Suicide-related thoughts and behaviors are not clinical diagnoses and are influenced by a complex set of risk factors and life circumstances. These thoughts and behaviors tend to cut across multiple diagnostic categories and may affect individuals of all ages, ranks, races, and education levels. When considering treatments for suicide-related thoughts and behaviors for patients, clinicians are advised to carefully consider the totality of a service member’s mental health (and not just the presence or absence of a diagnosis) prior to implementing any treatments.
In the 2019 VA/DOD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide, 10 treatment recommendations are presented in three groups: (a) non-pharmacologic treatments, (b) pharmacologic treatments, and (c) post-acute care. The strength of each recommendation is determined based on several factors, including the balance of desirable and undesirable outcomes, confidence in the quality of the evidence, patient/provider values and preferences, and other implications such as acceptability and feasibility.
Cognitive behavioral therapy focused on suicide prevention is the only treatment approach that received a “strong for” recommendation by the Assessment and Management of Suicide Risk Work Group for patients with a recent history of self-directed violence. Multiple non-pharmacologic and pharmacologic treatments received a “weak for” strength of recommendation. See the list of recommendations below.
Evidence-Based Treatments to Reduce Repetition of Suicide-Related Behaviors
|
Type
|
Recommendation
|
Strength
|
|
Non-pharmacologic
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6. Use cognitive behavioral therapy-based interventions focused on suicide prevention for patients with a recent history of self-directed violence to reduce incidents of future self-directed violence. |
Strong for |
|
7. Offer Dialectical Behavioral Therapy to individuals with borderline personality disorder and recent self-directed violence. |
Weak for |
|
8. Complete a crisis response plan for individuals with suicidal ideation and/or a lifetime history of suicide attempts. |
Weak for |
|
9. Offer problem-solving based psychotherapies to patients with a history of repeated self-directed violence, patients with a recent history of self-directed violence, and patients with hopelessness and a history of moderate to severe traumatic brain injury. |
Weak for |
|
Pharmacologic |
10. In patients with the presence of suicidal ideation and major depressive disorder, offer ketamine infusion as an adjunctive treatment for short-term reduction in suicidal ideation. |
Weak for |
|
11. Offer lithium alone (among patients with bipolar disorder) or in combination with another psychotropic agent (among patients with unipolar depression or bipolar disorder) to decrease the risk of death by suicide in patients with mood disorders. |
Weak for |
|
12. Offer clozapine to decrease the risk of death by suicide in patients with schizophrenia or schizoaffective disorder and either suicidal ideation or a history of suicide attempt(s). |
Weak for |
|
Post-acute care |
13. Send 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. |
Weak for |
|
14. Offer a home visit to support reengagement in outpatient care among patients not presenting for outpatient care following hospitalization for a suicide attempt. |
Weak for |
|
15. Offer the World Health Organization Brief Intervention and Contact treatment modality following presentation to the emergency department for suicide attempt, in addition to standard care. |
Weak for |
Reducing Access to Lethal Means as a Population-based Intervention
The last five recommendations included in the CPG focus on population-level interventions for suicide-related behaviors. The work group found insufficient evidence to recommend for or against community-based interventions, gatekeeper training, and buddy support programs. Lethal means safety involves reducing access to objects (e.g., firearms, medications, sharp objects) that can be used to engage in suicide-related behaviors. It is the only intervention approach that is recommended for decreasing suicide rates at the population level. Examples of lethal means safety procedures include safe storage of firearms, reduced access to poisons and medications associated with overdose, and barriers to jumping from lethal heights.
We have created some suicide risk clinical support tools for providers, patients, families, and military leaders based on the guidance in the CPG.