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A Comprehensive Overview of Treatments for Suicide

On #WorldSuicidePreventionDay I posted an article about the Question, Persuade, Refer model of suicide prevention and the limits of emergency care and hospitalization. An answer to this is effective treatment for suicide. These programs work at hierarchical levels: awareness education to combat stigma and change public perception, brief psychological interventions in the emergency room, and longer-term outpatient therapies.

Treatments to Improve Knowledge and Attitudes

Treatments to improve knowledge of and attitudes toward suicide in the general population include skills training and gatekeeper training programs (Mental Health First Aid, SAFETalk, and Question, Persuade, Refer). These programs provide helpers with knowledge about factors contributing to suicide, the development of ideation and attempts and ways we can intervene to help people at risk of suicide. Awareness curricula implemented in schools or institutions, and suicide screening policies in primary care also improve public knowledge by teaching suicide-related risk and protective factors, means safety and emergency protocol.

Treatments to Improve Risk and Protective Factors

Treatments at this level can be applied to anyone regardless of suicidal experience. They work to prevent future suicidal ideation by improving factors associated with suicide: depression, hopelessness, self-hate, and co-occuring disorders. They can also be implemented at any level of care and before or after a suicide attempt or crisis. Protective factors are things like social support, treatment adherence, and motivation. Before a patient is suicidal risk and protective factors can be targeted to prevent ideation from occuring, and after a suicidal crisis targeting these factors gets to the "root" of the suicidal feelings and prevents future attempts.

Treatment for Ideation and Attempts

As discussed in

An Overview of Ideation-to-Action Theories

, suicidal ideation results primarily from pain, hopelessness, and isolation. Suicide attempts, on the other hand, occur when ideation is coupled with the capability for suicide (experiences, biological factors, and knowledge that increase comfort with death and reduce fear). Thus, treatments that are effective in reducing suicidal ideation might not be effective in reducing attempts and vice versa. Notably, primary care management of depression is effective in reducing suicidal ideation, but not attempts. A novel mode of therapy termed "brief interventions" have been successful at reducing suicide attempts, notably Brief Intervention and Contact (BIC) and Attempted Suicide Short Intervention Program (ASSIP). These programs are built around safety planning: creating a plan for coping with future suicidal crisis, practicing means safety, and contacting social/professional supports. BIC elaborates on this by including nine follow-up contacts over 18 months post-attempt and ASSIP further individualizes the safety plan by creating a narrative of the individual's attempt over three sessions (rather than one).

Treatments to Reduce Death by Suicide

There are multiple effective treatments for reducing risk factors for suicide (depression, substance use and co-occuring disoders, self-injury etc.), suicidal ideation and suicide attempts. However, only BIC has evidence for reducing deaths by suicide. A problem with studying death as an outcome is the relative statistical rarity of suicide (known as the low base rate problem). Population-level means prevention efforts like gun control and bridge barriers also reduce death by suicide in regions where they are implemented, but many suicide methods are incompatible with means prevention efforts.

Men are more likely to die by suicide and are more likely to both use lethal methods and die by less-lethal methods.

Because most people who attempt using a highly lethal method will not be alive to access post-attempt treatment, these high-risk patients are not included in analyses of treatment effects. Thus, in order to effectively reduce suicide deaths, treatment must be accessible outside of the hospital and have few barriers.

Longer-Term Treatments for Suicidality

Three longer-term therapeutic interventions for suicide ideation and attempts have been designed and evaluated for efficacy. The first,

Dialectical Behaviour Therapy (DBT)

, was developed for patients with borderline personality traits including suicidality and self-injury. Since its conception, it has been generalized to suicidal patients without symptoms of BPD. DBT works through a combination of skills groups and individual sessions, behaviour change plans, analysis of reinforcement of maladaptive coping skills in the environment, telephone coaching to generalize skills to the environment, and consultation for the therapist with a team. DBT is effective in reducing suicidal desire and suicide attempts as well as improving psychosocial adjustment and treatment retention. These factors help keep suicidal ideation at bay in the long-term as patients develop a life worth living.

Cognitive therapy was adapted for suicide prevention

(CT-SP) by Dr. Gregory Brown. It begins with a narrative review of the most recent suicidal crisis, creating an individualized plan for understanding and treating suicidal desire. It follows a cognitive therapy model: changing maladaptive beliefs leading to suicidal ideation, coping ahead for future relapse, and the addition of booster sessions when new stresses emerge. CT-SP is most effective for managing depressive symptoms, but has promising evidence for reducing suicidal thoughts and behaviours as well.

Finally,

Collaborative Assessment and Management of Suicidality

(CAMS) is an open-ended framework that can be integrated into an existing therapeutic model. It is centered around the

Suicide Status Form

(SSF) that serves as a risk assessment, psychoeducational framework, safety plan, and treatment plan. The SSF is completed at the intial session, during treatment, and at the end of treatment in order to track suicidal risk, desire, and behaviours. Often the simple act of tracking behaviour decreases it, and tracking is a powerful element of CAMS. Different modalities of therapy (CBT, DBT, psychodynamic therapy) are used to approach each element of suicidality.

Implementation and Barriers to Access

The problem with these interventions is that there is no comprehensive implementation plan for hospitals and mental health outpatient services. There is a disconnect after the randomized controlled trials have been published and archived and before these programs are available for everyone to access. Safety plans, for example, are such a quick and simple way to care for a patient presenting to the emergency room with suicidal ideation and yet it is still unusual to receive a safety plan in the emergency room. It is my hope that implementing effective treatments for suicide becomes a priority for the suicide prevention movement.

Search for effective suicide treatments here.

Canadian resources can be found

here

and free/low-cost resources in the US can be found

here.

You can also find resources at our website,

on this page.

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