From the Guidelines
Evidence-based treatments for actively suicidal patients should prioritize a combination of immediate safety measures, psychotherapy, and medication, with a focus on cognitive behavioral therapy (CBT) and ketamine infusion as adjunctive treatment for short-term reduction in suicidal ideation, as suggested by the most recent guidelines 1. The first priority is ensuring patient safety through hospitalization or intensive outpatient programs with safety planning and means restriction.
- Cognitive Behavioral Therapy for Suicide Prevention (CBT-SP) has demonstrated effectiveness in reducing suicidal thoughts and behaviors, with weekly sessions for 3-6 months.
- Medication options include:
- Ketamine infusion (0.5mg/kg IV infusion) as an adjunctive treatment for short-term reduction in suicidal ideation in patients with major depressive disorder, as supported by recent guidelines 1.
- Clozapine (starting at 12.5mg and titrating up, with required blood monitoring) to reduce the risk of suicide attempts for patients with schizophrenia or schizoaffective disorder and either suicidal ideation or a history of suicide attempt(s) 1.
- A comprehensive approach combining safety planning, therapy, medication, and addressing underlying mental health conditions yields the best outcomes, with regular reassessment of suicide risk throughout the treatment process. Treatment should be individualized based on the patient's specific risk factors, comorbidities, and circumstances, with consideration of the most recent guidelines and evidence-based practices 1.
From the FDA Drug Label
Antiepileptic drugs (AEDs), including valproic acid, increase the risk of suicidal thoughts or behavior in patients taking these drugs for any indication Patients treated with any AED for any indication should be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, and/or any unusual changes in mood or behavior Should suicidal thoughts and behavior emerge during treatment, the prescriber needs to consider whether the emergence of these symptoms in any given patient may be related to the illness being treated
The evidence-based treatment for an actively suicidal patient is not directly addressed in the provided drug label. However, it is mentioned that suicidal thoughts and behavior should be monitored and addressed if they emerge during treatment with antiepileptic drugs like valproic acid.
- The label advises prescribers to balance the risk of suicidal thoughts or behavior with the risk of untreated illness.
- It is recommended that patients, their caregivers, and families should be informed of the increased risk of suicidal thoughts and behavior associated with AEDs.
- If suicidal thoughts and behavior emerge, the prescriber should consider whether the emergence of these symptoms may be related to the illness being treated 2.
From the Research
Evidence-Based Treatments for Actively Suicidal Patients
- The primary approach to managing suicidal patients involves a comprehensive proactive systems approach, including formalized suicide assessment, accurate diagnosis, and best practice treatment 3.
- A crucial tool in helping patients with suicidal urges is the suicide safety plan, which is a plan of action created by the clinician and patient to chart the course of action if the patient experiences suicidal urges 4.
- Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat depression, which is a major risk factor for suicidality, but their use requires a risk-benefit analysis due to potential adverse effects, including an increased risk of suicidality in children and young adults 5, 6.
- Research suggests that SSRI treatment may actually reduce the risk of suicidal behavior in both youths and adults, rather than increasing it 6.
- Important elements of patient history include intent, plan, and means; availability of social support; previous attempts; and presence of comorbid psychiatric illness or substance misuse 7.
- Care plans for patients with chronic suicidal ideation should include ensuring patient safety and medical stabilization, activating support networks, and initiating therapy for psychiatric diseases, as well as referral for specialty care 7.