in practice by any of the Work Group members. Dialectical behavioral therapy is also recommended for individuals with borderline personality disorder and recent self-directed violence. Originally designed to manage patients with borderline personality disorder, DBT is effective as a nonpharmacological option for the management of suicidal ideation and behavior by combining elements of emotion regulation, interpersonal effectiveness, and stress tolerance. The guidelines acknowledge the research evidence supporting DBT in the reduction of non-suicidal and suicidal behavior among patients with BPD. VA/DoD guidelines support dialectical behavior therapy (DBT), specifically outlining how findings from different patient focus groups indicate that patients have had positive experiences with treatment modalities that include various complementary and integrative therapies such as mindfulness, which is an integral component of DBT. Problem-solving-based psychotherapies such as humanistic therapy, behavior therapy, and cognitive therapy are also recommended, specifically for patients with a history of more than one incident of self-directed violence to reduce repeat incidents of such behaviors as well as suicidal ideation. There is also support for using these therapeutic interventions for patients experiencing hopelessness with a history of moderate to severe traumatic brain injury (Inoue et al., 2022) The VA/DoD guidelines specially recognize problem-solving therapy as an effective option for reducing the risk of repetitive and deliberate self-harm in suicidal patients. This nonpharmacological option is one type of cognitive-behavioral psychotherapy designed to improve a patient’s ability to navigate social stressors using active problem-solving skills. Medication Intervention Patients who have suicidal ideation and major depressive disorder may benefit from ketamine infusion as an adjunctive treatment for short-term reduction in suicidal ideation. In recent years, the focus of pharmacological research exploring drug alternatives in the management of suicidal ideation and behavior has shifted toward ketamine. VA/DoD guidelines support the use of ketamine as adjunctive therapy in at-risk patients selected for an acute therapy plan. It is recommended as a single dose at 0.5 mg/kg and has moderate evidence for acute symptom improvement of suicidal ideation within 24 hours of treatment, with a moderate effect size that continues for one week and even up to six weeks. However, clinicians are cautioned on the important barriers to ketamine therapy, as patients may not be receptive to receiving an infusion administered in an inpatient setting, and ketamine therapy may not be an option for patients living in rural areas, where its availability may be limited. There is also the risk of a transient elevation in blood pressure in a small number of patients that resolved without significant sequelae; continued repeat administration of ketamine is not recommended following the risk of addiction.
In patients with mood disorders, lithium is recommended alone (for patients with bipolar disorder) or in combination with another psychotropic agent (for patients with unipolar depression or bipolar disorder) to decrease the risk of death by suicide. In patients with unipolar and bipolar depression, lithium has long been used as a pharmacological option to reduce the risk of suicide attempts. The VA/DoD guidelines express moderate confidence in the quality of research evidence supporting the use of lithium in this context. However, despite the medical community’s general acceptance of lithium for SIB management, there are limitations and provider variabilities. The VA/DoD guidelines warn clinicians of the various side effects associated with lithium dis-continuation, including gastrointestinal upset, tremor, polyuria, polydipsia, weight gain, hypothyroidism, and leukocytosis. Lithium toxicity may result in lithium overdose, and some other side effects may not resolve when lithium is discontinued, including thyroid abnormalities, polyuria, and renal toxicity leading to reduced renal clearance. Overdosing can be prevented by considering the risks and benefits of extended-release versus immediate-release lithium formulations and by limiting the amount of lithium dispensed to specific patient populations. Other methods such as dispensing smaller quantities and safe medication storage can also help reduce the risk of toxicity and overdose. Clozapine has been shown to decrease the risk of death by suicide in patients with schizophrenia and other psychotic- spectrum disorders. Research studies investigating the clinical benefits of clozapine in the management of SIB in youth have reported a significant reduction in suicidal risk and behavior, especially in patients with schizophrenia and schizoaffective disorders. Compared to other pharmacological options, clozapine also lowers the overall risk of suicide behavior. VA/DoD guidelines warn about the significant challenges to clozapine use in certain subgroups of patients, such as the elderly and people who are unhoused, both because of the medication’s side effects and difficulties accomplishing the required medication monitoring. Other widely referenced recommendations in VA/DoD guidelines include: ● For post-acute care, it’s suggested: ○ Sending periodic caring communications (e.g., postcards) for 12–24 months in addition to usual care after psychiatric hospitalization for suicidal ideation or a suicide attempt. ○ Offering a home visit to support re-engagement in outpatient care among patients not presenting for outpatient care following hospitalization for a suicide attempt. ○ Offering the World Health Organization (WHO) Brief Intervention and Contact treatment modality the following presentation to the emergency department for a suicide attempt, in addition to standard care ● For technology-based modalities: ○ There is insufficient evidence to recommend for or against technology-based behavioral health treatment modalities for individuals with suicidal ideation. These include self-directed digital delivery of treatment protocols with minimal or no provider interaction (e.g., compact disc, web-based), and provider-delivered virtual treatment. ○ There is insufficient evidence to recommend for or against the use of technology-based adjuncts (e.g., web or telephone applications) to routine suicide prevention treatment for individuals with suicidal ideation.
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