TREATMENT MODALITIES FOR PATIENTS AT RISK FOR SUICIDE

Patients with suicidal thoughts warrant some form of emotional support or psychotherapy with a focus on learning more adaptive ways of coping in the future. They may also warrant medications for treatment of specific mental disorders such as major depression. Following assessment, each practitioner in each setting determines which treatment modality would be of most benefit for that particular patient.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a “solutions-oriented” type of talk therapy that can be provided for both adults and adolescents. It is based on these core principles:

  • Psychological issues are partly based on:
    • Problematic or unhelpful patterns of thinking
    • Learned patterns of unhelpful behavior
    • Problematic core beliefs, including central ideas about the self and the world
  • People experiencing psychological issues can learn better ways of coping with them.

CBT aims to help the patient identify harmful thoughts, assess whether they are an accurate depiction of reality, and if they are not, to employ strategies that challenge and overcome them.

Internet-delivered cognitive behavior therapy between a patient and therapist has also been shown to significantly decrease suicidal ideation among patients with severe depression (Cleveland Clinic, 2023a; CDC, 2022f).

Dialectical Behavior Therapy

Dialectic behavior therapy (DBT) is a type of cognitive-behavioral therapy that focuses on current situations and solutions. It is used for individuals with severe and persistent suicidality and who experience emotions very intensely. DBT is a 6-month to year-long therapy that involves a greater commitment on the part of both therapist and patient. It consists of four types of sessions:

  • DBT pre-assessment to ascertain if DBT is a good fit for the patient
  • Individual therapy to lessen suicidal and self-harming behaviors, to restrict actions that interfere with effective therapy, to remove obstacles to success, and to assist in replacing harmful behaviors with new skills
  • Skills training in groups
  • Telephone crisis coaching
    (Cleveland Clinic, 2023b; VYAS, 2022)

Problem-Solving Therapy

Problem-solving therapy (PST) is a brief form of treatment that teaches and empowers patients to solve the here-and-now problems contributing to suicidal ideation, self-directed violence, and hopelessness. Interventions include psychoeducation, interactive problem-solving exercises, and motivational homework assignments (VA, 2022c).

Collaborative Assessment and Management of Suicidality (CAMS)

CAMS is a therapeutic framework that emphasizes a collaborative assessment and treatment planning process between the patient and the clinician. Central to the CAMS approach is the use of the Suicide Status Form (SSF), which is a multipurpose clinical assessment and treatment planning, tracking, and outcome tool. CAMS and SSF can be used in a single session context or for ongoing care. When used in ongoing care, it assists the clinicians in organizing the sessions to target and treat suicide “drivers” and resolve suicidality (CSPAR, 2021).

Milieu Therapy

Milieu therapy is a type of psychotherapy that has been used in psychiatric hospitals, psychiatric wards in general hospitals, and group living situations for many years. Milieu therapy provides a healing culture rich in therapeutic interpersonal relationships and provides for optimum safety and comfort. It is a structured environment designed for teaching psychosocial skills and limiting maladaptive behavior (Belsiyal & Rentala, 2022).

Group Therapy

Group therapy offers numerous advantages as a suicide prevention strategy. Groups diminish social isolation and increase social support with those experiencing similar problems. Social relationships are critically important suicide risk and protective factors. Suicide group interventions can directly target social relationships by fostering a sense of community and belonging among group members (Sullivan et al., 2021).

Creative Arts Therapy

Creative arts therapies can support mental health. These therapies facilitate dialogue, reduce stigma, and enhance expression, coping skills, empathy, and personal and cultural resonance, all of which address risk factors for suicide. They can also address the motivational phase, facilitating expression of emotions such as entrapment, loneliness, and burdensomeness, thereby cultivating belonging and protecting against suicidal ideation (Sonk, 2021).

Medications

Some medications have been shown to be effective related to suicide prevention. These include:

  • Clozapine (Clozaril): The only medication to date with FDA approval for suicide risk reduction; has significant side effects that require close lab monitoring
  • Ketamine: Leads to rapid reduction of depressive symptoms and suicidal ideation in as little as one day, which is especially critical for people at high risk for self-harm; given by infusion under careful medical supervision or as a nasal spray (eskatamine/Spravato) along with an oral antidepressant
  • Antidepressants:
    • SSRIs:
      • Citalopram (Celexa)
      • Escitalopram (Lexapro) (approved for adolescents 12 years of age and older)
      • Paroxetine (Paxil)
      • Fluoxetine (Prozac) (currently approved for patients over the age of 8 years)
      • Sertraline (Zoloft)
    • SNRIs:
      • Venlafaxine (Effexor)
      • Disvenlafaxine (Pristiq, Khedezla)
      • Duloxetine (Cymbalta)

The FDA requires labeling on all antidepressants to include strong warnings about risks of suicidal thinking and behavior in children, adolescents, and young adults (Anderson, 2023; Black, 2023; DeGiorgi, 2022).