Assessment and Management of Patients at Risk for Suicide

Release Date : March 02 2023

VA/DoD clinical practice guideline for the assessment and management of patients at risk for suicide: Version 2.0

This guideline is an update to the 2013 guideline.
The guideline was updated by a panel of multidisciplinary subject-matter experts known as the Champions (three clinical leaders) and the Work Group (clinical specialists from psychiatry, psychology, nursing, social work, pharmacy, psychotherapy, mental health, and preventive medicine/public health).
Peer review and feedback were provided by American Psychiatric Association and Perelman School of Medicine, University of Pennsylvania.
The guideline provides 22 evidence-based recommendations on the management of patients at risk for suicide.
Algorithms are included to promote clinical decision-making processes.
The guideline is intended for VA and DoD healthcare practitioners and others caring for individuals at risk for suicide.
The intended outcomes of the guideline are to promote practitioner-patient collaboration in determining the best treatment methods, to emphasize patient-centered care, to optimize health outcomes, to improve quality of life, and to minimize preventable complications.

Become familiar with the recommendations in this guideline, especially if you work in an acute care setting.

The guideline provides three algorithms to aid in the identification of risk for suicide, the clinical evaluation for suicide, and the management of patients at acute risk for suicide.
Each algorithm includes steps of care, recommended examinations and observations, decisions to consider, and actions to be taken.
Practitioners should use the algorithms to guide their clinical practice.

Nonpharmacologic Treatment

Cognitive behavioral therapy (CBT) is strongly recommended to reduce suicidal ideation and behavior, and to reduce the incidence of future self-directed violence.
Dialectical behavior therapy (DBT) is suggested for the treatment of suicidal ideation and self- directed violence among individuals with borderline personality disorder.
A crisis response plan is suggested for individuals with a history of suicidal ideation, self-directed violence, moderate to severe traumatic brain injury, and hopelessness.
Problem-solving psychotherapies are suggested for individuals with a history of suicidal ideation and self-directed violence, and as treatment for hopelessness among individuals with moderate to severe traumatic brain injury at risk for suicide.

Pharmacologic Treatment

Ketamine adjunctive therapy is suggested for symptom improvement in patients with suicidal ideation and major depression. Infuse a single dose at 0.5 mg/kg within 24 hours for a moderate effect that continues for 1 week and even up to 6 weeks.
Lithium maintenance therapy alone is suggested to reduce the risk of suicidal ideation in patients with bipolar disorder. Patients with unipolar disorder may benefit from a combination of lithium and another psychotropic agent.
CloZAPine therapy is suggested to reduce the risk of death in patients with schizoaffective disorder or schizophrenia and a history of either suicidal ideation or suicide attempts.

Post-Acute Care

It is suggested that sending periodic caring communications (postcards, letters) within 12 to 24 months after psychiatric hospitalization for suicide attempt or suicidal ideation may lower the rates of recurrent suicide attempts, ideation, and death.
Home health visits are recommended for patients who fail to engage in outpatient care following hospitalization for a suicide attempt.
Individuals who present to the emergency department following a suicide attempt should be given the World Health Organization Brief Intervention and Contact (BIC) treatment modality in addition to standard care.

Technology-Based Modalities

There is insufficient evidence to recommend the use of technology-based behavioral health treatment modalities (compact disc, web-based, and virtual provider) for individuals with suicidal ideation.
There is insufficient evidence to recommend the use of technology-based adjuncts (web or telephone applications) in routine suicide prevention treatment for individuals with suicidal ideation.