Treatment and Management of Suicide Risk: Available Treatments

1. Treatment and Management of Suicide Risk: Available Treatments • Treatment Plan • Safety Plan • No-Suicide Contracts • Engaging Third Parties • Psychotherapy • Core therapeutic components • Pharmacotherapy • Electroconvulsive Therapy

2. Treatment Plan General Treatment Guidelines (given that hospitalization is not required) • Ensuring 24-hour coverage availability including holidays and vacations • Increasing frequency of sessions • Extending session times as necessary • Collaborating with family member and significant others to be involved in treatment • Ensuring the treatment plan is constantly updated • Following up to ensure patient compliance and disposition • Monitoring medication allocation and use • Establishing a check-in system with the patient

3. Treatment Plan Treatment plans should take into account issues gathered during the risk assessment, with risk management ongoing during treatment Assuming Professional Responsibility Follow through with treatment plan to ensure effectiveness. The clinician is responsible for managing the suicidality to the standard of care. Consider involvement of supportive third parties, such as family and friends. Patient and clinician should remain in contact, as well as any persons involved beyond primary care.

4. Treatment and Management of Suicide Risk: Safety Plan A predetermined list of coping mechanisms and support the client has access to • Reduces access to means to complete suicide • Developed with patient involvement • Recognization of the risk of suicide • Difference from No-Suicide Contracts

5. Safety Plan: Example

6. No-Suicide Contracts • Typically takes the form of asking a patient to promise to not commit suicide and seek help from professionals when in crisis • Effectiveness is not supported by empirical data • May obscure a patient’s actual level of suicidality • Does not provide the patient with adequately detailed information about support available and proper responses in times of crisis

7. No-Suicide Contract: Example

8. Treatment and Management of Suicide Risk: Third Parties • Educating supportive third party members along with the patient • Actions taken to reduce risk • Engaging third parties • Addressing the unique family, social, cultural, spiritual, and socioeconomic needs of patient through psychological interventions

9. Psychotherapy • Have been proven to be efficient in treating disorders associated with increased risk of suicide • Targets deficits in specific skills, which may reduce suicide attempts, when applied for the long-run • Mostly reduces suicide risk through cognitive-behavioral therapy, which helps identify the causes of dysfunctional emotions

10. Psychotherapy May help reduce symptoms of mood disorder Psychotherapies to consider: • Dialectical Behavioral Therapy for patients with personality disorders characterized by emotional dysregulation • Psychotherapies based on cognitive/behavioral approaches or skills training for BPD patients at high suicide risk • Psychodynamic psychotherapies for high risk patients with BPD

11. Psychotherapy: Core Therapeutic Components • Cognitive: deals with irrational negative thoughts, core beliefs and cognitive distortions, and problem solving deficits • Emotional: deals with avoidance of unpleasant experiences activated prior to the suicide attempt • Behavioral: deals with reduced activity and impulsive behavior • Interpersonal: deals with poor communication and impaired social function

12. Types of Therapies: • Cognitive-Behavioral Therapies: emphasizes modification of core beliefs and schemas related to perception of self, the world, and the future • Dialectical Behavior Therapy: emphasizes management of multiple severe problems, suicidal behavior, and extreme emotional sensitivity • Interpersonal Therapy: emphasizes reparation of impaired social functions and addresses interpersonal difficulties that lead to psychological problems • Mentalization-Based Therapy: emphasizes relational aspect of personality disturbance and restructuring self-image and understanding of others

13. Pharmacotherapy • Limited evidence that pharmacological interventions reduce suicide risk • Medication should be reviewed for connections to suicidal thoughts or behaviors • Lithium and Clozapine have been reported to reduce suicide risk in patients with mood disorders or schizophrenia

14. Pharmacotherapy Example Black Box Warning Drugs potentially used to help manage suicide • Anti-depressants • Anti-psychotics • Lithium • Clozapine • Antiepileptic drugs • Anti-anxiety drugs

15. Electroconvulsive Therapy • Can rapidly and efficiently resolve symptoms of several Psychiatric disorders • Could also be a potential treatment for resistant PTSD • Usually considered for suicidal patients who have failed to respond to other treatments • No significant evidence of long-term reduction of suicide risk

16. Electroconvulsive Therapy Risks and Contraindications • .002% result in death, usually as a result of cardiovascular complications • Adverse side effects include temporary confusion and memory loss, though modern techniques have reduced these side effects • Fractures are reduced by muscle relaxants, though teeth may be broken still • Contraindications are rare, and most can be overcome by preparation before the ETC

17. Treatment and Management of Suicide Risk: Continuity of Care • Discharge planning • Risk of suicide after discharge • Follow-ups • Transitions between care settings • Behavioral health providers • Connection with chain of healthcare • Updates to treatment plan and safety plan • Documentation