What Is in Your Treatment Toolbox? Clinical Interventions to Prevent Suicidal Behavior
Community behavioral health providers are expected to know how to treat suicidal patients. As so often is the case, though, the practice demands are ahead of the research. New studies are testing the best ways to treat and prevent suicidal behavior, but how do you treat these behaviors without a full toolbox?
Many individuals with suicidal ideation will receive medications to address symptoms and “underlying” psychiatric conditions. However, most medication takes weeks to provide relief from psychiatric symptoms.
Currently, the only medication with a specific FDA indication relevant to suicide is clozapine. Clozapine is indicated for reducing the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder. However, agranulocytosis, a rare side effect of clozapine, results in the need for frequent monitoring of white blood cells, which limits its use in practice.
Although not FDA-indicated, lithium medication has been associated with lowering suicide risk in individuals with bipolar disorder. Research has found that individuals who remained adherent to lithium treatment were at lower risk for suicide, but placebo-controlled studies of lithium are still needed to isolate the medication versus compliance benefits in reducing suicide risk.
Ketamine, originally used as an anesthetic, is a repurposed medication that is showing promise as a fast-acting treatment for severe depression and suicidal ideation. Additional research is needed to determine the safety, feasibility, dose and duration for the use of Ketamine, but it does open up the potential for future fast-acting medication treatments for suicidal ideation that could be used in acute care settings.
In addition to tracking possible untoward side effects, there is also a need to test suicidal events as outcomes in medication research studies focused on treating mental disorders. In the past, many industry-sponsored trials excluded suicidal individuals from efficacy trials.
Several research reviews have found that outpatient psychotherapies (e.g., cognitive behavior therapy; dialectical behavior therapy; problem solving therapy) reduce suicidal thinking and re-attempts among high-risk adult patients. One review notes that psychotherapy recipients had, on average, a 32 percent reduction in the likelihood of a suicide attempt compared with usual care within a year.
Another study from the Danish health care registry followed recipients of psychotherapy and those not receiving psychotherapy for up to 20 years. Those who received psychotherapy were 16 percent less likely to attempt suicide and 25 percent less likely to die by suicide.
Modeling the future
In 2014, the Action Alliance’s Research Prioritization Task Force modeled optimal implementation of evidence-based psychotherapy delivered to the U.S. population of adults seen in emergency care for suicide attempts. The model estimated that more than 109,000 suicide attempts and more than 13,000 suicide deaths could be averted over 5 years by delivering effective psychotherapy to adults seen in emergency care settings for self-harm. This demonstrates enormous potential for successful intervention. In the meantime, we must continue to invest in suicide research.
Research challenges include the need to better understand developmental and contextual factors:
• Youth, adult, older adult;
• Transitional, work and health contexts such as discharge from military and COPD onset;
• Co-occurring psychopathology (e.g., substance use);
• Social context (LGTBQ; domestic violence; recent loss);
• Prior suicidal behavior;
• Treatment history and
• Current setting–including immediate (referred from inpatient or emergency care)–in intervention research.
We need to know how to better match potential interventions to the patient’s needs. New treatment targets (e.g., isolation; anhedonia; insomnia; agitation; psychosis) might also be more efficiently addressed.
While suicide research around effective interventions is rapidly increasing, there remain many questions left to answer. For lives to be saved, effective research must be translated into practice.
As community behavioral health providers on the front line, you are the lifeline for patients at risk for suicide and those recovering from an attempt.
(See Section IX in the Research Agenda for citations for all research mentioned above. )
Register for upcoming webinars in this series:
Recordings of the first four webinars in this series can be found in the National Council for Behavioral Health’s webinar archives.
The National Action Alliance for Suicide Prevention is the public-private partnership advancing the National Strategy for Suicide Prevention (NSSP). This is achieved by catalyzing implementation of high priority NSSP objectives. One such example is the Prioritized Research Agenda for Suicide Prevention: An Action Plan to Save Lives. This groundbreaking document advances NSSP objective 12.1- Develop a national suicide prevention research agenda with comprehensive input from multiple stakeholders.