Treatment

Treatment for Suicide-related Thoughts and Behaviors

Suicidality itself is not a clinical diagnosis, but rather a transdiagnostic phenomenon that cuts across all diagnostic categories and affects individuals of all ages, ranks, races, and education levels. In fact, according to the CY 2015 DoDSER, only 49.1 percent of the active component service members who died by suicide had a behavioral health diagnosis documented in their medical history. When considering treatments for suicide-related thoughts and behaviors for their 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.

The treatments listed in this section have been recommended by the Assessment and Management of Risk for Suicide Working Group because they have demonstrated at least a moderate level of net benefit in at least one randomized controlled trial. A moderate level of net benefit was achieved when the suicide-related improvements attributed to a treatment outweighed any harms associated with that treatment.

All information on this page can be found in the VA/DoD Suicide CPG.

Treatments Recommended for Use

Suicide-focused Psychotherapies that Address the Suicide Risk

Type of Therapy/Targeted Outcome Brief Description and Main Goal
Cognitive therapy for suicide prevention
  • Patient Population:
    Individuals with multiple previous suicide attempts
  • Targeted Outcome:
    Prevention of repeated self-directed violence

10-session outpatient protocol whose main goal is teaching the patient that death is not the only option

Reference: Brown et al., 200518
DOI: 10.1001/jama.294.5.5

Problem-solving therapy
  • Patient Population:
    Individuals with multiple previous suicide attempts
  • Targeted Outcome:
    Prevention of repeated self-directed violence

Short-term therapy in which patients learn and practice problem-solving skills to address their current problems

Reference: Hatcher et al., 201119
DOI: 10.1192/bjp.bp.110.090126
Salkovskis et al., 199020

For pharmacological treatments, the VA/DoD Suicide CPG (p.106-107) contains the following general recommendations:

"All medications (prescription drugs, over-the-counter medications, and supplements [e.g., herbal remedies]) used by patients at risk for suicide should be reviewed to assure effective and safe treatment without adverse drug interactions."

"When prescribing drugs to people who self-harm, consider the toxicity of prescribed drugs in overdose and limit the quantity dispensed or available, and/or identify another person to be responsible for securing access to medications. The need for follow-up and monitoring for adverse events should also be considered."

Pharmacotherapies to Reduce Suicide Risk in Patients with Mental Disorders

Pharmacological Treatment Mental Disorder Treatment Considerations
Lithium Bipolar disorder “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.” (VA/DoD Suicide CPG, p.112)
Antidepressants Mood disorder “Consistent with the FDA box warning, clinicians must closely monitor young adult patients (18-24) for changes in thoughts of suicide or suicidal behaviors after an antidepressant is initiated or during a dose change.” (VA/DoD Suicide CPG, p.108)

Recommended for Use during Discharge Planning: Safety Planning

Whether a service member at risk for suicide is discharging from an inpatient setting or simply leaving the outpatient clinic following an appointment, it is recommended that clinicians and patients collaborate in-session to create a safety plan for the patient to use outside of the treatment setting. A safety plan consists of a written document that lists warning signs of a suicidal crisis as well as healthy coping strategies and help-seeking behaviors that can be used to counteract any suicidal urges. Safety plans are individualized to reflect each patient’s unique warning signs and preferred coping strategies.

In addition to giving a hard copy of the safety plan to the patient at risk, the VA/DoD Suicide CPG recommends including the safety plan in the patient’s medical record. Safety plans should be reviewed and updated regularly as suicide risk, warning signs, coping strategies, and other information on the form can change over time.

References

  1. Brown, G. K., Ten Have, T., Henriques, G. R., Xie, S. X., Hollander, J. E., & Beck, A. T. (2005). Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA, 294(5), 563-570.

  2. Hatcher, S., Sharon, C., Parag, V., & Collins, N. (2011). Problem-solving therapy for people who present to hospital with self-harm: Zelen randomised controlled trial. The British Journal of Psychiatry, 199(4), 310-316.

  3. Salkovskis, P. M., Atha, C., & Storer, D. (1990). Cognitive-behavioural problem solving in the treatment of patients who repeatedly attempt suicide. A controlled trial. The British journal of psychiatry, 157(6), 871-876.