SUICIDE PREVENTION AWARENESS DAY, March 1, 2007

Management & Treatment

Lorraine S. Roth, M. D.

North Chicago VA Medical Center

North Chicago, Illinois

Clinical Management

Clinical management consists of a broad array of therapeutic interventions that should be instituted for patients with suicidal thoughts, plans, or behaviors. It includes attending to patient safety, determining a setting for treatment and supervision, and working to establish a cooperative and collaborative clinician-patient relationship. Additionally, management may include encouraging treatment adherence and providing education to the patient and, when indicated, family members and significant others.

Patients with suicidal thoughts, plans, or behaviors should generally be treated in the setting that is least restrictive yet most likely to be safe and effective. Treatment settings and conditions include a continuum of possible levels of care, from involuntary inpatient hospitalization through intensive outpatient programs to ambulatory care in clinics. Choice of specific treatment [depends on] setting depends not only on the estimate of the patient's current suicide risk and potential for dangerousness to others, but also on other aspects of the patient's current status, including

1) medical and psychiatric comorbidity;

2) strength and availability of a psychosocial support network; and

3) ability to provide adequate self-care, give reliable feedback to the clinician, and cooperate with treatment.

In addition, the benefits of intensive interventions such as hospitalization must be weighed against their possible negative effects (e.g., disruption of employment, financial and other psychosocial stress, social stigma).

For some individuals, self-injurious behaviors may occur on a recurring or even chronic basis. Although such behaviors may occur without evidence of suicidal intent, this may not always be the case [may accidentally commit suicide]. Even when individuals have had repeated contacts with the health care system for self-injurious behavior, each act should be reassessed in the context of the current situation.

For difficult-to-treat patients, consultation or supervision from a colleague may help in affirming the appropriateness of the treatment plan, suggesting alternative therapeutic approaches, or monitoring and dealing with countertransference issues.

The suicide prevention contract, or "no-harm contract," is commonly used in clinical practice but should not be considered as a substitute for a careful clinical assessment. A patient's willingness (or reluctance) to enter into an oral or a written suicide prevention contract should not be viewed as an absolute indicator of suitability for discharge (or hospitalization).

“Contracts” are not recommended for use with patients who are agitated, psychotic, impulsive, or under the influence of an intoxicating substance. Furthermore, since suicide prevention contracts are dependent on an established physician-patient relationship, they are not recommended for use in emergency settings or with newly admitted or unknown inpatients.

Treatment

In developing a plan of treatment that addresses suicidal thoughts or behaviors, the clinician should consider the potential benefits of somatic therapies as well as the potential benefits of psychosocial interventions, including the psychotherapies. Clinical experience indicates that many patients with suicidal thoughts, plans, or behaviors will benefit most from a combination of these treatments:

1. Medications: Antidepressants, anti-anxiety, anti-manic/mood stabilizers, anti-psychotics, sedative-hypnotics.

2. Psychotherapy options: Psychotherapeutic, supportive; Cognitive behavioral; DBT (Dialectical Behavioral Therapy); EMDR (Eye Movement Desensitization and Reprocessing).

3. ECT (Electro-Convulsive Therapy, or “shock treatment.”)]

The treatment should address the modifiable risk factors identified in the initial evaluation and make ongoing assessments during the course of treatment. In general, therapeutic approaches should target specific mental illnesses; specific associated symptoms such as depression, agitation, anxiety, or insomnia; or the predominant psychosocial stressor

While the goal of pharmacologic treatment may be acute symptom relief, including acute relief of suicidality or acute treatment of a specific diagnosis, the treatment goals of psychosocial interventions may be broader and longer term, including achieving improvements in interpersonal relationships, coping skills, psychosocial functioning, and management of affects.

Since treatment should be a collaborative process between the patient and clinician(s), the patient’s preferences are important to consider when developing an individual treatment plan.

Antidepressants & Suicidality

An FDA commissioned meta-analysis of randomized controlled trials of antidepressant medications among adults with psychiatric disorders, made public in November, 2006 indicated that the risks of suicidal ideation and behavior were increased in adults younger than 25 years of age, but not older adults, following the initiation of treatment with antidepressants. The FDA report states:

Regardless of the exact mechanism, the observations contained in this review support the idea that antidepressant drugs can have two separate effects:

one that promotes suicidality or suicidal behavior, and

one that prevents it.

When results are analyzed by age it becomes clear that there is an

elevated risk for among adults younger than 25 years of age

neutral for adults between 25 and 64, and

reduced risk in subjects 65 years and older.

It is also likely that these effects vary among individuals of comparable ages.

The preventive effect may correlate with measures of clinical response.

The relative susceptibility to these two effects varies with age. In older subjects, the preventative effect appears to predominate while in younger subjects the opposite is true.

The observed relationship between suicidality, age, and antidepressant treatment appears to be generalizable to all subjects with psychiatric diagnoses.

Suicide is the 11th leading cause of death in the United States, accounting for 1.3% of all US deaths. In the US, older individuals, whites, and men are more likely to commit suicide. Patients of any age with mental illnesses are at greater risk, and those with co-occurring disorders, such as depression and alcohol abuse, are at still higher risk.

The FDA’s recent analyses extend findings that led to warnings regarding increased risks for suicidality among children and adolescents. On October 15, 2004, the FDA issued a “black box” warning for antidepressant medications prescribed for youths, and urged close monitoring of children and adolescents in the 12 weeks following antidepressant starts or dose changes. In a separate announcement on June 30, 2005, the FDA also urged similar close monitoring of adults with new prescriptions or dose changes. Close monitoring is needed to promote early detection of worsening depression, antidepressant induced mania, increased anxiety, dysphoria, restlessness, agitation, or other adverse effects that might follow antidepressant use and subsequently increase suicide risks.

Findings suggesting an increase in the risk of suicidality in adults younger than 25 years old receiving antidepressants should not constitute a barrier to antidepressant treatment for patients who need it. However, they point to the need for care in diagnosis and treatment planning as well as in monitoring for those receiving these medications.

Clinicians should consider recommending evidence-based psychotherapies [or medication other than antidepressants] for depressive disorders, anxiety disorders, or PTSD instead of, or in addition to, antidepressant medications. Before prescribing antidepressants, clinicians should carefully consider whether patients have disorders in which antidepressant medications are likely to be more effective than placebo or watchful waiting. For example, patients with moderate to severe major depression clearly have better outcomes when prescribed antidepressant medication while patients with minor depressive symptoms (Depression, NOS) often do no better when prescribed antidepressants than when they receive placebo or non-specific treatment. Patients with bipolar disease may deteriorate if they are treated with an antidepressant but not a mood-stabilizer.

For some adults, an increased risk of suicidality or suicidal behavior may be due to antidepressant initiation or changes. For others, risks may be increased at these times as a result of the underlying psychiatric illnesses and symptoms.

There are no definitive data on the frequency, types, or content of visits that are adequate to insure optimal detection of emergent suicidality or medication adverse effects. The current VA/DoD clinical practice guidelines on major depressive disorder recommend that a patient be seen 1 to 2 weeks after starting treatment, then again at 4-6 weeks. [1 week after start of treatment is preferable, and every week if possible, until stabilization.]

Despite best efforts at suicide assessment and treatment, suicides can and do occur in clinical practice. When the suicide of a patient occurs, the clinician may find it helpful to seek support from colleagues and obtain consultation or supervision to enable him or her to continue to treat other patients effectively and respond to the inquiries or mental health needs of survivors. The clinician should be aware that patient confidentiality extends beyond the patient's death and that the usual provisions relating to medical records still apply.