Review Article

When Suicidality Is Suspected

Authors: Raymond Pary, MD, Steven Lippmann, MD

Abstract

Physicians have the potential to detect a person in danger of suicide. A history of self-injury, abuse of illegal substances or alcohol, mood disorders, and schizophrenia may contribute to the risk of suicide. There are four recognized screening tools that can assist in identifying individuals at risk to commit suicide. A safety plan provides coping strategies that may alleviate suicidal behavior or a suicidal crisis. A written, mutually agreed upon safety plan can be helpful for those suspected of being in danger of suicide. Family members or friends should assist the patient with safety plans as well as closely observe the patient and ensure timely professional attention. Emergency medical services may be necessary, and firearms must either be removed from the home or locked to prevent access. The medications that have had a preventive effect against suicide include antidepressant drugs, lithium, clozapine, ketamine, and esketamine. Lithium has historical evidence in combating suicide.

 

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References

1. Horowitz LM, Ryan PC, Wei AX. Screening and assessing suicide risk in medical settings: feasible strategies for early detection. Focus 2023;21:145–151.
 
2. Hope H, Pierce M, Su Osam C, et al. Self-harm risk in pregnancy: recurrent-event survival analysis using UK primary care data. Br J Psych 2022;221:621–627.
 
3. Esang M, Abmed S. A closer look at substance use and suicide. Am J Psych 2018;13:6–8.
 
4. Bertolote JM, Fleischmann A, De Leo D, et al. Psychiatric diagnoses and suicide: revisiting the evidence. Crisis 2004;25:147–155.
 
5. Stanley B, Brodsky B, Monahan M. Brief and ultra-brief suicide-specific interventions. Focus 2023;21:129–136.
 
6. Rosenbaum J, Mehlum L. Practitioner review: treatment for suicidal and self-harming adolescents—advances in suicide prevention care. Focus 2023;21:209–216.
 
7. Powsner S, Gobert D, Richmond JS, et al. Suicide risk assessment, management, and mitigation in the emergency setting. Focus 2023;21:8–17.
 
8. Raue P, Ghesquiere AR, Bruce ML. Suicide risk in primary care: identification and management in older adults. Curr Psychiatry Rep 2014;16:466.
 
9. Rossom RC, Coleman KJ, Ahmedani BK, et al. Suicidal ideation reported on the PHQ9 and risk of suicidal behavior across age groups. J Affect Disord 2017;215:77–84.
 
10. Louzon SA, Bossarte R, McCarthy JF, et al. Does suicidal ideation as measured by the PHQ-9 predict suicide among VA patients? Psych Serv 2016;67:517–522.
 
11. Horowitz LM, Bridge JA, Teach SJ, et al. Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Arch Pediatr Adolesc Med 2012;166: 1170–1176.
 
12. DeVylder J, Taylor R, Cwik M, et al. Assessment of selective and universal screening for suicide risk in a pediatric emergency department. Focus 2023;21:217–224.
 
13. Posner K, Brown GK, Stanley B, et al. The Columbia-Suicide Severity Scale: initial validity and internal consistency findings from three multisite-studies with adolescents and adults. Am J Psych 2011;168:1266–1277.
 
14. Osman A, Bagge CL, Gutierrez PM, et al. The Suicidal Behaviors Questionnaire-Revised (SBQ-R): validation with clinical and nonclinical samples. Assessment 2001;8:443–454.
 
15. Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract 2012;19:256–264.
 
16. Weber AN, Michail M, Thompson A, et al. Psychiatric emergencies: assessing and managing suicidal ideation. Med Clin North Am 2017;101:553–571.
 
17. Sall J, Brenner L, Bell AM, et al. Assessment and management of patients at risk for suicide: synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines. Ann Intern Med 2019;171:343–353.
 
18. Melhem N, Moutier CY, Brent DA, et al. Implementing evidence-based suicide prevention strategies for greatest impact. Focus 2023;21:117–128.
 
19. Vander-Weele TJ, Li S, Tsai AC, et al. Association between religious service attendance and lower suicide rates among US women. JAMA Psychiatry 2016;73:845–851.
 
20. Reger MA, Ammerman BA, Carter SP, et al. Patient feedback on the use of predictive analytics for suicide prevention. Psychiatr Serv 2021;72:129–135.
 
21. D’Anci K, Uhi S, Girardi G, et al. Treatments for prevention and management of suicide: a systematic review. Ann Intern Med 2019;171:334–342.
 
22. Wenzel A, Jager-Hyman S. Cognitive therapy for suicidal patients: current status. Behav Ther 2012;35:121–130.
 
23. Miller IW, Guadiano BA, Weinstock LM. The coping long term with active suicide program description and pilot data. Suicide Life Threat Behav 2016;46:752–761.
 
24. Baldessarini RJ, Tondo L, Hennen J. Lithium treatment and suicide risk in major affective disorders: update and new findings. J Clin Psych 2003;64:44–52.
 
25. Sarai SK, Mekala HM, Lippmann S. Lithium suicide prevention: a brief review and reminder. Innov Clin Neurosci 2018;15:30–32.
 
26. Goodwin FK, Fireman B, Simon GE, et al. Lithium treatment and suicide risk in bipolar disorder during treatment with lithium and divalproex. JAMA 2003;290:1467–1473.
 
27. Hayes JF, Pitman A, Marston L, et al. Self-harm unintentional injury, and suicide in bipolar disorder during maintenance mood stabilizer treatment: a UK population-based electronic health records study. JAMA Psychiatry 2016;73:630–637.
 
28. Katz IR, Rogers MP, Lew R, et al. Lithium treatment in the prevention of repeat suicide-related outcomes in veterans with major depression or bipolar disorder: a randomized clinical trial. JAMA Psychiatry 2022;79:24–32.
 
29. Baldessarini RJ, Tondo L. Testing for antisuicidal effects of lithium treatment. JAMA Psychiatry 2022;79:9–10.
 
30. Meltzer HY, Alphs L, Green AI, et al. Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial. Arch Gen Psych 2003;60:82–91.
 
31. Hochschild A, Grunebaum MF, Mann JJ. The rapid anti-suicidal ideation effect of ketamine: a systematic review. Prev Med 2021;152:106524.
 
32. Ionescu DF, Swee MB, Pavone KJ, et al. Rapid and sustained reductions in current suicidal ideation following repeated doses of intravenous ketamine: secondary analysis of an open-label study. J Clin Psych 2016;77:e719–e725.
 
33. McIntyre RS, Rosenblatt JD, Nemeroff CB, et al. Synthesizing the evidence for ketamine and esketamine in treatment-resistant depression: an international opinion on available evidence and implementation. Am J Psych 2021;178:383–399.
 
34. Fu DJ, Ionescu DF, Li X, et al. Esketamine nasal spray for rapid reduction of major depressive disorder in patients who have active suicidal ideation with intent: double-blind, randomized study. Int J Neuropsychopharmacol 2021;24:22–31.
 
35. Zisook S, Domingues I, Compton J, et al. Pharmacologic approaches to suicide prevention. Focus 2023;21:137–144.
 
36. Stone M, Laughren T, Jones ML, et al. Risk of suicidality in clinical trials of antidepressants in adults: analysis of proprietary data submitted to the Food and Drug Administration. Br Med J 2009;339:b2880.