What is the best course of treatment for a patient with increased suicidal ideation (SI), self-harm (SH), and anxiety?

Management of Increased Suicidal Ideation, Self-Harm, and Anxiety

Implement immediate safety planning with collaborative crisis response planning, initiate cognitive-behavioral therapy focused on suicide prevention, and consider switching to an SSRI while ensuring close monitoring and follow-up. 1, 2

Immediate Risk Assessment and Safety Measures

Perform an urgent suicide risk assessment focusing on:

• Frequency and intensity of suicidal thoughts, specific plan details, access to lethal means, previous attempts, and current social support 1, 2
• Persistence in endorsing desire to die, continuous agitation, severe hopelessness, and inability to engage in safety planning indicate high risk requiring psychiatric hospitalization 2
• Comorbid substance abuse and high levels of anger or impulsivity increase risk substantially 2

Develop a collaborative crisis response plan immediately that includes:

• Identification of warning signs and triggers for suicidal ideation 1, 2
• Self-management coping skills and healthy activities 2
• Social support contacts and professional crisis resources 1, 2
• Instructions on how and when to access emergency services 2

Critical safety interventions:

• Remove all firearms and lethal medications from the home environment 2
• Arrange for a third party to monitor all medications and report mood changes, increased agitation, or side effects 1
• Avoid relying on "no-suicide contracts" as there is no empirical evidence supporting their efficacy 1

Psychotherapeutic Interventions

Initiate cognitive-behavioral therapy (CBT) focused on suicide prevention as the primary psychotherapy 1, 2

• CBT reduces suicidal ideation and cuts the risk of suicide attempts by half compared to treatment as usual 1
• CBT addresses negative cognitions about self, environment, and future that drive suicidal thinking 3
• Problem-solving therapy components help improve coping with life stressors 1

Consider dialectical behavior therapy (DBT) as an alternative, which combines CBT elements with skills training in emotion regulation, interpersonal effectiveness, and distress tolerance 1

Safety planning-type interventions (SPTIs) reduce suicidal behavior by 43% (NNT = 16) 3

• These interventions effectively reduce suicide attempts but may not directly reduce suicidal ideation 3
• Additional psychotherapeutic interventions like CBT or DBT are needed to address suicidal ideation specifically 3

Pharmacological Management

For the anxiety and depression component:

• Consider switching to an SSRI, which has better evidence for treating depression with suicidal features 1
• SSRIs are safe, have low lethality in overdose, and reduce suicidal ideation 3, 1
• Monitor carefully for new suicidal ideation or akathisia, particularly in the first weeks of treatment 3, 4
• Avoid tricyclic antidepressants due to their high lethality in overdose 3, 1

For severe, acute suicidal ideation:

• Ketamine infusion may be considered as adjunctive treatment for rapid short-term reduction in suicidal ideation 1, 2

Medications to use with caution or avoid:

• Benzodiazepines should be used cautiously as they may increase disinhibition or impulsivity 3, 1
• Any medication with high lethality in overdose should be avoided 3

If mood disorder features are prominent:

• Lithium may be beneficial as it reduces suicidal behaviors and deaths in patients with mood disorders 1

Follow-Up and Monitoring

Schedule definite, closely spaced follow-up appointments 3

• The greatest risk of suicide attempt occurs in the months following initial presentation 2
• Contact the patient immediately if appointments are missed 3

Send periodic caring communications (postal mail or text messages) for 12 months 1, 2

• This intervention reduces the risk of suicide attempts following crisis 1, 2

Consider self-guided digital interventions with CBT-based therapeutic content for additional support 1, 2

Ensure clinician availability:

• The treating clinician should be available for telephone contact outside therapeutic hours or have adequate coverage 3
• Clinicians managing suicidal patients need support systems for themselves 3

Critical Pitfalls to Avoid

Do not use coercive communications such as "unless you promise not to attempt suicide, I will keep you in the hospital" 1

Do not assume a patient who agrees to a no-suicide contract is no longer at risk 1

Do not relax vigilance just because a contract has been signed 3

Remember that 24% of suicide attempts are implemented within 0-5 minutes of deciding, highlighting the impulsive nature of many attempts 2