Treatment and Management of Suicide Risk: Available Treatments Treatment Plan Safety Plan No-Suicide Contracts Engaging Third Parties Psychotherapy Core therapeutic components Pharmacotherapy Electroconvulsive Therapy

Treatment Plan General Treatment Guidelines (given that hospitalization is not required) Ensuring 24-hour coverage availability including holidays and vacations Increasing frequency of sessions Extending session times as necessary Collaborating with family member and significant others to be involved in treatment Ensuring the treatment plan is constantly updated Following up to ensure patient compliance and disposition Monitoring medication allocation and use Establishing a check-in system with the patient

Treatment Plan Assuming Professional Responsibility Follow through with treatment plan to ensure effectiveness. The clinician is responsible for managing the suicidality to the standard of care. Treatment plans should take into account issues gathered during the risk assessment, with risk management ongoing during treatment Consider involvement of supportive third parties, such as family and friends. Patient and clinician should remain in contact, as well as any persons involved beyond primary care.

Treatment and Management of Suicide Risk: Safety Plan A predetermined list of coping mechanisms and support the client has access to Reduces access to means to complete suicide Developed with patient involvement Recognization of the risk of suicide Difference from No-Suicide Contracts

Safety Plan: Example

No-Suicide Contracts Typically takes the form of asking a patient to promise to not commit suicide and seek help from professionals when in crisis Effectiveness is not supported by empirical data May obscure a patient’s actual level of suicidality Does not provide the patient with adequately detailed information about support available and proper responses in times of crisis

No-Suicide Contract: Example

Treatment and Management of Suicide Risk: Third Parties Educating supportive third party members along with the patient Actions taken to reduce risk Engaging third parties Addressing the unique family, social, cultural, spiritual, and socioeconomic needs of patient through psychological interventions

Psychotherapy Have been proven to be efficient in treating disorders associated with increased risk of suicide Targets deficits in specific skills, which may reduce suicide attempts, when applied for the long-run Mostly reduces suicide risk through cognitive-behavioral therapy, which helps identify the causes of dysfunctional emotions

May help reduce symptoms of mood disorder Psychotherapy May help reduce symptoms of mood disorder Psychotherapies to consider: Dialectical Behavioral Therapy for patients with personality disorders characterized by emotional dysregulation Psychotherapies based on cognitive/behavioral approaches or skills training for BPD patients at high suicide risk Psychodynamic psychotherapies for high risk patients with BPD

Psychotherapy: Core Therapeutic Components Cognitive: deals with irrational negative thoughts, core beliefs and cognitive distortions, and problem solving deficits Emotional: deals with avoidance of unpleasant experiences activated prior to the suicide attempt Behavioral: deals with reduced activity and impulsive behavior Interpersonal: deals with poor communication and impaired social function

Types of Therapies: Cognitive-Behavioral Therapies: emphasizes modification of core beliefs and schemas related to perception of self, the world, and the future Dialectical Behavior Therapy: emphasizes management of multiple severe problems, suicidal behavior, and extreme emotional sensitivity Interpersonal Therapy: emphasizes reparation of impaired social functions and addresses interpersonal difficulties that lead to psychological problems Mentalization-Based Therapy: emphasizes relational aspect of personality disturbance and restructuring self-image and understanding of others

Pharmacotherapy Limited evidence that pharmacological interventions reduce suicide risk Medication should be reviewed for connections to suicidal thoughts or behaviors Lithium and Clozapine have been reported to reduce suicide risk in patients with mood disorders or schizophrenia

Drugs potentially used to help manage suicide Pharmacotherapy Drugs potentially used to help manage suicide Example Black Box Warning Anti-depressants Anti-psychotics Lithium Clozapine Antiepileptic drugs Anti-anxiety drugs

Electroconvulsive Therapy Can rapidly and efficiently resolve symptoms of several Psychiatric disorders Could also be a potential treatment for resistant PTSD Usually considered for suicidal patients who have failed to respond to other treatments No significant evidence of long- term reduction of suicide risk

Electroconvulsive Therapy Risks and Contraindications .002% result in death, usually as a result of cardiovascular complications Adverse side effects include temporary confusion and memory loss, though modern techniques have reduced these side effects Fractures are reduced by muscle relaxants, though teeth may be broken still Contraindications are rare, and most can be overcome by preparation before the ETC

Treatment and Management of Suicide Risk: Continuity of Care Discharge planning Risk of suicide after discharge Follow-ups Transitions between care settings Behavioral health providers Connection with chain of healthcare Updates to treatment plan and safety plan Documentation