Tip Cautiously Use Standardized Questionnaires. Tip Screen for Access to Firearms.
- Suicide risk assessment and prevention.
- Preventing Patient Suicide.
Tip Inquire about Internet Use. Tip Probe for Homicidal Ideation.
Tip Examine Reasons for Living. Tip Identify Other Protective Factors. Tip Pay Attention to Culture. Tip Estimate Acute Risk for Suicide. Tip Estimate Chronic Risk for Suicide. Tip Document Generously. Tip Collaboratively Develop a Safety Plan. Tip Encourage Delay. Tip Problem-Solve around Access to Firearms.
Tip Seek Consultation. Treatment interventions that have been shown to be effective in reducing the risk for repeated self-directed violence or preventing suicide in patients with specific conditions need to be considered or optimized in those with these conditions who are at risk for suicide e. For Active Duty Service members the command should always be involved in the treatment plan of a high-risk suicidal patient. Suicide-Focused Psychotherapy Addressing the Suicide Risk Suicide-focused psychotherapies that have been shown to be effective in reducing risk for repeated self-directed violence should be included in the treatment plan of patients at high risk for suicide, if the risk for suicide is not adequately addressed by psychotherapy specific to the underlying condition.
Psychotherapy may include: Cognitive therapy for suicide prevention for non-psychotic patients who have survived a recent suicide attempt [B] and others at high risk. There is inconsistent evidence regarding the efficacy of psychotherapy in reducing the risk for repetition of self-directed violence in patients with co-occurring disorders. Borderline Personality Disorder See the original guideline document for a discussion of the evidence for specific therapies.
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Risk for Suicide in Schizophrenia There is insufficient evidence to recommend for or against use of CBT to reduce the risk of suicide behavior in patients with schizophrenia [I] K4. In addition to suicidality-focused interventions, treatment should be provided for an underlying SUD condition e. Ensure that management of suicide risk is coordinated or integrated with treatment for SUD and comorbid conditions.
Intervention strategies in patients in whom suicide risk is associated with using substances should emphasize safety, relapse prevention, and address the substance use. In the effort to limit access to lethal means, pay special attention in this population to restriction of lethal means as firearms, and prescribed medication dosage and quantities.
Pharmacotherapy to Reduce Risk of Suicide This Guideline recommends against the use of drug treatment as a specific intervention for prevention of self-directed violence in patients with no diagnosis of a mental disorder. When a person expresses thoughts of self-harm or has demonstrated self-harm behavior, the patient's medication regimen prescription drugs, over-the-counter medications, and supplements [e. The continuation of such medications should be carefully evaluated and documented see Appendix B-3 Table, "Drugs Associated with Suicidality," in the original guideline document.
Pharmacological Treatment to Reduce Risk for Suicide in Patients with Mental Disorders When self-harm behavior or suicide risk is attributable to a psychiatric illness, that illness needs to be identified and treated and the treatment plan modified when appropriate to specifically address the risk of suicide. Pharmacological intervention may be markedly helpful in managing underlying mental disorders and the danger of repeated or more dangerous self-directed violence. All medications prescription drugs, over-the-counter medications, and supplements [e.
Preventing Patient Suicide
The need for follow-up and monitoring for adverse events should also be considered. Use of Antidepressants to Prevent Suicide in a Patient with a Mood Disorder Closely monitor patients for changes in thoughts of suicide or suicidal behaviors after antidepressant treatment has been initiated or the medication dose is changed. Antidepressants may provide benefit to address suicidal behavior in patients with mood disorders.
Treatment for the underlying cause should be optimized according to evidence-based guidelines for the respective disorder. Young adults started on an antidepressant for treatment of depression or another psychiatric disorder should be monitored and observed closely for emergence or worsening of suicidal thoughts or behaviors during the initiation phase of treatment. When prescribing antidepressants for patients at risk for suicide, pay attention to the risk of overdose and limit the amount of medication dispensed and refilled.
Use of Antipsychotics to Prevent Suicide in a Patient with a Non-Psychotic Disorder Closely monitor patients for changes in thoughts of suicide or suicidal behaviors after an antipsychotic is added to treatment for a mood disorder. There is no evidence that antipsychotics provide additional benefit in reducing the risk of suicidal thinking or behavior in patients with co-occurring psychiatric disorders.
Treatment for the psychiatric disorder should be optimized according to evidence-based guidelines for the respective disorder. Patients who are treated with antipsychotics should be monitored for changes in behavior and emergence of suicidal thoughts during the initiation phase of treatment or after any change in dosage. When prescribing antipsychotics in patients at risk for suicide pay attention to the risk of overdose and limit the amount of medication dispensed and refilled.
Use of Lithium for Reducing Suicide in Patients with Unipolar Depressive Disorder Providers should consider treating patients with a unipolar depression disorder with lithium in an effort to reduce the risk of suicide.
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Lithium augmentation should be considered for patients diagnosed with unipolar depressive disorder who have had a partial response to an antidepressant and for those with recurrent episodes who are at high risk for suicidal behavior, provided they do not have a contraindication to lithium use and the potential benefits outweigh the risks. When prescribing lithium to patients at risk for suicide, it is important to pay attention to the risk of overdose by limiting the amount of lithium dispensed and the form in which it is provided.
Use of Lithium for Reducing Suicide in Patients with Bipolar Disorder Providers should consider treating patients with a bipolar disorder with lithium in an effort to reduce the risk of suicide. Lithium should be considered for patients diagnosed with bipolar disorder who do not have contraindications to lithium as it has been shown to reduce the increased risk of suicide associated with this illness.
When prescribing lithium to patients at risk for suicide, it is important to pay attention to the risk of overdose by limiting the amount of lithium dispensed, and to the form in which it is provided. Use of Clozapine in the Treatment of a Patient with Schizophrenia Risk for Suicide Providers should consider treating patients with schizophrenia with clozapine who have a history of suicide attempt, high risk for suicide, or who are symptomatic after two adequate trials with other antipsychotics. Clozapine should be considered for patients diagnosed with schizophrenia at high risk for suicide, who do not have contraindications to clozapine, and will be compliant with all required monitoring.
Patients started or who are managed with AEDs should be monitored for changes in behavior and the emergence of suicidal thoughts. There is no evidence that AEDs are effective in reducing the risk of suicide in patients with a mental disorder M7. Use of Anti-anxiety Agents in Suicidal Patients Use caution when prescribing benzodiazepines to patients at risk for suicide. It is important to pay attention to the risk of disinhibition from the medication, and respiratory depression particularly when combined with other depressants by limiting the amount of benzodiazepines dispensed.
Avoid benzodiazepines with a short half-life and the long-term use of any benzodiazepine to minimize the risk of addiction and depressogenic effects. Providers should consider dispensing intranasal naloxone for patients with history of opioid overdose and those who are at high risk. When dispensed, patient and family or other caregiver should be educated on the use of the intranasal naloxone to treat the overdose while waiting for the emergency team to arrive. ECT is recommended as a treatment option for severe episodes of major depression that are accompanied by suicidal thoughts or behaviors indicating imminent risk for suicide, considering patient preferences.
Under certain clinical circumstances and, considering patient preference, ECT may also be considered to treat suicidal patients with schizophrenia, schizoaffective disorder, or mixed or manic episodes of bipolar disorder. The decision of whether to initiate ECT treatment should follow evidence-based recommendation for the specific disorder, and be based on documented assessment of the risks and potential benefits to the individual, including: the risks associated with the anesthetic; current co-morbidities; anticipated adverse events; and the risks of not having treatment.
Since there is no evidence of a long-term reduction of suicide risk with ECT, continuation or maintenance treatment with pharmacotherapy or with ECT is recommended after an acute ECT course. ECT should be performed by experts in centers that are properly equipped and experienced in the treatment. In general, the following conditions increase the indications to use ECT: A history of prior good response to ECT Need for rapid, definitive treatment response Risks of other treatments outweigh the risks of ECT History of poor response to medication treatment Intolerable side effects to medication treatments Patient preference The risk-versus-benefits ratio must be considered in patients with relative contraindications such as [B] : Space occupying lesions Elevated intracranial pressure Cardiovascular problems to include recent myocardial infarction, severe cardiac ischemic disease, or profound hypertensive illness Degenerative skeletal disease Monoamine oxidase inhibitors should be discontinued two weeks prior to ECT to prevent possible hypertensive crisis.
Lithium: Patients may develop neurotoxic syndrome with confusion, disorientation, and unresponsiveness. Retinal detachment Pheochromocytoma High anesthesia risk: American Society of Anesthesiologists level 4 or 5 Module D: Follow-up and Monitoring of Patient at Risk for Suicide Follow-up and Monitoring Follow patients at risk of suicide regularly and reassess risk frequently, particularly when the patient's situation changes. Follow-up should commence in the immediate period after discharge from acute care settings. The frequency of contact should be determined on an individual basis, and increased when there are increases in risk factors or indicators of suicide risk.
Support should include reinforcement of the safety plan at regular intervals, including practice and, if needed, revisions. Contact and support can be helpful even when telephone, letters, or brief intervention provides it. Follow-Up Establish timely and ongoing follow-up care for those who attempt suicide and others at high acute risk in the immediate period after discharge from acute care settings and identify the responsible provider during this period.
Is This Patient Suicidal? Tips for Effective Assessment
Patient should be re-evaluated following an inpatient or Emergency Department discharge, as soon as possible, but not later than 7 days. High acute risk patient should be actively managed to assure adherence and coordinated care. Patients at high acute risk should be followed closely e.