What is the best course of treatment for a patient with suicidal ideation, possibly with underlying depression or anxiety, and a history of previous suicidal attempts?

Management of Suicidal Ideation

Immediately assess suicide risk using a structured approach, implement safety planning with lethal means restriction, and initiate cognitive-behavioral therapy focused on suicide prevention as first-line treatment, with consideration of psychiatric hospitalization for high-risk patients. 1

Immediate Risk Assessment

Conduct a comprehensive suicide risk evaluation focusing on multiple critical domains:

• Assess suicidal thoughts systematically: frequency, intensity, specific plans, intended course of action if symptoms worsen, access to lethal means (especially firearms), and reasons for living 2, 1
• Evaluate psychiatric factors: current psychiatric conditions, presence of hopelessness, psychotic symptoms, command hallucinations, substance abuse, and high levels of anger or impulsivity 2, 1
• Review historical risk factors: previous suicide attempts (particularly high-lethality attempts), history of self-directed violence in the past 6 months, family history of suicidal behavior, and recent psychosocial stressors 2, 1
• Assess protective factors: quality of social support system, sense of responsibility to others, religious beliefs, and strength of therapeutic alliance 2

High-Risk Indicators Requiring Hospitalization

Psychiatric hospitalization should be strongly considered when patients meet any of these criteria:

• Persistent endorsement of desire to die despite intervention 1
• Continuous severe agitation or hopelessness 1
• Inability to participate meaningfully in safety planning 1
• Inadequate support system at home 1
• History of high-lethality suicide attempts 1
• Active psychosis with command hallucinations 2

Critical timing consideration: 24% of suicide attempts occur within 0-5 minutes of the decision, making impulsivity assessment essential 1

Safety Planning and Lethal Means Restriction

Develop a collaborative safety plan immediately—this is non-negotiable and evidence-based for reducing suicidal behavior (NNT=16). 2

The safety plan must include specific, actionable components:

• Warning signs identification: Specific thoughts, images, moods, situations, and behaviors that indicate crisis onset 1
• Internal coping strategies: Concrete activities the patient can do independently without contacting others 1
• Social contacts for distraction: Specific people and settings that provide support 1
• Professional contacts: Names, phone numbers, and specific instructions for when and how to access emergency services 1
• Environmental safety measures: This is critical and must be addressed explicitly 1

Lethal Means Counseling (Essential Component)

Counsel patients and families on restricting access to lethal means—this is a fundamental discharge requirement:

• Remove all firearms from the home entirely (not just locked storage) 1
• Lock up all medications with a third party controlling access 1, 3
• Secure or remove knives and other sharp objects 1
• Restrict alcohol access 4

Important caveat: The greatest risk for repeat attempts occurs in the months immediately following an initial attempt, requiring sustained vigilance 1

First-Line Treatment: Psychotherapy

Cognitive-Behavioral Therapy for Suicide Prevention

CBT focused specifically on suicide prevention is the recommended first-line treatment and reduces suicide attempts by 50% compared to usual care. 1, 3

• CBT targeting suicide prevention should be initiated for all patients with suicidal ideation or history of self-directed violence in the past 6 months 1
• Problem-solving therapy (a CBT variant) is also effective for reducing suicidal ideation 1
• Treatment typically involves 12-16 weekly sessions with a 6-month booster phase 2

Dialectical Behavior Therapy

For patients with borderline personality disorder and recurrent suicidal behavior, DBT is the evidence-based treatment of choice. 4

• DBT combines CBT elements, skills training, and mindfulness techniques to develop emotion regulation, interpersonal effectiveness, and distress tolerance 1, 4
• Evidence specifically supports DBT for reducing both suicidal ideation and repetition of self-directed violence in BPD 4

Note: For general depression with suicidal ideation (without BPD), evidence for DBT over standard CBT is insufficient 1

Pharmacological Management

Antidepressants

For patients with comorbid major depression:

• Preferred agents: SSRIs (escitalopram, sertraline, or fluoxetine) due to better safety profile in overdose 4, 3
• Avoid: Tricyclic antidepressants due to high lethality in overdose 2, 4, 3
• Critical monitoring period: Risk of suicidal behavior exists during the first 10-14 days of antidepressant treatment, requiring close follow-up 5
• Consider switching from duloxetine to an SSRI if currently prescribed, as SSRIs have better evidence for depression with suicidal features 3

FDA warning consideration: Bupropion and other antidepressants carry warnings about increased suicidal thoughts in young adults during initial treatment months, necessitating careful monitoring 6

Mood Stabilizers

Lithium has the strongest evidence for suicide prevention in mood disorders:

• Long-term lithium treatment is highly effective in preventing both completed suicide and suicide attempts in unipolar and bipolar depression 3, 5
• Consider lithium for patients with mood disorders and recurrent suicidal ideation 3

Antipsychotics

Clozapine is indicated specifically for reducing suicide attempts in schizophrenia/schizoaffective disorder:

• Clozapine reduces suicide risk in patients with schizophrenia or schizoaffective disorder who have suicidal ideation or history of attempts 1
• Do not use clozapine for borderline personality disorder—indication is specific to schizophrenia spectrum disorders 4

Ketamine for Acute Crisis

For severe, treatment-resistant suicidal ideation with major depression, ketamine infusion provides rapid short-term relief:

• Dose: 0.5 mg/kg IV over 40 minutes as adjunctive treatment 1, 4
• Benefits begin within 24 hours and last up to one week 4, 3
• Requires 2-hour post-treatment monitoring 4
• This is for acute stabilization only, not long-term management 1

Medications to Use Cautiously or Avoid

• Benzodiazepines: Use cautiously as they may increase disinhibition or impulsivity in some patients 3
• Short-term anxiolytics/hypnotics are acceptable for severe anxiety or insomnia but should be time-limited 5
• Avoid prescribing large quantities of any medication with high overdose lethality 3

Follow-Up and Ongoing Monitoring

Schedule definite, closely spaced follow-up appointments and contact the patient if appointments are missed—this is not optional. 1, 3

Caring Contacts Intervention

Send periodic caring communications (postal mail or text messages) for 12 months following any hospitalization or crisis:

• This simple intervention reduces suicide attempts 1, 4, 3
• Communications should be brief, non-demanding expressions of care 1

Digital Interventions

• Self-guided digital interventions (apps or web-based) with CBT-based content can provide short-term reduction in suicidal ideation as an adjunct 1
• Internet-based CBT targeting suicidal ideation demonstrates effectiveness for reducing both suicidal ideation and depression severity 7

Medication Monitoring

• Have a third party (family member or trusted contact) monitor medications and report changes in mood, increased agitation, or side effects 3
• This is particularly important during the first weeks of antidepressant treatment 5

Common Pitfalls to Avoid

Do not rely on "no-suicide contracts"—there is no empirical evidence supporting their efficacy. 3

• Avoid coercive statements like "unless you promise not to attempt suicide, I will keep you in the hospital" 3
• Never assume a patient who agrees to a no-suicide contract is no longer at risk 3
• Implicit coercions (telling patients they won't be discharged until they say they're not suicidal) should be avoided 2

Additional critical errors to avoid:

• Do not discharge patients who continue expressing desire to die, remain severely hopeless, or cannot engage in safety planning 1
• Do not prescribe medications with high lethality in overdose when suicidal thoughts are present 3
• Do not assume exposure to other suicidal patients increases risk—evidence does not support this concern 2
• Do not neglect family involvement and psychoeducation 5

Special Populations

Children and Adolescents

• Treatment with antidepressants should only be given under specialist supervision 5
• CBT appears more effective than family or supportive therapy initially, though differences diminish after 2 years 2
• The same risk assessment and safety planning principles apply 2, 1

Patients with Substance Abuse

• Comorbid substance abuse significantly increases risk and must be addressed concurrently 1
• Consider integrated treatment approaches addressing both conditions 2