Safety should be the primary consideration when determining the appropriate level of treatment for a patient with suicidal ideation. Providers should consider the least restrictive environment available for the patient in light of the patient’s unique presenting situation and safety needs. A treatment plan can be developed after comprehensive evaluation. The VA/DoD Suicide CPG discusses treatment options in Module C: Treatment of the Patient at Risk for Suicide. To date, DoD has not found conclusive evidence to support one therapy over another; however, specific forms of cognitive therapy appear to be effective in preventing subsequent suicide attempts with previous suicide attempters, and have been shown to decrease the risk of suicide in patients. Providers should know and understand relevant military-specific policies and directives and use resources such as the VA/DoD Suicide CPG, clinic guidance, and case consultation. Therapeutic and pharmacologic options should be matched to the patient’s level of risk.
Reassessment and monitoring of symptoms is an important part of treating patients with suicidal ideation. Based on the level of risk, requirements of the specific treatment (and any co-occurring disorders), and the patient’s preference, a plan should be built to ensure timely access to follow-up care where adherence can be monitored.
Pharmacological Treatment Options
The VA/DoD Suicide CPG states that evidence for the use of pharmacological interventions specifically to address suicide risk is limited and it recommends against the use of drug treatment as a specific intervention for prevention of self-directed violence in patients with no diagnosis of a mental disorder. Rather, pharmacological intervention may be helpful in managing the underlying mental disorder in patients with suicidal ideation. The VA/DoD Suicide CPG notes that all medications used by patients at risk for suicide should be reviewed to assure effective and safe treatment without adverse drug interactions. Providers should consider the toxicity of prescribed medications in overdose and limit the quantity dispensed or available, as well as identify another individual to be responsible for securing access to medications.
Common Methods of Suicide in Military Personnel
When working with military personnel, it is important to note that the primary methods for suicide completion in this population include firearms (majority non-military issued) and suffocation (e.g., hanging). Per the Department of Defense Suicide Event Report (DoDSER) Calendar Year 2013 Annual Report, primary methods for suicide attempts were drugs and/or alcohol overdose. Approximately half of suicide attempters (47.2 percent) and two-thirds of suicide completers (66.5 percent) had previously been deployed; however less than 20 percent had a history of direct combat for either group (14.7 percent suicide completers, 19.4 percent attempters). Almost 40 percent of suicide completers had a mental health diagnosis, while 59 percent of attempters had a diagnosis of a mood disorder, anxiety disorder, or adjustment disorder, with posttraumatic stress being one of the most common diagnoses. Well over half of suicide completers (57.6 percent) and attempters (69.2 percent) had been seen by medical or support services in the previous 90 days. For more specific data, see the DoDSER Calendar Year 2013 Annual Report. This information may be important to consider when assessing the safety of a patient and the level of care required.
Privacy of Service Members
There may be additional hurdles that impact working with service members with suicidal ideation. Consideration of the patient’s privacy needs to be balanced with involving command, particularly when military readiness may be compromised. Providers should understand requirements for communication with providers and policies to include Department of Defense Instruction (DoDI) 6490.04 Mental Health Evaluations of Members of the Military Services and DoDI 6490.08 Command Notification Requirements to Dispel Stigma in Providing Mental Health Care to Service Members, which dictate guidance on disclosure to a service member’s chain of command.
Limiting Access to Lethal Means
Research of rates and methods of suicide have found a relationship between suicide and reduction in the availability of lethal methods. As such, strategies aimed at limiting access to lethal means should be an integral part of suicide prevention. The VA/DoD Suicide CPG outlines the research underlying this factor, noting that providers should consider several ways to limit access to lethal means including restricting access to firearms (both military issued and personally owned) and ammunition; prescription medication; access to alcohol and illicit drugs; and modifying the environment to limit potential hazards (door hinges, shower curtains, belts). It is recommended that these precautions be discussed with the service member (when applicable) to gain buy-in to the process. Additionally, it may be necessary to discuss these precautions with the service member’s chain of command. As part of the 19 executive actions to improve the mental health of service members, veterans, and their families issued by the President in August 2014, DoD was tasked to implement policy to facilitate requests for at-risk service members or at-risk military family members to voluntarily secure their firearms.
Research indicates that service members are at greater risk for suicidal ideation during periods of transition including transition to new duty stations, after separation from unit, and separation from military service. Additional caution should be taken to ensure continuity of care is maintained during these periods. Also resulting from the 19 executive actions issued in August 2014, DoD will automatically enroll all service members who are transitioning locations or leaving the military and are receiving care for a mental health condition into the inTransition program which offers additional support to ensure service members are able to continue treatment seamlessly.
A safety plan is a written, prioritized list of coping strategies and sources of support that can be used by patients to help guide them through a suicidal crisis. A safety plan is developed collaboratively between the provider and patient, with the goal of anticipating the suicidal crisis and preventing the patient from acting on their suicidal thoughts. The process of creating the safety plan offers a means by which providers can build therapeutic alliance with their patients, discussing the very personal experience of suicidal ideation as well as the elements that can enhance coping and minimize suicidal ideation. The safety plan should include these steps:
- Recognition of the personal warning signs or stressors of a suicidal crisis
- Employment of internal coping strategies
- Use of social support contacts to distract from suicidal thoughts
- Use of family members or friends to help resolve crisis
- Contact information for mental health providers to reach out to for help
- Ways of restricting access to lethal means
A safety plan should be updated and reviewed frequently, with attention to any relevant changes to the above elements. It can be shared with family members or friends to enhance adherence and the patient may elect to post it in a place where he or she can easily access it.
 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. doi:10.1001/jama.294.5.563.
 The Assessment and Management of Risk for Suicide Working Group. (2013). VA/DoD clinical practice guideline for assessment and management of patients at risk for suicide. Washington, DC: Department of Veterans Affairs, Department of Defense. Retrieved from http://www.healthquality.va.gov/guidelines/MH/srb/VADODCP_SuicideRisk_Full.pdf.
 National Center for Telehealth and Technology (2014). Department of Defense Suicide Event Report (DODSER) Calendar Year 2013 Annual Report. Retrieved from http://t2health.dcoe.mil/sites/default/files/DoDSER-2013-Jan-13-2015-Final.pdf.
 Sarchiapone, M., Mandelli, L., Iosue, M., Andrisano, C., & Roy, A. (2011). Controlling access to suicide means. International Journal of Environmental Research and Public Health, 8(12), 4550–4562. http://doi.org/10.3390/ijerph8124550.
 Brenner, L. A., & Barnes, S. M. (2012). Facilitating treatment engagement during high-risk transition periods: A potential suicide prevention strategy. American Journal of Public Health, 102(Suppl 1), S12–S14. http://doi.org/10.2105/AJPH.2011.300581