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New Guideline Helps Doctors Assess and Manage Patients at Risk for Suicide

August 27, 2019

By Will Boggs MD

NEW YORK—New guidelines from the U.S. Department of Veterans Affairs (VA) and US Department of Defense (DoD) offer 22 recommendations for screening, evaluating, treating and managing patients who may be at risk for suicide.

"Screening for suicide risk in our patients does not have to be overly complex, and once a patient is identified as being at risk for suicide, there are effective interventions," Dr. James Sall from Veterans Health Administration, in Washington, D.C., and Texas A and M University, in Corpus Christi, told Reuters Health by email.

Nationwide suicide rates increased 25% from 1999 to 2016, while suicide-related deaths more than doubled among active service members, from 10.7 to 21.5 per 100,000 service members, Dr. Sall and colleagues note in the Annals of Internal Medicine, online August 27. Twenty veterans die each day by suicide, they add.

Dr. Sall and colleagues in the VA/DoD Evidence-Based Practice Work Group systematically searched and evaluated the literature through April 2018, created several algorithms, and developed a set of recommendations to help healthcare providers assess and manage patients at risk for suicide.

The panel found strong support for assessing risk factors as part of a comprehensive evaluation of suicide risk. This assessment should begin with direct questions about recent thoughts of suicide to those presenting with warning signs (including those with suicidal ideation or recent self-directed violence), those identified to be at a high risk for suicide via predictive analytics, and those who present for routine suicide risk screening.

Ideally, individuals who screen positive but are not at imminent risk of suicide should undergo secondary suicide screening or comprehensive suicide-risk evaluation by a local provider, the panel advises.

This assessment would allow assignment to one of three suicide-risk categories based on several essential features: high risk (suicidal ideation with intent to die by suicide, along with an inability to maintain safety independent of external support/help); intermediate risk (suicidal ideation with intent to die by suicide, but with an ability to maintain safety independent of external support/help); and low risk (no current suicidal intention and no specific and current suicidal plan and no recent preparatory behaviors and collective high confidence in the ability of the person to independently maintain safety).

Management then depends on the assigned level of acute risk. High-risk patients need to be directly observed on a secure unit in an environment with no access to lethal means. Intermediate-risk patients can be managed as outpatients with frequent contact and a well-articulated safety plan. Low-risk patients can be managed in primary care, although outpatient mental health treatment may also be necessary.

Recommended interventions include various counseling approaches, pharmacotherapy for suicide prevention, lethal means safety (firearm restrictions, reduced access to poisons and medications associated with overdose, barriers to jumping from lethal heights, and so on), and community-based programs to prevent suicide.

A systematic review used to inform the guideline, and published with it, evaluated interventions to prevent suicide and reduce suicide behaviors in at-risk adults.

Dr. Kristen E. D'Anci and colleagues from ECRI Institute's Center for Clinical Evidence and Guidelines, in Plymouth Meeting, Pennsylvania, found that both cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT, which combines elements of CBT, skills training, and mindfulness techniques) showed modest benefit in reducing suicidal ideation compared with treatment as usual. But only CBT was shown to reduce suicide attempts (by 53%).

The evidence base for other nonpharmacological interventions was too limited to make reliable conclusions regarding their efficacy.

Among pharmacological interventions, subanesthetic doses of intravenous ketamine appeared to reduce suicidal ideation, and oral lithium therapy significantly reduced suicide rates compared with placebo (but not compared with other active treatments), the researchers found.

Newer-generation antidepressants were not significantly better than placebo for reducing suicide or hopelessness.

"Physicians should be aware that there are treatments, such as CBT or DBT that can be helpful for people who have thoughts of suicide," Dr. D'Anci told Reuters Health by email. "The use of medications is less well-studied, but for some patients medication may be an option. Like many health conditions, there is no one-size-fits-all approach."

Dr. Eric D. Caine of the University of Rochester Medical Center, in Rochester, New York, who wrote an accompanying editorial, told Reuters Health by email, "Persons in primary care - especially adult and elder men - with depression (or another common condition such as anxiety), or insomnia, or poorly treated pain, or alcohol/substance misuse (e.g., multiple drinks daily, even as they may continue working), or related complex conditions (e.g., type 2 diabetes) deserve active interventions before (they) become suicidal."

"Separately, and especially in combination, these conditions are associated with premature mortality from multiple causes, including suicide and fatal drug/alcohol intoxications," he said. "We don't know which person will die by suicide, but these all are potentially treatable."

Dr. Michael Hogan of Case Western Reserve School of Medicine, in Cleveland, Ohio, who wrote another linked editorial, told Reuters Health by email, "A single question inquiring about thoughts of suicide (e.g., question 9 on the PHQ-9 health questionnaire) is quite sensitive for identifying future risk, though like a Framingham score it cannot predict exactly if or when death will occur."

"A brief intervention called Safety Planning Intervention or Crisis Response Plan is usually effective in reducing risk by giving the patient tools to use instead of ruminating about death (e.g., calling the National Suicide Prevention Lifeline at 1-800-273-TALK)," he said. "A key part of safety planning and the most important single intervention is collaboratively identifying and reducing means of self-harm the patient has considered (e.g., safe storage of weapons). And finally, since isolation with loss of hope drives suicide, a few ‘caring contacts' (e.g., texts, phone calls, letters) have strong evidence for reducing risk."


Ann Intern Med 2019.

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