How to handle suicidal ideation (SI) in patients via telehealth psychology?

Managing Suicidal Ideation via Telehealth Psychology

Immediately initiate cognitive behavioral therapy (CBT) focused on suicide prevention via telehealth, as this reduces suicide attempts by 41% and is the most strongly supported intervention for managing suicidal ideation remotely. 1

Immediate Safety Assessment and Crisis Planning

Conduct a comprehensive suicide risk assessment at the start of every telehealth session that includes:

• Frequency and intensity of suicidal thoughts, specific plans, and access to lethal means 2
• History of previous attempts and current psychiatric symptoms 3
• Social support availability and recent stressors or triggers 2
• Use validated screening tools such as the Columbia Suicide Severity Rating Scale Screener, Beck Scale for Suicidal Ideation, or PHQ-9 4

Develop a collaborative crisis response plan immediately that includes:

• Clear identification of warning signs (behavioral, cognitive, affective, or physical) 5
• Self-management coping skills and steps the patient can take independently 5
• Social support contacts including friends and family members 5
• Crisis resources including medical providers, professionals, and the suicide lifeline 5
• Scheduled follow-up appointments with definite dates 3

Critical pitfall: Never use "no-suicide contracts" as they have no empirical evidence and create false reassurance 4

Psychotherapeutic Interventions via Telehealth

Initiate CBT focused on suicide prevention immediately, delivered weekly via video telehealth:

• This approach reduces suicide attempts by 32-50% in adults with recent suicidal behavior 2, 3
• Target suicidal thoughts directly and develop alternative coping strategies 4
• Continue weekly sessions initially for patients with suicidal behavior within the past 6 months 4
• The Collaborative Assessment and Management of Suicidality (CAMS) framework can be effectively adapted for digital delivery 6

Consider dialectical behavior therapy (DBT) for specific populations, though evidence is insufficient for general recommendation:

• DBT combines CBT, skills training, and mindfulness techniques 5
• Most beneficial for patients with borderline personality disorder and recent self-directed violence 5
• Addresses emotion regulation, interpersonal effectiveness, and distress tolerance 3

Implement problem-solving therapy as an adjunctive approach:

• Specifically aimed at improving coping with stressful life experiences 5
• Can be delivered effectively via telehealth 2

Lethal Means Safety Counseling

Restrict access to lethal means as a critical intervention regardless of other treatments:

• Collaborate with family or support persons to secure or remove firearms from the home 2
• Dispense medications in smaller quantities with frequent follow-up 2
• Address access to other means (knives, medications) based on the patient's specific plan 3
• This intervention reduces suicide risk by firearms, jumping, or medication overdose 5

Important consideration: 24% of suicide attempts occur within 0-5 minutes of deciding, making impulsive access to lethal means particularly dangerous 3

Enhanced Communication Protocols for Telehealth

Establish clear emergency procedures before beginning telehealth treatment:

• Obtain patient's physical location, local emergency contact information, and nearest emergency department 7
• Identify local resources and establish communication pathways with patient's family and local emergency services 8
• Document these procedures and review them with the patient at each session 7

Implement immediate enhanced communications when suicidality escalates:

• Use videoconference to assess symptoms and develop safety plans in real-time 8
• Coordinate with patient's family, treatment team, and local resources simultaneously 8
• Arrange transportation to inpatient units when hospitalization is necessary 8

Follow-Up and Monitoring

Schedule definite, closely spaced follow-up appointments:

• Contact the patient if appointments are missed 2
• Monitor weekly for emergence or worsening of suicidal ideation during initial 4 weeks 4
• Adjust to bi-weekly appointments from weeks 5-12, then monthly from months 4-12 4
• Conduct systematic suicidal ideation screening at every visit 4

Send periodic caring communications for 12 months following any crisis or hospitalization:

• Use postal mail or text messages in addition to usual care 5
• This reduces suicide attempts, though sustained contact is necessary (single postcards are ineffective) 5
• Evidence shows weak but positive support for this intervention 5

Self-Guided Digital Interventions as Adjuncts

Recommend self-guided digital interventions (apps or web-based) that include CBT-based therapeutic content:

• These provide short-term reduction in suicidal ideation 5
• Should be used as adjuncts to, not replacements for, direct telehealth therapy 3
• Evidence is weak but supportive for this approach 5

Pharmacological Considerations

Coordinate with prescribing providers to optimize medication safety:

• Avoid prescribing medications with high lethality in overdose (tricyclic antidepressants) 2
• Use benzodiazepines cautiously or avoid them, as they may increase disinhibition or impulsivity 2
• Consider SSRIs over other antidepressants due to better safety profile 2
• Ketamine infusion may be considered for rapid short-term reduction in severe suicidal ideation, though evidence for preventing actual attempts is insufficient 5

Hospitalization Criteria

Consider psychiatric hospitalization if the patient:

• Continues to express a desire to die despite intervention 3
• Remains agitated or severely hopeless 3
• Is unable to participate in a safety plan 3
• Lacks adequate support system 3
• Has a history of high-lethality suicide attempts 3

Evidence on Telehealth Effectiveness

Telehealth delivery of suicide-specific treatment is feasible and effective:

• Over 85% of patients enrolled in telehealth suicide care complete at least 4 sessions 6
• All patient subgroups experience declines in depressive symptoms, anxiety symptoms, and suicidal ideation frequency via telehealth 6
• BCBT delivered via video telehealth reduces suicide attempts by 41% compared to control therapy 1

Critical limitation: The 2019 VA/DoD guidelines noted insufficient evidence for technology-based methods as routinely practiced, but this was based on older studies that did not assess telehealth as currently implemented 5. The 2024 updated guidelines and recent high-quality trials now support telehealth delivery 5, 1.