Current Status of Suicide-Focused Assessment and Treatment

Physical Illness

Certain medical conditions have also been associated with an increased risk for suicide:

• Asthma
• Cancer
• Chronic pain
• COPD
• Coronary artery disease
• Diabetes
• Parkinson’s disease
• Spinal disc disorders
• Stroke
• Traumatic brain injury

Chronic or terminal illness places patients at higher risk. For example, having chronic pain doubles the risk of dying by suicide (Racine, 2018; Schreiber & Culpepper, 2020; Tang & Crane, 2006). Functional impairment also increases risk.

Moreover, patients with pain and an opioid use disorder can be at particularly high risk of suicide. An unexpected finding is that the number of firearm suicides in this population is even greater than the number of overdose suicides (Oquendo & Volkow, 2018).

Access to Firearms

Firearms account for approximately half of all suicides in the U.S. (CDC, 2020). Over the past decade, the rate of suicide by firearm has increased by 13% (CDC WONDER, 2020; Everytown Research & Policy, 2021). Nearly 90% of suicide attempts with a firearm are fatal (Conner et al., 2019).

Studies suggest that individuals who live in a household with a firearm have at least a 3-fold increased risk of suicide (Anglemyer et al., 2014). Yet, studies show that there are no significant differences in rates of depression, substance use disorders, or suicidal ideation between those living in homes with firearms and those living in homes without them (Ilgin et al., 2008; Harvard T.H. Chan, n.d.).

Moreover, this heightened risk of suicide by firearm applies not only to the gun owner, but also to others in the home, such as spouses and children. In 82% of youth firearm suicides, the gun belonged to another household member (Johnson et al., 2010; Knopov et al., 2019).

Parents may not be aware of this danger. According to a recent study, 40% of parents who owned firearms mistakenly believed that their children did not know where their guns were stored, and 22% mistakenly believed that their children had never handled these guns (Parikh et al., 2017).

The statistical risk of suicide by firearm is increased among certain groups. Eighty-six percent of firearm suicides occur in men (CDC WONDER, 2020; Everytown Research & Policy, 2021). The rate is particularly high among males 65 and older.

However, among women, the rate is highest in those between the ages of 40 and 60 (Everytown Research & Policy, 2021). Most female handgun owners who died by suicide used their own handgun to kill themselves (Studdert et al., 2020).

Most firearm suicides involve guns purchased years earlier (Mann & Michel, 2016). Although new handgun owners are at higher risk of dying by suicide immediately after the purchase, a recent study shows that over half of all firearm suicides take place a year or more after the purchase (Studdert et al., 2020).

The takeaway is that having a handgun increased risk, even if the handgun was not originally purchased with the intention to die by suicide.

Eighty-five percent of firearm suicides occur in white individuals, though American Indians and Alaskan Natives also have a disproportionately high suicide rate by firearm compared to other racial and ethnic groups (CDC WONDER, 2020; Everytown Research & Policy, 2021).

The rate of suicide by firearm is higher in rural areas than urban areas. This discrepancy exists even though people in rural areas do not show higher rates of depression than those living in urban areas (Harvard T.H. Chan, n.d.; Wang, 2004).

Unfortunately, many of the groups most likely to use a firearm for their suicide attempt (e.g., older adult males, active-duty military and veterans, law enforcement) are also the same groups found to be most likely to underutilize mental health resources and underreport suicidal ideation. This complicates their identification and potential intervention by traditional suicide assessment methods (Jin et al., 2016).

“Whether or not a plan is present, if a patient has acknowledged suicidal ideation, there should be a specific inquiry about the presence or absence of a firearm in the home or workplace.” – APA, 2003, p. 11

Psychological and Cognitive Risk Factors

Some factors, such as personality traits, thinking styles, and coping skills have also been associated with increased risk of suicide (APA, 2003). These psychological factors include:

• Thought constriction
• Polarized (either-or) thinking
• Perfectionism
• Impulsivity
• Hopelessness
• Incapacity for reality testing
• Inability to tolerate rejection
• Subjective loneliness
• Intolerable mental pain
• Feeling like a burden

Psychosocial Risk Factors

The sociological perspective of suicide is primarily based on the theories of Emile Durkheim. According to Durkheim (1897), there are four types of suicides:

• Altruistic: Occurs among individuals with excessive connections to social groupings, resulting in loss of individuality (e.g., suicide bombers)
• Egoistic: Occurs among individuals with few connections to social groupings of any kind (e.g., single people are more likely to commit suicide than married people)
• Anomic: Occurs when there is an abrupt shift in an individual’s circumstances that remove them from membership in what had been a well-integrated group (e.g., divorce)
• Fatalistic: Occurs among individuals who feel that they cannot escape from oppressive external forces, such as the values and norms of society or persecution.

Durkheim’s theories are supported by data on suicide. For example, persons who are single, divorced, or widowed are at higher risk for suicide (Curtin & Tejada-Vera, 2019).

A more modern analysis expands on the theory that suicides are caused by social disconnectedness, proposing that “the need to belong is so powerful that, when satisfied, it can prevent suicide even when other powerful risk factors are operative” (Joiner et al., 2006, p. 179).

For a more complete discussion of Joiner’s theory of the relationship between “pulling together” and suicide, see: Joiner et al., 2006.

Other social factors that can influence suicide risk include:

• Acute psychosocial crises and chronic psychosocial stressors, especially triggering events leading to humiliation, shame, or despair
• History of abuse or neglect
• Employment status
• Living situation
• Presence or absence of external social supports
• Family constellation
• Quality of relationships
• Cultural or religious beliefs about death or suicide

Promising New Methods for Assessing Suicide Risk

The assessment of suicide risk is challenging for several reasons (e.g., Ballard et al., 2021). For one, suicidal thoughts are often transient in nature and/or intermittent. They may not be present during a clinical interview, but can resurface with deadly intent later (Nock & Banaji, 2007).

Moreover, some suicidal individuals will intentionally deny or hide suicidal plans because they want to avoid hospitalization or unwanted intervention (Glenn et al., 2017; Nock et al., 2010; Nock & Banaji, 2007).

Whereas studies have found that most persons who die by suicide (50-69%, depending on the study) had communicated their intention to others in some way and at some point (Coombs et al., 1992; Pompili et al., 2016; Robins et al., 1959), others indicate that nearly 80% of those on inpatient units had explicitly denied suicidal intent the last time they were asked (Busch et al., 2003).

Suicidal individuals may also unintentionally conceal suicidal risk; they may have poor insight or they may not report their past suicide attempts if they did not consider them to be serious (Busch et al., 2003; Chung, 2015; Ploderl et al., 2011).

Because the instruments and methods we currently use to assess suicide risk rely heavily on self-report, and are, therefore, subject to all the limitations of self-report measures, researchers have been working on identifying more objective behavioral and biological markers of suicide risk (for a recent review, see Ballard et al., 2021).

Although none of these measures are ready for clinical use at this time, it is important for clinicians to be aware of their findings and the future directions of the field.

Ecological Momentary Assessment (EMA)

One relatively new method researchers have begun using to help understand and account for the transient nature of suicidal thoughts is known as ecological momentary assessment (EMA), which is an experience-sampling method that gathers data in real time using digital tools, such as mobile phone apps (Morgieve et al., 2020).

A benefit of EMA is that it can enable one to monitor a behavioral, physiological, or psychological process outside of a laboratory or clinical setting (Nock et al., 2009).

It has been demonstrated that suicidal ideation comes and goes. Suicidal thoughts can surface quickly (Kleiman et al., 2017) and last for relatively short periods of time (e.g., less than an hour) (Nock et al., 2009). Suicide attempts can occur in response to a rapid increase in suicidal thoughts (Kleiman et al, 2017, Kleiman et al., 2018; Millner et al., 2017).

Findings such as these complicate clinical decision-making, which has traditionally relied upon intermittent assessment of risk for such judgments as to when a suicidal patient may be ready for an increase in privileges or even hospital discharge (Morgieve et al., 2020).

EMA enables changes in suicidal thoughts and behaviors to be studied and monitored in real-time, outside the lab, the clinic, or mental health providers’ office (Ballard et al., 2021; Nock et al., 2009).

By definition, EMA assessments are recurrent. Thus, they have the ability to gather information with respect to fluctuations in suicidal ideation and other symptoms, which is harder to obtain using less frequent traditional assessment methods (Ballard et al., 2021).

Research on EMA is helping us better understand suicidal thoughts and behaviors and how they vary over short periods. For example, Kleiman and colleagues (2017) recently conducted two EMA studies of suicidal ideation. They found that suicidal ideation varies dramatically over the course of most days. Responses given a few hours apart often differed by more than a standard deviation (Kleiman et al., 2017).

Nock and colleagues (2009) demonstrated the feasibility of using EMA methods to examine suicidal thoughts and behaviors in a sample of adolescents and young adults. The study found that suicidal thoughts were less frequent, but lasted longer than thoughts of non-suicidal self-injury (NSSI).

Also, suicidal thoughts and thoughts of NSSI rarely co-occurred in this study, corroborating other evidence that suicidal thoughts and behaviors and NSSI are distinct from each other.

At this time, the process of assessment of imminent risk is still very challenging. The hope is that a frequent, real-time assessment method, such as EMA, could be combined with traditional techniques to help clinicians better identify individuals who may be at a heightened risk for imminent suicide and who, therefore, may require a more rapid intervention (Bagge et al., 2017; Morgieve et al., 2020).

Real-time data collection methods have advantages, such as increased reliability and ecological validity, as well as decreased susceptibility to recall biases. However, EMA methods are still based on self-report and, therefore, are still prone to the many well-known limitations of self-report data (Nock et al., 2009).

Digital Phenotyping

Digital Phenotyping is way of analyzing large EMA and other real-time monitoring data sets. The digital phenotyping method involves identifying patterns in data derived from EMA or other real-time monitoring sources (e.g., mobile devices, GPS, speech samples, internet and social activity, keyboard activity) (Ballard et al., 2021).

For example, a recent study using digital phenotyping looked at whether there are subtypes of suicidal thinking. Researchers used smartphone-based real time monitoring to assess suicidal thoughts 4 times a day in two samples.

The first sample recruited adults who had attempted suicide in the past year from online forums; the second sample included psychiatric inpatients with recent SI or attempts. Across both samples, five distinct phenotypes of suicidal thinking emerged, primarily differing on the intensity and variability of suicidal ideation.

The profile of those most likely to have made a recent suicide attempt was characterized by more severe and more persistent suicidal thoughts (e.g., higher mean and lower variability around the mean). This study has aided our understanding of suicidal thinking as suicidal thinking has historically been understood to be a homogenous construct.

The study raises questions for future research, such as how these phenotypes may prospectively relate to future suicidal behaviors (Kleiman et al., 2018).

Researchers have noted that suicidal individuals can lack insight into the thoughts and feelings that drive their suicidal behavior and, thus, unable to tell others about them (Nock & Banaji, 2007). One advantage of digital phenotyping is that it potentially allows for the detection of changes in suicidal thinking that occur outside of conscious awareness (e.g., smartphone movement, ambient light, text messages).

However, there are also some ethical concerns related to this novel method. Digital phenotyping relies on the use of passively collected data, thereby raising concerns not only about privacy, but also about the security of the data being collected and its potential to be inappropriately used in clinical and/or forensic settings.

More research is needed before digital phenotyping is ready for clinical use (Ballard et al., 2021).

Recently, a panel of experts, including individuals with lived experience, was convened to produce a consensus statement on best practices related to ethical and safety concerns in digital monitoring studies (Nock et al., 2020). View their findings.

Cognitive and Implicit Bias Measures

Implicit Cognition

Because individuals may be reluctant or unable to report suicide-related intentions, researchers are studying whether measures of implicit cognition could detect suicide risk beyond traditional self-report measures.

Measures of implicit cognition have the potential to improve clinical assessment and may be able to help explain why some individuals with the same risk factors will cope with difficult circumstances and extreme distress with adaptive methods, whereas others will choose maladaptive suicidal behavior as a means of escape (Nock et al., 2010).

One such measure is the Implicit Association Task (IAT). In this task, participants’ reaction times are measured as they classify words into categories (e.g., “self” or “other”) to measure the relative strength of their mental associations between various concepts.

In the Suicide IAT (S-IAT), Nock and colleagues adapted the IAT to measure associations between self/other and death/life (Ballard et al., 2021; Nock & Banaji, 2007; Nock et al., 2010).

In the Self-Injury IAT (SI-IAT), associations are measured between self/other and images related to self-injury. In Nock and Banaji’s (2007) study of 89 adolescents, the SI-IAT was able to differentiate non-suicidal individuals, suicide ideators, and suicide attempters.

S-IAT performance has also been found to predict future suicide attempts, exceeding the predictive validity of other suicide risk factors, such as history of depression or suicide attempt (Nock et al., 2010).

These findings have been replicated in emergency department, veteran, and internet samples (Ballard et al., 2020; Barnes et al., 2017; Glenn et al., 2017; Randall et al., 2013).

Building on earlier studies about the specificity of self-harm related implicit cognition, Glenn and colleagues (2017) randomly assigned participants to one of three self-harm IATs: self/other and cutting; self/other and suicide, or self/other and death.

Self-harm associations were stronger among individuals with a history of suicide attempt and non-suicidal self-injury compared to those without. Furthermore, results show that the implicit associations were sensitive to recency and severity of self-harm history.

Future work will be needed before the S-IAT and SI-IAT are used to make clinical interpretations. However, if employed in combination with other assessment tools, the S-IAT and SI-IAT may be able to increase the accuracy of suicide risk assessments.

For example, given that the IAT seems to be more resistant to dishonesty than traditional self-report measures, these tools could potentially be used in the future prior to making decisions about patient discharge for high-risk suicidal patients (Glenn et al., 2017).

Emotional/Suicide Stroop Task

The Stroop Task is a popular neuropsychological test that is used to measure selective attention, cognitive flexibility, processing speed, and executive function. The Stroop Task measures how easily a person can suppress automatic responses when presented with incongruent stimuli.

There are several versions of the Stroop Task. To help improve suicide risk assessment, researchers have been studying attentional biases toward suicide-related stimuli with an adapted version of Stroop Task known as the Suicide Stroop Task (Wilson et al., 2019).

Suicide-specific attentional bias is conceptually linked with a cognitive model of suicide (Wenzel & Beck, 2008), which posits that suicidal individuals have difficulty disengaging from suicide-related thoughts because their attention is fixated on suicide-relevant information.

The Suicide Stroop Task is adapted from the Emotional Stroop Task. In the Suicide Stroop Task, individuals are asked to name the font color of suicide-related, emotionally valanced, and neutral words as quickly as possible (Wilson et al., 2019).

The assumption is that suicidal individuals will be preoccupied by the suicide stimuli and that this will interfere with their naming of the color of the font. In other words, they will be slower to name the suicide-related words than the neutral or emotional words.

In an early study, Cha and colleagues (2010) used the Emotional Stroop Task to explore suicide-specific attentional bias in a sample of patients in a psychiatric emergency department.

They found that the ED patients who had a history of suicide attempt had an attentional bias to suicide-related words (as opposed to neutral words) compared to the ED patients who never made a suicide attempt. The attentional bias was strongest for those who had a suicide attempt within the past six months.

In addition, the researchers found that this suicide-specific attentional bias assessed by the Emotional Stroop Task added significantly to the prediction of who would make a subsequent suicide attempt during the following 6-month follow-up period, when the instrument was used along with other clinical measures.

Chung (2015) examined the concurrent and predictive validity of the Emotional Stroop Task as a behavioral marker for suicidal behaviors in a college population. In this study, 820 college students were asked to perform on the EST and to respond to suicide-related self-report measures. The same 820 students were followed up 18 months later.

Results indicated that the students in the sample who had a history of past suicide attempts had longer response latencies to the word “suicide” on the Emotional Stroop Task, compared to those students who did not have a history of an attempt. Furthermore, the students with attentional bias toward suicide-relate words at baselines were more likely to report suicidal behaviors during the follow-up period.

The Chung (2015) study examined whether latencies on the Emotional Stroop Task might be affected by the ethnicity of the student.

This is an interesting question as the traditional suicide risk assessment were not developed or standardized using culturally or ethnically diverse samples and there is concern that persons from various ethnic/cultural groups may interpret questions during the assessment differently or may be reluctant to report suicidal symptoms for a variety of reasons (e.g., fear of discrimination).

Chung (2015) found that performance on the Emotional Stroop Task, which does not rely on self-report, was not at all affected by ethnicity. However, a possible gender effect was noted. In a 2015 paper, Chung & Jeglic found that females who had made a past attempt showed more delayed response on the EST when their most recent attempt was within the past year.

Another important issue in suicide risk assessment is differentiating suicide ideators from suicide attempters. To study this question, Stewart and colleagues (2017) administered the Suicide Stroop Task to a sample of adolescent ideators and adolescent attempters recruited from a residential treatment center. Results indicated that suicide attempters showed greater interference for suicide and positive stimuli than suicide ideators.

The benefits of these Stroop tasks are not only that they do not necessitate direct self-report of suicide related symptoms, but also that they are relatively quick to administer and low-cost. However, there have been concerns regarding their reliability and validity as measures of suicide risk (Wilson et al., 2019), and there is little evidence that the these tasks, in their current forms, outperform traditional self-report measures (Chung & Jeglic, 2015).

Moreover, findings using the Suicide Stroop Task have been less consistent than those using the suicide-specific Implicit Association Task (SI-IAT) (e.g., Ballard et al., 2021; Richard-Devantoy et al., 2016), discussed above. In a recent article, Wilson and colleagues (2019) explain some of the problems with the Suicide Stroop in its current form and suggest several concrete ways the Suicide Stroop could be improved upon in the future.

The hope is that with these improvements, the Suicide Stroop could potentially be used alongside other evidence-based assessment methods to better identify individuals at high risk for suicide attempt and completion.

Impaired Decision Making

Iowa Gambling Test

Decision-making deficits have been associated with suicidal behavior in both adults and adolescents. Jollant and colleagues (2005) were the first to report a specific impairment in decision-making in suicide attempters.

They found that suicide attempters scored lower on the Iowa Gambling Test (IGT) than healthy comparison subjects. Other studies have since confirmed these findings with a variety of samples, including adults with bipolar disorder (Maloy-Diniz et al., 2009) and youth with psychiatric conditions (Bridge et al., 2012).

Suicide attempters seem to have difficulty learning an advantageous decision-making strategy from feedback over the course of the task. Other studies have shown that suicide attempters are less responsive to reward/punishment feedback (Dombrovski et al., 2011).

These converging findings suggest that impaired decision-making and cognitive flexibility may be a component of suicidal behavior. In the future, clinicians may be able to incorporate more objective measures of impaired decision-making and cognitive inflexibility into their suicide risk assessments.

Delay Discounting

The tendency to devalue outcomes over the course of a delay, also known as delay discounting, is a specific type of decision-making that may be linked to suicide risk. Individuals with higher rates of delay discounting exhibit a preference for smaller, immediate rewards over larger, delayed ones.

There are several ways to measure delay discounting. All of them involve asking individuals to make choices between smaller, immediate rewards and larger, delayed ones. Thus, researchers are examining whether this more objective measure of impulsive choice can be valuable in the assessment of suicide risk.

Dougherty and colleagues (2009) studied delay discounting in adolescents who engaged in non-suicidal self-injury (NSSI) with or without a history of suicide attempts. Adolescents who had history of a suicide attempt were more likely to choose the smaller, immediate rewards over the larger delayed one, consistent with the notion that impulsivity is a risk factor for suicide in youth.

Dombrovski and colleagues (2011) found that older adults who had contemplated suicide or made low-lethality suicide attempts had higher rates of delay discounting than non-suicidal control subjects, consistent with Dougherty and colleagues’ (2009) findings in adolescents.

However, interestingly, those who made high-lethality/high-planning suicide attempts had significantly lower rates of delay discounting than those who made low-lethality attempts and non-suicidal subjects.

While impulsivity is a known risk factor for suicide, these findings suggest that suicidal individuals who think more about the future and plan out their attempts may also be at heightened risk of dying by suicide. Thus, both low and high rates of delay discounting may be of concern to clinicians and further refine suicide risk assessments.

Neurobiological Markers

Neuroimaging studies show that specific brain regions are implicated in suicidal thoughts and behavior. Suicidal ideation and behavior are accompanied by local as well as long-range brain network changes. Structural and functional connectivity disturbances have been found in the ventral prefrontal cortex, insula, anterior cingulate, amygdala, hippocampus, and ventral striatum (Ballard et al., 2020). For a review of these studies, see Ballard et al., 2021.

However, most neuroimaging studies to date have used “lifetime history of suicide attempt” to characterize suicide risk. These attempts could have happened recently, or they could have happened years ago.

Only a few studies have examined the neurobiology of suicidal thoughts in real-time. In one study, Ballard and colleagues (2020) used the suicide implicit association test (IAT) to examine the electrophysiological correlates of the implicit association between self/life and self/death.

The study found that gamma activity increased in the amygdala and anterior insula. Furthermore, connectivity estimates between the early visual cortex, anterior insula, and amygdala distinguished individuals with a recent suicide crisis from healthy volunteers with 77-82% sensitivity and 80-85% specificity. While replication in larger samples is needed, these findings show promising implications of such methods for suicide evaluation.

Another group of researchers, Hazlett and colleagues (2016), examined whether startle amplitude during unpleasant pictures is greater in those with a history of multiple suicide attempts, as well as whether it was predictive of a future suicide attempt.

Startle amplitude was measured using electromyography. Multiple attempters showed greater startle amplitude during unpleasant pictures than passive ideators, active ideators, and single attempters.

In this study, startle amplitude also predicted future suicide attempt at a 12-month follow-up. The study underscores the potential value in identifying biological processes (e.g., an overactive amygdala) that may contribute to suicide risk (Hazlett et al., 2016).

Just and colleagues (2017) used functional MRI to measure neural activity in response to positive, negative, and death-related concepts. Their sample was composed of both suicidal and non-suicidal youth. They then developed a machine learning algorithm, which used neural representations of these concepts to differentiate between the suicide ideators and controls with 91% accuracy.

Moreover, the algorithm could differentiate between the ideators who had made a suicide attempt and the ideators who did not make a suicide attempt with 94% accuracy. Although this is just one study with a very small sample size, the findings were impressive, and suggest that machine learning methods may be able to improve upon traditional clinical assessment methods.

Jollant and colleagues (2011) conducted a literature review of neuroimaging and neuropsychological studies related to suicidal behavior. Studies supported the idea that there are alterations in the brain in persons with suicidal behaviors and that the alterations among those with suicidal behavior differ from those with comorbid conditions without a history of suicidal behavior.

In addition, these findings, taken together with findings from neuropsychological studies mentioned above (e.g., that suicide attempters have impaired decision-making, lower problem-solving abilities, less cognitive flexibility, and higher attention to specific negative emotional stimuli) support the notion that neurocognitive dysfunctions may facilitate suicidal crises among vulnerable individuals.

Lipid Levels

In their search for potential biomarkers for suicide and suicidal behaviors, researchers have been studying lipid levels (Kulak-Bejda et al., 2021).

The link between lipid levels and suicidality has biologic plausibility. Cholesterol plays an important role in the function of cellular membranes, and specifically in the function of the 5-HT1A serotonin receptor.

One theory is that “lower cholesterol levels may decrease membrane fluidity and cause an increase in the order of the membrane lipid bilayer” which can lead to a reduction in serotonergic transmission (Kulak-Bejda et al., 2021). Lipid levels appear to affect both the serotonin metabolite 5-HIAA as well as the dopamine metabolite homovanillic acid.

The consequent imbalance between serotonin and dopamine is hypothesized to exacerbate suicide risk (Reuter et al., 2017). Other mechanisms have also been proposed (e.g., Segoviano-Mendoza et al., 2018).

Studies have found an association between lower cholesterol levels and suicidality in various patient populations, including depressed patients (e.g., Ma et al., 2019; Messaoud et al., 2017; Park et al., 2014), psychotic patients (e.g., Shrivastava et al., 2017), and those with a history of impulsive or violent behavior.

For example, Segoviano-Mendoza et al. (2018) found lower total cholesterol, LDL-cholesterol, VLDL-cholesterol, and triglyceride serum levels in patients with major depressive disorder and suicide attempts compared to those without suicidal behavior (Kulak-Bejda et al., 2021).

Aguglia and colleagues (2019; 2020) found that those who had made high lethality suicide attempts and those who made repeat suicide attempts had lower cholesterol levels than other attempters in their sample of 632 attempters (Kulak-Bejda et al., 2021).

A study was also conducted on 128 veterans who had had either suicidal ideation, attempt, or had died by suicide between 2009 and 2015. The study found that those veterans with total cholesterol levels below 168 mg/dl had a greater risk of dying by suicide than those with higher total cholesterol levels.

The cholesterol level of the suicidal group (who reported suicidal ideation or an suicide attempt at a visit) was also significantly lower than the cholesterol level of the non-suicidal group (who reported neither suicidal ideation nor attempt at a visit) (Kulak-Bejda et al., 2021; Reuter et al., 2017).

A recent meta-analysis of 65 epidemiological studies found an 85% increased risk of suicide death and a 123% increased risk of suicide attempt in persons with lower serum cholesterol levels (Wu et al., 2016). Lower cholesterol in the recent past has been associated with greater risk of suicide death, according to a study by Chen and colleagues of 41 suicide deaths and 205 matched controls in Japan (Chen et al., 2019).

They found that suicide risk was increased in those with lower serum total cholesterol levels in the three years preceding death (Chen et al., 2019). Specifically, those in the lowest tertile of serum cholesterol had a three to four-fold greater risk of dying by suicide compared to those in the highest tertile of total serum cholesterol.

Each decrease of 10 mg/dl in total serum cholesterol was associated with an 18% increased risk of suicide death in the study (Chen et al., 2019).

However, not all studies have found an association between lipid level (i.e., total cholesterol, LDL, triglycerides) and suicidal behavior or death (e.g., Bartoli et al., 2017a; 2017b) and some studies have even found an association in the opposite direction (i.e., that high cholesterol levels are associated with greater risk) (see e.g., Kulak-Bejda et al., 2021; Svensson et al., 2017).

While it is appealing to imagine that we might be able to someday add something as simple and inexpensive as monitoring lipid levels to our clinical repertoire to help screen and perhaps treat suicide risk, the science is not yet there.

Additional research, especially longitudinal studies on larger and more diverse patient samples, is needed before any conclusion can be made as to whether one’s lipid level is actually a biological marker for suicide and to develop clinical applications from these findings (De Barardis et al., 2012).

Conclusion

It is impossible to predict suicide in an individual. No study has ever shown that risk factors, either alone or in combination, can predict who will attempt or die by suicide, or when it might happen (APA, 2003; Franklin et al., 2017). However, knowing the particular risk factors and drivers of suicide for an individual can help the clinician devise a tailored treatment plan, such as medication, psychotherapy, and treatment setting (including hospitalization).

Moreover, there is a growing body of literature examining cognitive and biological markers of suicidal ideation and behavior, which may provide more objective measures of suicide risk than traditional self-report measures (e.g., Ballard et al., 2021; Chung, 2015; Hamedi et al., 2019; Nock et al., 2009; Nock et al., 2010).

In addition, researchers are currently studying whether machine learning algorithms, which can combine and weigh risk factors, might support assessment of suicidal risk with greater accuracy than current approaches (American Psychological Association, 2016; Franklin et al., 2017; Just et al., 2017; McCoy et al., 2016).

In addition to listening, the professional who is assessing patients for suicide can also look for nonverbal indicators of suicidality. For example, how a patient answers the question, “Are you thinking about suicide?” may provide highly relevant information.

If there is a long pause, and the patient finally responds with a succinct “no,” further inquiry may be needed. Conversely, if the patient is too vigorous in denying any risk, one can probe further into what may be an automatic denial. A straightforward confrontation, such as “Are you really telling me the truth?” can sometimes be powerful and lead to an acknowledgment that there is more to the story.

Countertransference is a common issue in evaluations of suicidality (Maltsberger & Buie, 1974). Clinicians who are aware of their own internal state as they are monitoring the patient’s condition can reduce a potential barrier to the challenging task of the assessment of suicide risk.

Glen O. Gabbard, MD is clinical professor of psychiatry at Baylor College of Medicine and Training and supervising analyst at the Center for Psychoanalytic Studies in Houston.

Determination of Risk Level and Intervention

Mental health clinicians use clinical judgment to determine a patient’s level of suicide risk and the corresponding intervention.

Persons who may be considered to be at high risk for suicide include those who have made a potentially lethal suicide attempt and/or who have a strong intent to die. High risk patients usually have one or more psychiatric disorders or may have experienced an acute precipitating event.

In contrast, those deemed to be at low risk for suicide may have thoughts of death, but no plan, intent, or self-injurious behavior. Low risk patients often have modifiable risk factors, strong protective factors, and are engaged in ongoing treatment (Jacobs, 2016).

Clinical judgment regarding the overall level of risk and appropriate intervention also includes assessing the patient’s cognitive capacity and reasoning, ability to control impulses, and willingness to accept and adhere to treatment. The clinician may take into account the acuteness or chronicity of the patient’s suicidal status and their ability to sustain or form a therapeutic alliance (Jacobs et al., 1999).

A recent systematic review has shown that a strong therapeutic alliance is associated with fewer suicidal thoughts and self-harming behaviors (Dunster-Page et al., 2017).

Through his research on the National Suicide Prevention Lifeline, Joiner and colleagues (2007) identified key factors for determining risk level through telephone contact.

In their framework, risk level is based on the presence or absence of four factors—suicidal desire, suicidal capability, suicidal intent, and the presence or absence of buffers/protective factors.

Low to moderate risk callers will have either the desire, capability, or intent. Moderate to high risk callers will have desire paired with either intent or capability. The absence or presence of protective factors may raise or lower the risk for these two groups. In contrast, high risk callers will have all three of these core factors and their risk will remain high despite the presence of protective factors.

Documentation

The final step in a suicide assessment is documentation. Although documentation is usually thought of as a risk management issue, it allows communication about a patient’s clinical status between shifts and to other disciplines. It also allows communication of changes in a patient’s risk level that can inform the treatment plan.

When to Document Suicide Risk Assessments

• At first psychiatric assessment or admission
• With the occurrence of any suicidal behavior or ideation
• Whenever there is any noteworthy clinical change
• Before increasing privilege level
• Before giving passes
• Before discharge

The Joint Commission, an independent, non-profit agency which accredits heath care programs and organizations throughout the United States, views documentation as a means to improve patient safety. In 2018, they published a 262-page “Go-To Guide” titled “Documentation of Care, Treatment or Services in Behavioral Health Care: Your Go-To Guide.”

View a sample of this guide. It is important to note that the Joint Commission does not require nor recommend that facilities under their purview use any specific format for suicide risk assessments (Joint Commission, 2021).

Treatment Setting and Hospitalization

This section discusses selecting a treatment setting for at-risk patients, including situations where hospital admission may be warranted. The information is from Table 8 of the American Psychiatric Association’s “Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors” (APA, 2003).

Admission is generally indicated…

…after a suicide attempt or aborted/interrupted attempt if:

• Patient is psychotic
• Attempt was violent
• Precautions were taken to avoid rescue or discovery
• Persistent plan and/or intent is present
• Distress is increased or patient regrets surviving
• Patient is male, older than 45 years, especially with new onset of psychiatric illness or suicidal thinking
• Patient has limited family and/or social support, including lack of stable living situation
• Current impulsive behavior, severe agitation, poor judgment, or refusal of help is evident

…in the presence of suicidal ideation with:

• Specific plan with high lethality
• High suicidal intent

Admission may be necessary...

…after a suicide attempt or aborted/interrupted attempt, except in circumstances for which admission is generally indicated.

…in the presence of suicidal ideation with:

• Psychosis
• Major psychiatric disorder
• Past attempts, particularly if medically serious
• Lack of response to or inability to cooperate with partial hospital or outpatient treatment
• Need for supervised setting for medication trial or ECT
• Need for skilled observation, clinical tests, or diagnostic assessments that require a structured setting
• Limited family and/or social support, including lack of stable living situation
• Lack of an ongoing clinician-patient relationship or lack of access to timely outpatient follow-up

…in the absence of suicide attempts or reported suicidal ideation/plan/intent, but evidence from the psychiatric evaluation and/or history from others suggest a high level of suicide risk and a recent acute increase in risk.

Outpatient treatment may be more beneficial than hospitalization...

…if patient has chronic suicidal ideation and/or self-injury without prior medically serious attempts, and if a safe and supportive living situation is available and outpatient psychiatric care is ongoing.

Immediate Safety Needs of Hospitalized Patients

Hospitals have their own procedures for applying these principles of suicide assessment and determining the safety needs of their patients.

Typically, once a patient is admitted to the hospital for suicidality, an initial psychiatric evaluation with a suicide risk assessment will determine the observation level. The monitoring of the suicidal patient includes a range of frequency of observation from continuous observation (1:1) to 5-, 15-, or 30-minute checks.

In the hospital setting, there are also different categories of restriction, such as supervised bathroom use, restriction to the unit or to public areas, supervised sharps, and placement in hospital clothing.

The levels of observation and restriction depend upon the level of risk assessed at the time and is subject to change based upon the clinical condition of the patient (Jacobs, 2007).

The initial level of observation/restrictions and changes in the level require a physician order. The order may be verbal and is signed within a certain period of time. Nursing staff may institute 1:1 observation when there are clinical indications (e.g., overt or covert expressions of suicidal ideation, actions, or aggressive behavior).

Reduction of 1:1 usually occurs after evaluation by a physician. The attending/covering physician is notified and an order is issued.

Patient monitoring on a psychiatric unit involves conducting checks or observations at a clinically appropriate frequency, restricting the patient to safe areas when indicated, and supervising potentially dangerous activities (e.g., shaving, eating with utensils), again, when clinically indicated.

Treatment

Current evidence-based treatments for reducing suicide risk include medication, brain stimulation techniques, and psychotherapy. Some newer treatments can be very helpful for those who have been struggling with depression that has not responded to other treatments or who need rapid treatment intervention. As all treatments can have side effects, clinicians use a risk-benefit estimation to inform treatment.

Medication

Antidepressants

The FDA has approved many medicines for treatment of depression, notably antidepressants. Antidepressants can reduce suicidal thoughts in patients as depression improves, but they require time to take effect.

Most patients experience significant improvement within three months of antidepressant treatment, usually with some benefit within the first month. Antidepressants must be taken consistently and at adequate doses.

Some common reasons patients may not experience improvement with antidepressant treatment are:

• The drug was not suited for this person, who needs a different kind of medication
• Not taking the medication at the right time or doses
• An additional therapy is required (e.g., psychotherapy, ECT, rTMS, ketamine, lithium, or antipsychotic).

The currently most frequently prescribed antidepressants are selective serotonin reuptake inhibitors (SSRIs). They are effective, have a favorable side-effect profile, and are unlikely to be lethal on overdose. Examples include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft).

Other types of antidepressants include serotonin and noradrenaline reuptake inhibitors (SNRIs; e.g., duloxetine, levo-milnacipran, and venlafaxine), tricyclics (e.g., amitriptyline, desipramine, imipramine, and nortriptyline), monoamine oxidase inhibitors (MAOIs; such as phenelzine and tranylcypromine) and some with other action mechanisms (e.g., bupropion and mirtazapine).

There is inconsistent evidence about effects of antidepressant treatment and suicidal risks. One would expect that treatments that are effective for depression should reduce suicidal risk. However, compelling evidence of reduction of rates of suicide attempt and suicide during antidepressant treatment is lacking, although suicidal ideation typically decreases, usually along with improvement of other symptoms of depression (Gibbons et al., 2012).

Moreover, the FDA requires all antidepressants to carry a black-box (severe) warning that persons under age 25 years may experience new or increased thoughts of suicide, especially when first starting treatment.

Monitoring of suicidal status in patients taking an antidepressant is important, not only to detect early clinical changes that may include increased suicidal risk, but also because antidepressants can unmask previously undiagnosed bipolar disorder, which requires a different treatment approach.

Patients and, when indicated, parents/significant others, are apprised of this warning when this communication is documented. The warning applies to any medication approved as an antidepressant [e.g., quetiapine (Seroquel), cariprazine (Vraylar)].

Anti-Anxiety Agents

Since anxiety is a modifiable risk factor for suicide, use of antianxiety agents may decrease this risk. More specifically, in the presence of depression, acute suicidal risk may be associated with psychic anxiety, panic attacks, agitation, and insomnia (Fawcett et al., 1990). These symptoms might be reduced by short-term benzodiazepine treatment (1–4 weeks).

However, research on suicide risk with antianxiety treatment is very limited, and findings from randomized, controlled trials are lacking. To minimize severe recurrent or rebound anxiety or agitation, long-acting benzodiazepines may be preferable to short-acting ones, although long-acting benzodiazepines are more likely to cause daytime sedation.

Persistent, severe insomnia is also a modifiable risk factor for suicide and can be addressed with the use of a benzodiazepine, a sedating second-generation antipsychotic (Londborg et al., 2000; Smith et al., 2002; Smith et al., 1998), or a sedating antidepressant, such as mirtazapine (APA, 2003).

In treating potentially suicidal patients, benzodiazepines are sometimes avoided because of concerns about their potential for inducing dependency (Salzman, 1998), respiratory depression, or behavioral disinhibition.

Such adverse responses have occurred among patients with borderline personality disorder or cognitive dysfunction (Cowdry & Gardner, 1988; Dietch & Jennings, 1988; Gardner & Cowdry, 1985; Kalachnik et al., 2002; O’Sullivan et al., 1994).

Nevertheless, the risk of such adverse effects appears to be small (Rothschild et al., 2000). Since benzodiazepines can limit psychic distress in depressed patients and improve sleep, they can potentiate clinical benefits of antidepressant treatment (Londborg et al., 2000; Joughin et al., 1991; Smith et al., 1998; Smith et al., 2002).

In general, decisions about initiating or continuing benzodiazepines in suicidal patients will address the preceding potential risks and benefits as they relate to individual patients (APA, 2003).

In short, providing treatments aimed at reducing anxiety, psychic distress, agitation, and insomnia, regardless of the primary diagnosis, can reduce suicide risk. Antianxiety agents may have a useful empirical role in such situations, when employed with due regard to their risk of disinhibiting impulsive or aggressive behavior (APA, 2003; Fawcett, 1988).

Lithium

Researchers have found that long-term maintenance treatment with lithium reduces suicide risk in patients with bipolar I disorder, bipolar II disorder, and possibly unipolar depressive disorder. In bipolar disorder patients, suicide risk during lithium treatment maintenance therapy became similar to that in the general population in one study (Tondo & Baldessarini, 2009).

Lithium may provide this benefit by reducing dysphoric-agitated symptoms, aggression, and impulsivity. Lithium is given cautiously because amounts that are three or more times the typical or standard dose can be toxic or even lethal.

There also is evidence that lithium may be superior to other mood stabilizing agents in reducing suicide attempts in bipolar disorder patients, notably compared to carbamazepine or valproate (Baldessarini & Tondo, 2009; Fazel & Runeson, 2020; Song et al., 2017).

A recent study found that juveniles being treated with lithium had half as many suicide attempts, improved depressive symptoms, less psychosocial impairment, and less aggression (Hafeman et al., 2019). Find additional references on the topic of lithium and suicide risk.

Other Mood-Stabilizing Agents

Evidence for a protective effect against suicide of “mood-stabilizing” agents other than lithium is limited. Studies show that patients have fewer suicide attempts and suicides when treated for bipolar disorder with lithium than with carbamazepine (e.g., Tegretol) and divalproex (e.g., Depakote), neither of which is approved as effective for long-term, maintenance treatment of bipolar disorder patients.

Goodwin and colleagues (2003) found, for example, that the risk of suicide was 2.7 times higher when treated with these two medicines than with lithium, after controlling for potential confounds. The risk of suicide attempts resulting in emergency department care was 1.7 times higher for patients treated with these two anticonvulsants than with lithium (APA, 2003; Goodwin et al., 2003).

There is even more limited information on risks of suicide and suicide attempts during treatment with other mood-stabilizing agents aside from lithium, notably carbamazepine, and divalproex. This is despite the growing use of anticonvulsants and some second-generation antipsychotics for the treatment of bipolar disorder because of their relative simplicity of use as well as rapid efficacy in treating mania.

Thus, when weighing the risks and benefits of various medications for bipolar disorder, the efficacy of lithium in decreasing suicidal behavior is taken into consideration when indicated (APA, 2003).

Ketamine^[6]

Originally synthesized as a cyclohexaylamine anesthetic in the 1960’s (Domino, 2010), evolving research over the past 20 years has yielded unexpected utility for ketamine in psychiatry.

The preponderance of evidence, at the time of this writing, centers on ketamine’s clinical utility in select patients struggling with depression and suicidality (McIntyre et al., 2021); its potential role in other psychiatric disorders is less well established, with an abundance of questions and unknowns that require systematic, rigorous investigation.

Generic ketamine is composed of esketamine and its mirror image, arketamine. When administered intravenously at sub-anesthetic doses for the treatment of depression, this “racemic” mixture is generally given.

Spravato, the sole ketamine that is FDA approved (Office of the Commissioner, 2019) for the treatment of any psychiatric illness, is composed of esketamine only, and is administered intranasally. In clinical practice within this sub-specialty of psychopharmacology, both treatments are often found.

Racemic Ketamine

Subanesthetic doses of racemic ketamine, responsibly administered, have demonstrated robust anti-suicidal and anti-depressant properties (Sing et al., 2016). While a single infusion can, in some patients, produce a decrease in general symptoms of depression within several hours of administration, the response tends to last only for several days (Kishimoto et al., 2016).

Other work has demonstrated that the anti-depressant effect can be prolonged through carefully controlled, repeated administrations. Phillips et al (2019), for example, demonstrated that serial infusions have sustaining and cumulative antidepressant effects, with a response rate twice that of placebo, and with nearly 60% of patients achieving a traditionally defined “response.”

Most contemporary racemic IV ketamine protocols begin with two treatments per week, with variation in duration and frequency of treatment thereafter (Kryst et al., 2020; Murrough et al., 2013); evidence-based dosing, at time of this writing, generally begins at approximately .5 mg / kg (Fava et al., 2020). More research is needed to better define optimal longitudinal protocols.

The importance of adequate patient selection and careful medical and psychiatric monitoring cannot be underestimated in considering treatment with racemic ketamine (McIntyre et al., 2021; Sanacora et al., 2017), as standards of practice and attention to the evidence base can vary quite widely between centers.

In general, there remain many critical unanswered questions regarding key clinical and mechanistic aspects in the evolving use of ketamine for therapeutic purposes, supporting conservative, cautious approaches and a healthy index of suspicion when extraordinary claims appear (Sanacora & Schatzberg, 2014).

Likewise, while ketamine has been a life-saving treatment for many, it is a known illicit drug of abuse (Bokor & Anderson, 2014); in the addictions literature, the consequences of inappropriate or over-exposure to ketamine are striking.

Patients and clinicians alike have ample reason to carefully discuss what is known and unknown about ketamine prior to engaging in treatment. This is especially true for administration of generic racemic ketamine, which is not FDA approved for the treatment of depression or suicidality, and is not subject to as stringent monitoring and oversight as one might expect.

Esketamine

In March of 2019, the FDA approved esketamine for the adjunctive treatment of treatment resistant depression (Office of the Commissioner, 2019). The FDA subsequently granted a second FDA approval for treating depressive symptoms in adults with MDD with acute suicidal ideation or behavior based on data collected through the Aspire Trials (Fu et al., 2020; Ionescu et al., 2021).

This medication, which is administered intranasally, can only be given by registered centers that engage in a program known as REMS (Risk Evaluation and Mitigation Strategy). Esketamine does not take the place of a standard, concurrent anti-depressant.

The associated protocol begins with an Induction phase in which the medication is administered twice weekly for 4 weeks, followed by a second phase of once weekly administrations for one month. A maintenance phase, with administration occurring every one to three weeks, follows the second phase and continues indefinitely.

Many patients find the FDA approval associated with esketamine, its REMS requirement, and its established protocol to be reassuring. Little is known regarding which of the two treatments above may be more effective in clinical populations; this remains an area of important research as preliminary data begins to emerge (Bahji et al., 2021).

Clozapine

Approximately 50% of patients who have schizophrenia or schizoaffective disorder attempt suicide. Estimates suggest that about 5–10% die of suicide over a lifetime (Meltzer et al., 2003; Palmer et al., 2005). For years, clozapine was the only medication approved by the FDA for “reducing suicidal behavior” and only in patients diagnosed with schizophrenia.^[7]

In general, clozapine is used for patients with schizophrenia or schizoaffective disorder who have not been helped by other treatments or who have tried to kill themselves and are likely to try again, regardless of their previous responses to treatment. Clozapine is available only through a restricted distribution and monitoring program to limit risks of potentially lethal aganulocytosis.

Clozapine is an old drug, but widely considered to be the first of a class designated as “second-generation” or atypical antipsychotics, reflecting their far lower risk of adverse neurological effects that were typical of the early antipsychotics, including the phenothiazines, thioxanthenes, and haloperidol.

Clozapine produces complex changes in brain chemistry and its special status as one of the most effective treatments for psychotic illness remains unexplained.

Evidence that treatment of schizophrenia patients with clozapine substantially reduces their risk of suicidal behavior is quite secure (Masuda et al., 2019), including a randomized trial that found it more effective than olanzapine (Meltzer et al., 2003). There is no evidence that clozapine treatment reduces suicidal risk in depressive disorders and it remains poorly studied in bipolar disorder.

Other Antipsychotic Agents

While first-generation antipsychotics (e.g., fluphenazine, thiothixene, and haloperidol) are very effective in treating psychotic symptoms (delusions, hallucinations, agitation, aggression, and confusion), studies have found them to be less effective in treating suicide risk than clozapine (Taipale et al., 2020; APA, 2003).

They are also associated with prevalent adverse side effects, including extrapyramidal neurological side effects, akathisia, and possibly also worsening of depression.

Because of this, they have been replaced over time in the United States by second-generation antipsychotics, which have lower risks of most extrapyramidal adverse effects (APA, 2003; Meltzer & Okayli, 1995; Walker et al., 1997).

Studies found that the risk of suicide in patients with schizophrenia was 57% lower among those treated with clozapine than those treated with haloperidol (Glazer, 1998; Glazer & Dickson, 1998).

In another study, Spivak and colleagues (1998) compared 30 patients with chronic, treatment-resistant schizophrenia who had been maintained on clozapine for at least 1 year with an equal number of patients who had been treated with first-generation antipsychotics for similar lengths of time. They found that clozapine treatment was associated with fewer suicide attempts.

Because of clozapine’s efficacy in reducing suicide risk, the use of first-generation antipsychotics in suicidal patients is specifically reserved for those whose psychosis has not responded to a second-generation antipsychotic, or those for whom economic considerations encourage use of less expensive drugs (APA, 2003).

However, clozapine treatment has also been associated with some potentially serious adverse effects, including seizures, weight gain, hyperlipidemia, type II diabetes, agranulocytosis, cardiomyopathy, myocarditis, ileus, and rare atypical forms of a syndrome similar to neuroleptic malignant syndrome, which can also reduce longevity.

Thus, in clinical practice, the evident advantage of clozapine in reducing the rate of suicide attempts and perhaps the rate of suicide must be weighed against the risks of death from these adverse effects (Glazer, 1998).

Therefore, when deciding whether to institute or continue clozapine treatment in patients with psychosis who are at risk for suicidal behaviors, the clinician will need to weigh the advantages and disadvantages of clozapine therapy for the individual patient (APA, 2003).

Hypnotics

Although the use of hypnotics is not generally recommended, a recent randomized controlled trial compared a hypnotic in combination with an SSRI to placebo and found that the combined medications reduced suicidal ideation in suicidal adults with insomnia.

The authors suggest that prescribing controlled-release zolpidem when starting SSRI antidepressant treatment may be beneficial for suicidal patients with severe insomnia. It is known that severe insomnia is a risk factor for suicide (McCall et al., 2019).

Medication for Addiction Treatment

Twenty-five percent of people who die by suicide are misusing or dependent on alcohol or drugs. Those who use opioids regularly are twice as likely to attempt suicide than those who do not report any opioid use. Those who use opioids regularly are also 75% more likely to make a suicide plan (Ashrafioun et al., 2017; Oquendo, 2017).

Medication for addiction treatment (MAT) for opioid use disorder has been associated with a decreased rate of suicide. Opioid-dependent individuals who used methadone or buprenorphine to treat their addiction exhibited less suicidal behavior and lower rates of crime (Ahmadi et al., 2018; Fazel & Runeson, 2020; Molero et al., 2018; Yovell et al., 2015).

A recent study found an approximately 50% reduction in suicide mortality in those who received medication treatment of opioid use disorder through the VA medical system. The reduction in suicide risk occurred during stable treatment periods. Stopping periods were associated with an increase in suicide risk (Watts et al., 2022).

Of the three medications for addiction treatment under study, buprenorphine was associated with the greatest reduction in suicide risk (65%) and was the only medication associated with reductions after adjusting for demographics, comorbidities, and health care utilization.

Methadone was associated with decreased risk in the unadjusted models only. Naltrexone showed no effect on suicide mortality in this large, retrospective cohort study (Mooney, 2022; Watts et al., 2022).

Watts et al (2022) theorize that the 65% reduction in suicide mortality with buprenorphine may be related to its unique property as a kappa receptor antagonist. Buprenorphine treatment protocols also seem to be better tolerated than other treatment protocols used in the U.S. (Watts et al., 2022).

Studies have shown that buprenorphine has antidepressant, antisuicidal, and analgesic effects, and may be helpful for those with treatment-resistant depression or chronic pain (Mooney, 2022).

Brain Stimulation Techniques

Electroconvulsive Therapy (ECT)

Electroconvulsive Therapy (ECT) is one of the most effective treatments for patients with treatment-resistant depression or severe depression, with or without psychotic features. The treatment is effective for both bipolar and unipolar depression, and ECT can be helpful for psychotic and mood symptoms in some patients with schizophrenia.

ECT helps rapidly resolve catatonia, a life-threatening syndrome that can occur in multiple psychiatric disorders. It can also be used to treat mania in bipolar disorder.

ECT is also used for suicidal patients who require a rapid treatment intervention. ECT can rapidly reduce suicidal ideation (Watson, 2019). Over 60% of patients with major depressive disorder may achieve remission by the third week of treatment with ECT, though the risk of relapse of depression is highest within the following 6 months.

Accordingly, most people treated with ECT require some form of maintenance treatment (e.g., psychotherapy, medication, additional ECT), which is not surprising for lifelong, recurring illnesses. Overall, 70 to 90% of patients benefit from the treatment.

ECT involves applying a brief, controlled electrical stimulation to the brain to induce a generalized seizure, while the patient is under general anesthesia and given a muscle-relaxant to avoid injury. In the U.S., ECT is frequently performed on an outpatient basis. ECT may be used for severe cases when other treatments (including medication and psychotherapy) have failed to yield adequate responses (APA, 2001).

However, as techniques and equipment have advanced, ECT has become safer and more comfortable, and memory side effects can be minimized. Therefore, ECT is no longer considered a treatment of last resort and may be used earlier in a patient’s overall treatment course.

Repeated Transcranial Magnetic Stimulation (rTMS)

Repeated Transcranial Magnetic Stimulation (rTMS) is sometimes used to treat patients with major depressive disorder who do not respond to one or more adequate trials of antidepressants. rTMS uses magnetic stimulation to activate selective brain sites without inducing a generalized seizure.

rTMS may resolve suicidal ideation in some patients with treatment-resistant depression. In one study, bilateral, left-unilateral, and sham rTMS were evaluated for effects on suicidal ideation (Weissman et al., 2018). It resolved in 40.4% of patients exposed to bilateral rTMS, 26.8% with left-unilateral rTMS, and 18.8% with sham rTMS, indicating superiority of bilateral treatment.

Although rTMS does not seem to be as effective as ECT, it does not require anesthesia and has far less adverse effects on memory and cognition, and bilateral rTMS may be a useful alternative for suicidal ideation when ECT is declined, not tolerated, or not readily available.

Stanford Neuromodulation Therapy (SNT)

Researchers at Stanford University School of Medicine are testing a promising new protocol known as Stanford neuromodulation therapy (SNT) for treatment-resistant depression.

Although SNT does not yet have FDA approval, preliminary results have shown an 80%-90% remission rate in patients after 5 days of open label treatment (Cole et al., 2020; Cole et al., 2021). This is significantly better than the efficacy of current treatments, including ECT and rTMS, which require significantly longer treatment courses (Cole et al., 2021).

Before receiving SNT, individuals will undergo a structural MRI and resting-state fMRI. The strategy is to individually excite the nerve cells in the brain underactive in depression (the left dorsolateral prefrontal cortex to the subgenual anterior cingulate cortex) and stimulate them with a magnetic coil.

SNT relies upon a form of rTMS known as intermittent theta-burst stimulation (iTBS), which is a more efficient form of rTMS. Ten sessions of iTBS are delivered daily, for a total of 18,000 pulses per day, over 5 consecutive days (Cole et al., 2021). This iTBS has 5 times the power of conventional rTMS (Williams, 2021).

A recent double-blind randomized controlled trial found that SNT was more effective than sham stimulation for treatment-resistant depression; 78.6% of the SNT treatment group achieved remission compared to 13.3% of the sham treatment group.

Moreover, there was a 52.5% mean reduction in scores on the Montgomery-Asberg Depression Rating Scale 4 weeks after treatment in the group who received the 5 days of SNT, whereas those in the sham treatment group had an 11.1% mean reduction in score. In fact, the trial was halted at midpoint because of the large antidepressant effect size for SNT compared to sham treatment (Cole et al., 2021).

Although the sample size in this RCT was small (n=29) and SNT is still an experimental treatment which has not yet been approved as a therapeutic tool, the high rate of efficacy and short treatment course makes SNT a potentially appealing choice for suicidal patients who are in crisis and for whom a rapid-acting treatment is very much needed.

Larger trials of SNT, funded by NIH, are currently underway. Preliminary findings from one of these trials shows a significant reduction in suicidal ideation after the first day of SNT treatment (Williams, 2021).

Dr. Nolan Williams, director of Stanford’s Brain Stimulation Lab, hopes that hospitals may be able to eventually use SNT “as a fast-acting antidepressant to stabilize suicidal patients who may, after weeks of intensive treatments, leave the hospital feeling safe” (Cohen, 2021).

The expectation is that SNT treatment given in the emergency or inpatient setting would be followed with less intensive maintenance treatment (e.g., medication, psychotherapy, brain stimulation) (Cole et al., 2021).

Magnetic Seizure Therapy (MST)

In this relatively new intervention for patients with treatment-resistant depression, a therapeutic seizure is induced by magnetic stimulation of the brain at higher frequencies than are used in rTMS. Patients given MST are anesthetized and given a muscle-relaxant to avoid injury similar to the protocol for ECT.

MST can reduce suicidal ideation in some patients with treatment-resistant depression: In one study 44.4% of patients treated with MST experienced resolution of suicidal ideation (Sun et al., 2018).

Psychotherapy

In addition to pharmacotherapies and brain stimulation techniques, psychotherapies play a central role in the management of suicidal behavior in clinical practice. Psychotherapy is often used to treat patients who have suicidal thoughts or who have made suicide attempts.

Evidence-based treatments include cognitive behavior therapy (CBT), cognitive therapy for suicide prevention (CT-SP), brief cognitive-behavioral therapy (BCBT), dialectical behavioral therapy (DBT), collaborative assessment and management of suicidality (CAMS) and mindfulness-based cognitive therapy (MBCT).

Although there is limited research, clinical consensus suggests that psychodynamic and interpersonal psychotherapy can be of significant benefit, even if there are fewer studies. Psychotherapy can be used by itself, but typically is used in conjunction with medication treatment.

Cognitive Behavior Therapy (CBT)

CBT is a psychological treatment that addresses faulty or unhelpful thoughts and behaviors. The goal is to build skills to better cope with distress. A number of cognitive-behavioral treatment protocols have been evaluated using randomized controlled trials (for systematic reviews, see Tarrier et al., 2008 and D’Anci et al., 2019).

There is substantial evidence that CBT can reduce suicidal ideation, attempts, and hopelessness (D’Anci et al., 2019), with some gains made in therapy being sustained over time (Wenzel & Jager-Hyman, 2015). CBT appears to be especially effective in reducing suicidal behavior when the treatment specifically targets suicidal thoughts and behaviors (as opposed to thoughts and behaviors related to depression or mental illness in general).

Cognitive Therapy for Suicide Prevention (CT-SP)

CT-SP is suicide-specific cognitive behavioral therapy. It is based on the premise that suicidal behavior is the “primary problem” rather than a symptom of a psychiatric disorder and, therefore, suicide-related thoughts and behaviors should be targeted directly in therapy (Wenzel & Jager-Hyman, 2012). The goal of CT-SP is the “elimination of suicidal behavior” (Jobes et al., 2015, p. 365).

More specifically, CT-SP is centered on the idea that if you can teach individuals how to more effectively manage proximal stressors, these stressors, while potentially still extant, will no longer trigger suicidal behavior (Jobes et al., 2015). Like other CBT treatments, CT-SP is structured and time-limited. Completing all three phases will typically take ten (50 minute) sessions to complete.

CT-SP has “strong empirical validation” (Brown et al., 2005; Wenzel et al., 2009, Jobes et al., 2015, p. 365). For example, Brown and colleagues (2005) conducted a randomized controlled trial of CT-SP versus treatment as usual. The sample consisted of 120 adults who had attempted suicide and were evaluated at a hospital emergency department within 48 hours of the attempt.

The study found an approximately 50% reduction in subsequent suicide attempts over an 18-month period with CT-SP. In other words, those who had received CT-SP were 50% less likely to make a repeat suicide attempt during the 18-month follow-up period than those who received usual treatment (Brown et al., 2005, Jobes et al., 2015).

Brief Cognitive-Behavioral Therapy (BCBT)

BCBT is a brief, time-limited, cognitive behavioral outpatient treatment. Similar to other suicide-specific cognitive therapies, BCBT is based on the belief that “effective treatment of risk for suicidal behavior does not require complete remission of a psychiatric diagnosis or symptom severity, but rather the development of core skills in the areas of emotion regulation, interpersonal functioning, and cognitive restructuring.” (Rudd et al., 2015, p. 447).

Brief CBT consists of 12 outpatient sessions with the first lasting 90 minutes and subsequent sessions lasting 60 minutes.

There is evidence of BCBT’s effectiveness for a primarily male military sample. 152 active-duty soldiers who were experiencing suicidal ideation with intent or who had made a suicide attempt within the past month were randomly assigned to either receive BCBT along with treatment as usual or just treatment as usual.

The findings were impressive. Soldiers who had received brief CBT along with treatment as usual were approximately 60% less likely than those who had only received treatment as usual to make a suicide attempt during the two-year follow-up period (Rudd et al., 2015).

Dialectical Behavior Therapy (DBT)

DBT combines methods of CBT with skills-training and mindfulness meditation techniques to improve emotion regulation, interpersonal relationships, and ability to tolerate distress.

DBT was originally developed as a treatment for suicidal behavior in women with borderline personality disorder (Linehan & Kehrer, 1993), but has since shown effectiveness for other disorders, including mood disorders, eating disorders, substance misuse, and PTSD.

A recent meta-analysis of 18 controlled studies found DBT to be effective for treatment of suicidal behavior, though there was no significant pooled effect for suicidal ideation in this meta-analysis. This may reflect the fact that DBT prioritizes behavior over thoughts (DeCou et al., 2019).

Several recent studies have found DBT to be an effective treatment for reducing repeat suicide attempts in highly suicidal patients, including adolescents (McCauley et al., 2018; Asarnow et al., 2021). A cornerstone of DBT is the idea that the patient must build a life worth living, even when the patient has many problems and wishes to die. View some online DBT skills training courses.

Mindfulness-Based Cognitive Therapy (MBCT)

This form of psychotherapy integrates mindfulness meditation practices and cognitive therapy techniques. A growing body of evidence indicates that training in mindfulness can help break the link between depressive symptoms and suicidal thinking.

For example, in a randomized controlled trial conducted by Barnhofer and colleagues, previously suicidal patients were assigned to four different conditions, including a mindfulness-based cognitive therapy (MBCT) condition.

Results showed a weaker correlation between symptom levels and suicidal cognitions in the group who had received MBCT than in the groups who had not received training in mindfulness. The MCBT group also showed a reduction in suicidal cognitions.

Such findings suggest that MBCT may help protect against depressive relapses that are common in those with a history of suicidal ideation and behavior (Barnhofer et al., 2015).

Collaborative Assessment and Management of Suicidality (CAMS)

The Collaborative Assessment and Management of Suicidality (CAMS) is a therapeutic framework that specifically targets the reduction of suicide risk. CAMS focuses on identifying risk factors and patient articulated “drivers” of suicidal ideation and intent (i.e., specific thoughts, feelings, and behaviors that are leading or contributing to the patient’s suicidal ideation).

A main tool within CAMS is the Suicide Status Form (SSF), which contains open-ended questions about psychological pain, stress, hopelessness, reasons for living, and other such variables along with quantitative ratings. CAMS relies on a collaborative partnership between the clinician and the patient, who decide together how to manage and treat the patient’s suicidality.

Clinicians work to understand the struggle of the suicidal patient with empathy and without judgment. The SSF functions as a clinical roadmap, guiding and documenting suicide assessment, treatment planning, stabilization planning, the on-going tracking of risk, and accounting for all clinical outcomes.

CAMS is an evidence-based approach with five published randomized controlled trials showing that CAMS reliably reduces suicidal ideation, symptom distress, depression, hopelessness, and emergency department visits for suicidal behavior in a variety of populations (e.g., Comtois et al., 2011; Huh et al., 2018; Jobes et al., 2018; Pistorello et al., 2020; Ryberg et al., 2016).

In addition, there is growing evidence that it can treat self-harm and suicide attempts (e.g., Andreasson et al., 2016). Evidence for the effectiveness of this approach can be found can be found here. Learn about how to become trained in this technique. A new meta-analysis of 9 CAMS trials reports that CAMS is a “well-supported” intervention for suicidal ideation as per Center for Disease Control and Prevention criteria (Swift et al., 2021).

Interpersonal Psychotherapy (ITP)

Interpersonal Psychotherapy (IPT) is an evidence-based approach for treating mood disorders.

While ITP was originally developed to treat major depressive disorder in adults, there is now evidence of its effectiveness for treating other disorders (e.g., eating disorders, perinatal depression, substance use disorders, dysthymia, bipolar disorder) and other populations (e.g., adolescents, older adults), and a growing body of evidence that it may be able to reduce suicidal ideation in particular (Bentum et al., 2021; Diamond et al., 2010; Wiffley & Shore, 2015).

The main goal of IPT is to improve the quality of interpersonal relationships and social functioning to help reduce distress (Wiffley & Shore, 2015).

Attachment-Based Family Therapy (ABFT)

ABFT is a 16-week treatment program for youth aged 12-24 who have experienced suicidal thoughts or attempts, depression, or trauma. ABFT is based on the interpersonal theory of depression, which posits that the quality of family relationships can impact suicidal ideation and depression.

The goal of ABFT is to repair parent-adolescent bonds and improve family communication, so that parents can become a resource to the adolescent coping with stress. ABFT is the first manualized family therapy specifically designed to target family processes associated with depression and suicide (Diamond et al., 2010).

ABFT has been designated as a “Program With Evidence of Effectiveness” for reducing suicidal thoughts and behaviors as well as for depression and depressive symptoms (SPRC, n.d.). Diamond et al. (2010) conducted a randomized controlled trial of ABFT in the city of Philadelphia.

For the study, adolescents were randomized to either receive ABFT or to receive enhanced usual care (EUC). Adolescents in the EUC condition were referred to private practice or community mental health centers, where they received individual therapy, group therapy, family therapy, and/or case management. Results showed ABFT to be more effective than EUC for reducing suicidal ideation and depressive symptoms in this sample of adolescents.

Those in the ABFT group were more likely than those in the control group to self-report suicidal ideation in the normative range. They were also more likely to report having had no suicidal ideation in the past week, compared with the control group (SPRC, n.d.).

Interpersonal Psychotherapy (ITP) for Suicidal Patients

The Interpersonal Theory of Suicide, proposed by Thomas Joiner in the 2007 book, “Why People Die by Suicide,” posits that for a suicide to occur, there needs to be not only a desire to die by suicide, but also an “acquired capability” (Joiner, 2007; Van Orden et al., 2010).

The desire to die by suicide is driven by two psychological states: perceived burdensomeness and low sense of belongingness (social alienation/isolation). The “acquired capability” is the result of repeated exposure to painful or fear-inducing events which, in turn, leads to “habituation,” which, in turn leads, to increased pain tolerance and lessened fear of death.

The interpersonal theory of suicide has a growing body of evidence to support it (e.g., Joiner et al., 2002; Van Orden et al., 2006; Conner et al., 2007).

A clinical manual that applies the Interpersonal Theory of Suicide to clinical work with suicidal patients has been developed (Joiner et al., 2009). ITP clinicians are particularly attuned to whether their clients are socially isolated or feel like a burden, and whether they have the acquired capability to die by suicide (e.g., fearlessness of death; previous suicide attempts; access to lethal means), as these three factors together are thought to significantly heighten suicide risk.

The clinical framework assumes that suicide risk will be reduced in therapy by reducing thwarted belongingness and perceived burdensomeness, and by addressing the presence of acquired capability (e.g., safety planning) (Van Orden et al., 2012; Van Orden et al., 2010).

There are case studies suggesting that targeting constructs of thwarted belongingness and perceived burdensomeness with ITP may help suicidal patients resolve suicide ideation and avert suicidal crises (e.g., Van Orden et al., 2012).

Because of fearlessness of death, these patients can be in a higher risk category and, thus, the focus of treatment is also on means restriction.

Psychodynamic Psychotherapy

Psychodynamic psychotherapy helps patients to improve self-esteem and interpersonal relationships by understanding and working through the way in which past experiences have shaped current feelings and behavior.

There is increasing evidence that psychodynamic therapies are effective for a wide range of mental health conditions (Leichsenring & Klein, 2014), and that they can help to reduce suicidal behavior (Briggs et al., 2019). Psychodynamic psychotherapists often integrate techniques from CBT and DBT in an empathic frame that is flexible in addressing the patient’s problems (Schechter et al., 2019).

There are promising studies of several specific psychodynamically based psychotherapies for recurrent suicidality that have demonstrated efficacy in decreasing suicidal behavior: mentalization-based treatment (MBT;Bales et al., 2012; Bateman & Fonagy, 1999; 2001; 2008; 2009; Bateman et al., 2016; 2021; Vogt & Norman, 2019), good psychiatric management (GPM; Links et al., 2015), transference-focused psychotherapy (TFP; Doering et al., 2010), and schema focused psychotherapy (SFP; Giesen-Bloo et al., 2006).

Informed Consent

Informed consent is a conversation between the clinician and the patient about the risks and benefits of a particular treatment. Frequently, informed consent requires the patient to sign a written document verifying their consent.

Clinicians and/or designees provide information that a patient needs to know to make a well-informed decision about engaging in the treatment, such as taking psychiatric medication or undergoing ECT (Darby & Weinstock, 2018). Clinicians may need to assess the patient’s competency to understand what is being presented to them (Appelbaum, 2007).

Moreover, even if a patient is admitted to a hospital against their will, they still retain the right to consent to treatment. For example, medications can only be administered involuntarily when the patient is acutely unstable and a danger to themself or others.

Confidentiality and Duty to Warn

Clinicians have a duty to maintain confidentiality of information disclosed to them by patients. This standard goes back to the Roman Hippocratic Oath and has been codified in state and federal laws in the U.S. Clinicians can be held liable if they breach patient confidentiality (NCSL, 2018).

However, there are certain situations in which clinicians, based on their clinical judgment, can respond to confidential information that the patient communicates to them. While confidentiality is the norm, clinicians can breach confidentiality if the patient is at risk of harming themselves or others. Psychiatrists and other mental health professionals often tell new patients upfront about situations in which they may breach patient confidentiality (Darby & Weinstock, 2018).

The duty to respond when a patient indicates they may be a danger to others is known as the “duty to warn” or the “duty to protect” (NCSL, 2018). There also must be an identified victim and intent (Monahan, 2006). Additional situations in which clinicians must respond include intent to commit a crime or communication of child or elder abuse (Mass. Gen. Laws ch. 123 § 12).

While this law is meant to protect potential victims, some have voiced concern that the “duty to warn” will preclude certain patients from seeking help or from disclosing their suicidal or homicidal intent (NCSL, 2018).

The “duty to warn” varies from state to state. In Massachusetts, for example, there has been a “duty to warn” statute since 1989. Massachusetts General Laws Chapter 123, the Massachusetts mental health statute, includes laws regarding the “duty to warn.”

The statute also includes laws regarding hospitalization and emergency restraint for persons with mental illness who are at risk of harming themselves or others. These laws allow for a 3-day holding period. Find more information about the mental health statute in Massachusetts.

Safety Planning

A suicide safety plan is an individualized written list of coping strategies and resources that can help a person know what to do when they are experiencing an acute suicidal crisis (Stanley & Brown, 2012). This collaborative plan between the clinician and the patient (and family when indicated) is a living document that can be modified over time as circumstances change. The safety plan typically covers the following areas:

1. Recognizing warning signs of suicide risk in oneself (e.g., thoughts, images, mood, situation, behavior)
2. Employing internal coping strategies without needing to contact another person (e.g., relaxation technique, physical activity)
3. Socializing with others who may offer support as well as distraction from the crisis
4. Contacting family members or friends who may help resolve a crisis
5. Contacting mental health professionals or agencies
6. Reducing the potential for use of lethal means

The Safety Planning Intervention was developed by Dr. Barbara Stanley, Professor of Medical Psychiatry at Columbia University Medical Center, and Dr. Gregory Brown, Director of the Center for Prevention of Suicide at the University of Pennsylvania.

The concept behind the Safety Planning Intervention is that it is important to have advanced knowledge of what to do in an emergency because the person who is in crisis and at acute risk of suicide may be in an impaired state and may have more difficulty generating solutions. There can be a higher risk of death if one does not know what to do in the event of an emergency.

At the 2020 National Stop A Suicide Today Town Hall, Dr. Barbara Stanley spoke about the utility of the Safety Planning Intervention as one component of suicide prevention.

She discussed how safety planning is based on evidence-based coping strategies (e.g., social support, reasons for living) to reduce suicide risk, and relies heavily on “distraction.” Suicidal crises are transient, lasting for a few minutes to hours, and survival will often depend on getting through this very challenging period of acute risk.

The Safety Planning Intervention helps a person identify ways to distract themselves, in order to buy time between suicidal urges and lethal actions. Distracting from suicidal thoughts and reducing access to lethal means buys time and mitigates risk. View Dr. Stanley’s 20 minute talk and advance the recording to 1:06 hrs:min.

There is empirical support for this approach. A recent meta-analysis found that safety-planning type interventions decreased the risk of suicidal behavior by 43% (Nuij et al., 2021).

Stanley and colleagues (2021) used ecological momentary assessment (EMA) to study the effectiveness of 7 common coping strategies in reducing suicidal ideation. They found that strategies that were distraction-oriented (e.g., keeping busy, socializing) were more likely to lower the intensity of suicidal thoughts in the short-term than strategies that were more mindfulness-based (e.g., calming self, sitting with feeling until they passed).^[8]

The Safety Planning Intervention is a collaboration between the clinician, the patient, and the patient’s family (if the patient wishes their family to be involved). Clinicians can be trained to implement the Safety Planning Intervention.

Find information on how to become trained on the Safety Planning Intervention. To utilize the Safety Planning Intervention for one’s records, permission is also necessary. Permission can be obtained from Barbara Stanley, PhD by contacting her via email or through her website.

However, there is evidence that safety plans work. A recent study found that safety planning with telephone follow-up reduced suicidal behaviors over a 6-month period by 45% (Stanley et al., 2018). There is also accumulating evidence that the safety planning intervention can increase the likelihood that a suicidal patient will engage in follow up outpatient treatment.

Some clinicians and hospitals have been using mobile safety planning apps in addition to, or in lieu of, written safety plans. Many of these apps are free of charge and publicly available, such as the Safety Plan, which was developed by the New York State Office of Mental Health with permission from Stanley and Brown. Preliminary data evaluating the effectiveness of safety planning smartphone apps is encouraging (e.g., Melvin et al., 2019).

Safety plans are different from no-suicide contracts, which were frequently used in the past, but had limited usefulness and depended on a strong therapeutic alliance (Miller et al., 1998).

Problems With No-Suicide Contracts

• No studies demonstrating ability to reduce suicide
• Not a legal document, whether signed or not
• Gives false sense of security

Brief Suicide Interventions and Continuity of Care

Suicide interventions can be targeted towards periods when patients are at very high risk of suicide in the short term, such as following discharge from an emergency department or psychiatric hospital (Olfson et al., 2014).

Suicidal patients can have difficulty with treatment compliance after discharge from acute care settings. Indeed, only around one-third of patients who have an outpatient appointment scheduled within one week of discharge follow through with that appointment (Melhem & Brent, 2020). Brief interventions aim to increase linkage to care during these critical transition periods (Olfson et al., 2014).

Research syntheses show that brief interventions can actually reduce suicide attempts and increase linkage to care (Doupnik et al., 2020; Jobes, 2020; McCabe et al., 2018;Melhem & Brent, 2020).

Brief interventions include not only the Safety Planning Intervention (SPI) discussed in the section “Safety Planning” above, but also follow-up phone calls, post cards, or letters to remind the patient to follow up with outpatient care (Jobes, 2020; Jobes & Chalker, 2019; Luxton et al., 2013).

While more research is needed to determine what makes certain “caring contacts” more effective than others, it appears that the frequency of the contact as well as the degree of personalization are important factors (Motto, 1976; Motto & Bostrom, 2001; Luxton et al., 2013).

Another type of brief intervention is care coordination. Care coordination can involve scheduling an appointment or a mobile crisis response team evaluation, or delivering a warm handoff to another mental health clinician.

The primary goal of most of these interventions is to promote connectedness between the suicidal patient and another mental health clinician, or between the patient and their community or family (Doupnik et al., 2020).

One suicide-specific brief intervention that has received empirical support from a randomized controlled trial is the Attempted Suicide Short Intervention Program (ASSIP). The study found that those who had received the ASSIP intervention in addition to treatment as usual were 80% less likely than those who received only treatment as usual to make at least one repeat suicide attempt during the two-year follow-up period (Gysin-Maillart et al., 2016).

The ASSIP intervention is cost-effective (Park et al., 2018); it is completed in just 3 sessions, each lasting 60 to 90 minutes. Components important to the therapy include the development of an early therapeutic alliance, safety planning, psychoeducation, as well as continued long-term outreach via personalized letters (Gysin-Maillart et al., 2016; Jobes et al., 2015).

Another brief intervention for suicidal behavior that has been studied with a randomized controlled trial is the Crisis Response Plan (CRP).

The CRP was originally developed to be used as part of brief cognitive behavioral therapy (BCBT), but has since been tested as a stand-alone intervention for use in emergency departments and other behavioral health settings. The CRP is typically handwritten on a note card and completed in one session.

CRP specifies self-management strategies, reasons for living, and available sources of social and professional support. A randomized control trial testing the efficacy of the CRP was done in active duty soldiers.

The RCT found that those soldiers who received the CRP intervention were 76% less likely to attempt suicide during the following 6 months than soldiers who received standard treatment (Bryan et al., 2017b). Moreover, the CRP seemed to be most effective when the clinician was perceived as “especially understanding and empathetic” (Bryan et al., 2019). Learn more about the CRP.

Lethal Means Restriction and Counseling

In 2019, half (50.4%) of all suicide deaths in the United States were due to injuries related to firearm use. Males are more likely to die by suicide by firearm (55.6%) than females (31.4%). Females seem to be about equally likely to die from suicide by firearm (31.4%), poisoning (30%), or suffocation (29%) (Stone et al., 2021).

In recent years, there have been some changes in the means used for suicides. For example, between 1999 and 2019, the rate for suicide by suffocation tripled for females (from 0.6 to 1.8 deaths per 100,000) and doubled for males (from 3.3 to 6.6 deaths per 100,000). Suffocation is defined by the CDC as hanging, asphyxiation, strangulation, and other such methods.

In addition, poisoning is no longer the leading means of suicide for females. Since 2016, the number of suicides by poisoning have declined, while the number of suicides by firearms and by suffocation have increased (Hedegaard et al., 2021).

The proportion of suicide attempts that result in death is known as the case fatality ratio. With suicide deaths, the case fatality ratio varies significantly by method. For example, nearly all suicide attempts by firearm (85-90%) will result in death, whereas only 1-2% of suicide attempts with medication or sharp instruments result in death.

Firearms and jumping have high case fatality ratios; they do not offer the same opportunity for rescue or a change of mind as other methods, like medication overdoses or carbon monoxide poisoning (Barber & Miller, 2014).

The particular method an individual chooses for their suicide attempt depends to a large extent on its accessibility/availability. As Barber & Miller (2014) point out, “A gun in the closet poses a greater risk than a very high bridge 5 miles away, even if both measures have equal lethality if used” (p. S265).

A study of 30 survivors of suicide attempts by firearm found that the most common response given to why they used a firearm was, “Availability.” (Harvard T.H. Chan School of Public Health, n.d.; Peterson et al., 1985).

Multiple studies have found that restricting access to guns reduces the number of suicides, without an increase in suicide by alternative means (Kaufman et al., 2018). While some individuals will substitute other methods, virtually all other methods are less lethal than firearms (Harvard T.H. Chan School of Public Health, n.d.).

Moreover, suicide is often impulsive: A significant proportion of suicides (24-53%) are contemplated for as little as 5 minutes. Actual suicides may be averted if the firearms are kept unloaded and/or locked because this increases the time to access the firearm (Shenassa et al., 2004). Parents are often more amenable to locking up their weapons than disposing of them (Kreusi et al., 1999; Barber & Miller, 2014).

However, in some cases, it may be necessary to consider having the firearm removed from the home, even if only on a temporary basis. Extreme risk protective orders (ERPOs), also known as “red flag laws,” are laws that allow immediate family members or law enforcement to petition a court to allow for removal of a gun when a person is in acute crisis and a potential danger to themselves or others.

Currently, nineteen states, including the District of Columbia, have laws permitting extreme risk protective orders (Frattaroli & Horwitz, 2020).

The American Psychiatric Association’s (2003) practice guidelines state that, “Whether or not a plan is present, if a patient has acknowledged suicidal ideation, there should be a specific inquiry about the presence or absence of a firearm in the home or workplace” (p. 23).

When indicated, clinicians may be in a position to apprise family members of red flag laws. Clinicians should be aware that, “If there is one gun, there are usually more than one.” (Harvard T.H. Chan School of Public Health, n.d.)

Unfortunately, suicidal individuals may have access to other lethal means at home or work, which makes suicide-proofing challenging and realistically impossible. For example, suffocation (hanging) is now the second leading cause of suicide deaths in the United States and its use has increased in recent years, but this method is not very amenable to means restriction, except perhaps in controlled settings such as prisons or hospitals (Barber & Miller, 2014).

Moreover, while restricting access to firearms may in certain circumstances avert a suicide, it does not always work for a given individual, particularly if there is ongoing suicide risk (Harvard T.H. Chan School of Public Health, n.d.).

Still reducing access to suicide methods with high case fatality rates has the potential to mitigate risk. A recent study found that opioids are the most commonly identified substance in fatal suicide poisonings (Miller et al., 2020). Suicide completion is over five times more common in suicide acts involving opioids than in suicide acts not involving opioids.

Opioid fatalities have increased exponentially in recent years due to the increasing risk of death associated with fentanyl and other synthetic opioids. The study found that 75% to 87% of these deaths would not have occurred if the decedent lacked access to opioids….” (Miller et al., 2020, p. 9).

Other substances with high relative risks for suicide completion are barbiturates, antidepressants, antidiabetics, and alcohol. The authors suggest that lethal means restrictions in certain circumstances extend to these drugs with high case fatality rates (Miller et al., 2020).

Moreover, there is evidence that youth younger than 21 years use different drugs than adults for suicidal acts (Miller et al., 2020). Youth are more likely to use nonopioid pain relievers (e.g., acetaminophen, aspirin, or ibuprofen), antidepressants, and allergy medications that are readily available, whereas adults are more likely to use opioids, benzodiazepines, alcohol, cocaine, and drugs to treat chronic conditions (e.g., epilepsy, Parkinson’s disease) (Miller et al., 2020).

Awareness of these findings can be useful for clinicians when treating families whose children are at risk, and can be incorporated into treatment planning and lethal means restrictions, when indicated (Brent et al., 2000; Harvard T.H. Chan School of Public Health, n.d.; Kruesi et al., 1999; McManus et al., 1997; Barber & Miller, 2014).

Counseling on access to lethal means (CALM) is a free online training for clinicians. The goal of the training is to teach clinicians how to identify those who could benefit from lethal means counseling and to provide strategies for working with patients and families to reduce access to lethal means (Everytown Research & Policy, 2021). Strategies that work for one group may not be effective or appropriate for another group (Jin et al., 2016). Access this course here.

System Change

Zero Suicide is a system-wide, transformational model for how health care systems can identify and care for individuals at risk for suicide.

The Zero Suicide framework is based on the belief that suicides can be significantly reduced for those engaged with health care by using a bundled set of evidence-based practices reliably and with training about how to incorporate these practices.

Health care programs who have implemented Zero Suicide are a version of High Reliability Organizations (HROs) where organizations deliver quality care, routinely examine outcomes, and remain committed to fidelity. The framework emphasizes the need to keep both patients and clinical staff safe, prepared, and supported.

The website contains a toolkit and other resources that may be helpful to clinicians and health care system leaders.

SafeSide Prevention offers educational, governmental, behavioral health, and other health care organizations assistance with implementing a “Zero Suicide” approach. Learn more about their video-based trainings.

Postvention

The term “postvention” was coined in 1972 by Edwin Shneidman, the founder of the nation’s first comprehensive suicide prevention center (Shneidman, 1973).

The term refers to interventions that are conducted after a suicide death to support those who have been affected, including family, friends, coworkers, classmates, and community at large. Those grieving a suicide often receive less community support for their loss than those grieving deaths by other means, which can lead to isolation (Pitman et al., 2014).

One of the main purposes of postvention is to offer comfort and support to the bereaved, and potentially reduce the aftereffects of a suicide. In a later section, we discuss the importance of postvention for clinicians who experience a patient suicide.

One in every 5 people report exposure to a suicide during their lifetime (Andriessen et al., 2017). Those who have been exposed to a suicide are at an increased risk of suicide.

For example, those who experience the suicide death of a first-degree relative are 3 times more likely to die by suicide themselves. Those whose spouses died by suicide have between 3 and 16 times increased suicidal risk (Agerbo, 2005). Men who have been exposed to suicide in the workplace are 3.5 times more likely to die by suicide than those not exposed (Hedstrom, Liu, & Nordvik, 2008).

One study found that 4.5-7.5 immediate family members and 15-20 extended family, friends, and colleagues were “intimately and directed affected” by a suicide (Berman, 2011). The information below indicates that friends, family, and others who were emotionally close to the deceased are likely to require support and postvention services (Berkowitz et al., 2011).

One study found an increased incidence of depression, anxiety, and post-traumatic stress disorder (PTSD) in adolescents exposed to the suicide of a peer (Brent et al., 1996). Another study found that, without early intervention, a significant proportion of prepubertal children who had lost a sibling or a relative to suicide were likely to go on to develop major depression or PTSD (Pfeffer et al., 1997).

Those Most Likely to Need Support Following a Suicide

• Those emotionally close to the deceased (e.g., friends and family members)
• People who were already depressed and possibly suicidal before the death
• Those who might psychologically identify with the deceased (e.g., similar in lifestyle, values, or life circumstances)
• Family members and peers who were aware or suspicious of suicidal planning by the deceased
• Members of the community who might have felt responsible for the wellbeing of the deceased (e.g., teachers, coaches, school counselors)
• Supervisors and colleagues in the deceased’s workplace

(Berkowitz et al., 2011)

Research shows that those who knew about the deceased’s suicide plans are at greater risk of PTSD and depression, and that those who had witnessed the suicide or viewed the scene afterward are at greater risk of PTSD and anxiety (Brent et al., 1996). Adverse mental health outcomes following a suicide are also more common among those who have a psychiatric disorder or a family history of psychiatric disorder, particularly a mood disorder (Andriessen et al., 2019; Pitman et al., 2016).

Negative Impacts of Suicide Exposure on Mental Health

• Life partners have an increased risk of suicide
• Co-workers have increased risk of suicide
• Parents have an increased risk of psychiatric admission
• Mothers have an increased risk of suicide after an adult child’s suicide
• Children have an increased risk of depression after suicide of a parent
• Peers have increased risk of depression, anxiety, and PTSD
• Those who knew about an individual’s suicide plans have increased risk of PTSD and depression
• Those who witnessed a suicide have greater risk of PTSD and anxiety
• Relatives report more rejection and shame

(Agerbo, 2005; Brent et al., 1996; Hedstrom et al., 2008; Pfeffer et al., 1997; Pitman et al., 2014)

The goals of postvention are to assist with the grieving process, stabilize the environment, reduce the risk of contagion or suicide clusters, and identify and treat mental health problems among survivors. Clinicians providing postvention typically emphasize that suicide is multifactorial, not the result of a single factor or event.

They also emphasize that there are alternatives to suicide when one is feeling depressed and hopeless, that suicide is a permanent solution to a temporary problem, and that there are resources available in the community for getting help. Clinicians also use the forum to provide psychoeducation on grieving, depression, PTSD, suicide, and means reduction (Berkowitz et al., 2011).

Andriessen and colleagues (2019) examined the effectiveness of interventions for people who had been bereaved through suicide. The most promising interventions were those led by a trained facilitator, that included supportive, therapeutic, and educational approaches, and that met regularly for an appropriate period of time.