From the Guidelines
For someone who is chronically suicidal, Dialectical Behavior Therapy (DBT) is the most recommended psychotherapy approach, as it has been shown to reduce suicidal ideation and behavior by combining elements of Cognitive Behavioral Therapy (CBT), skills training, and mindfulness techniques 1.
Key Components of DBT
- Individual therapy sessions (usually weekly for 6-12 months)
- Group skills training
- Phone coaching
- Therapist consultation teams DBT is specifically designed for chronic suicidality and has been found to be effective in reducing nonsuicidal and suicidal self-directed violence among patients with borderline personality disorder and recent self-directed violence 1.
Additional Recommendations
- Cognitive Behavioral Therapy (CBT) can also be effective in reducing suicidal ideation and behavior by identifying and changing negative thought patterns 1
- A crisis response plan should be developed in collaboration with the patient and clinician, including components such as identifying clear signs of crisis, self-management skills, and social support 1
- Medication management may be integrated with therapy, but should be tailored to the individual patient's needs and monitored regularly
- Regular psychiatric evaluation and hospitalization during acute crises may be necessary to ensure patient safety
Prioritizing Patient Safety
- A safety plan should be essential, including identifying triggers, coping strategies, social supports to contact, and emergency resources like the 988 Suicide & Crisis Lifeline
- The patient's treatment plan should be regularly reviewed and updated to ensure that it remains effective in reducing suicidal ideation and behavior.
From the Research
Psychotherapy Recommendations for Chronically Suicidal Individuals
- Cognitive Behavioral Therapy (CBT) has been shown to reduce suicide attempts, suicidal ideation, and hopelessness compared to treatment as usual (TAU) 2
- Dialectical Behavior Therapy (DBT) has been found to reduce suicidal ideation compared to wait-list control or crisis planning, with modest benefits in reducing suicidal ideation compared to TAU or wait-list control 2, 3
- DBT has also been shown to reduce self-directed violence, including suicide attempts and non-suicidal self-injury (NSSI), and reduce frequency of psychiatric crisis services 3
- A study on adolescents with prior suicide attempts, self-harm, and suicidal ideation found that DBT was associated with greater improvements in emotion regulation and self-harm remission compared to individual and group supportive therapy (IGST) 4
- Therapeutic alliance and therapeutic limits are important considerations when working with chronically suicidal patients with borderline personality disorder (BPD), and DBT can be an effective framework for modifying therapeutic limits and improving outcomes 5
Pharmacologic Interventions
- Ketamine has been shown to reduce suicidal ideation with minimal adverse events compared to placebo or midazolam 2
- Lithium has been found to reduce rates of suicide among patients with unipolar or bipolar mood disorders compared to placebo, but there is limited information on harms 2
- Selective Serotonin Reuptake Inhibitors (SSRIs) have a black box warning for increased risk of suicidality in children and young adults aged 18-24, but adults without certain risk factors do not seem to carry this increased risk 6
Key Considerations
- A risk-benefit analysis must be conducted when prescribing pharmacologic interventions, taking into account potential treatment effects, adverse effects, and dangers of the illness to be treated 6
- Therapeutic alliance and therapeutic limits are crucial when working with chronically suicidal patients, and DBT can be an effective framework for modifying therapeutic limits and improving outcomes 5