How to manage a patient with suicidal ideation but no active intent to harm themselves?

From the Guidelines

When dealing with a patient who has thoughts of harming themselves but is not actively suicidal, immediate assessment and supportive intervention are essential, and a crisis response plan should be developed in collaboration with the patient, as recommended by the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines 1. This plan should include a semi-structured interview regarding recent suicide ideation and history of suicide attempts, an unstructured conversation about recent stressors and current problems, collaborative identification of clear signs of crisis, identification of self-management skills, and collaborative identification of social support, including friends and family members who have helped in the past and whom the patient would feel comfortable contacting in a crisis 1. The patient should also be referred to mental health services for evaluation, which may include psychotherapy approaches like Cognitive Behavioral Therapy (CBT) or Dialectical Behavior Therapy (DBT), both of which have shown effectiveness for self-harm thoughts, as supported by studies such as those found in the Annals of Internal Medicine 1. Some key points to consider when developing a crisis response plan include:

• Removing access to potential means of self-harm
• Identifying warning signs
• Listing coping strategies
• Providing emergency contact information, including crisis hotlines such as the National Suicide Prevention Lifeline at 988
• Collaborative identification of social support
• Review of crisis resources, including medical providers, other professionals, and the suicide lifeline
• Recommendations for treatment, including follow-up appointments and other referrals as needed Regular follow-up appointments are crucial to monitor changes in risk level and treatment response, and to adjust the crisis response plan as needed, with the goal of reducing the patient's risk of suicide and improving their overall quality of life, as emphasized in the clinical practice guidelines 1.

From the Research

Dealing with Patients who have Thoughts of Harming Themselves

• Patients who have thoughts of harming themselves but are not actively suicidal require a comprehensive approach to management, including therapeutic interventions and medication 2.
• Therapeutic approaches that show promise include cognitive behavioral therapy, dialectical behavior therapy, and mentalization, as well as medications that act on the serotonergic, dopaminergic, and opioid systems 2.
• Effective models of care aim to enhance therapeutic relationships with staff, providers, and encourage the internal shift toward recovery within the patient 2.

Management of Self-Harm and Suicidal Ideation

• Primary care providers play a critical role in the detection and management of patients with suicidal behavior, and should possess good clinical skills and evidence-based knowledge to assist patients presenting with suicidal ideation and behavior 3.
• A thorough suicide risk assessment should be conducted as soon as the patient is medically stable, evaluating suicidal ideation/intent, preceding circumstances, predisposing and protective factors 3.
• For patients with a low level of suicide risk, outpatient management may be considered in the presence of a good social support system at home and a well-documented safety plan 3.

Treatment Strategies

• Combining selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy (CBT) has been shown to produce greater improvement than either treatment alone in youth with depression and anxiety 4.
• The combination of SSRI and CBT has been found to decrease symptoms by week 4, with continued improvement at week 8 and 12, although the additive benefit of CBT over SSRI monotherapy may not be statistically significant until week 12 4.
• The fastest response to SSRI+CBT has been found to be for patients who are younger, with milder baseline anxiety/depression symptoms and depressive disorders, while the slowest response is for boys, adolescents, minoritized children, those with severe symptoms and externalizing disorders 4.

Risk Assessment

• There is insufficient evidence to support the use of any one tool, including clinician assessment of risk, for self-harm and suicidality 5.
• The SAD PERSONS Scale has been found to outperform the Beck Scale for Suicide Ideation in predicting hospital admissions and stay following suicide and self-harm, but failed to predict repeat suicide and self-harm and was not recommended for routine use 5.
• Structured professional judgment is widely accepted for risk assessment, and the discourse around risk assessment needs to move toward a broader discussion on the safety of patients who are at risk for self-harm and/or suicide 5.