TREATMENT

Antidepressants can reduce suicidal thoughts in patients with depression, but require time to take effect. Most people experience improvement within 3 months of antidepressant use.

The currently most frequently prescribed antidepressants are selective serotonin reuptake inhibitors (SSRIs). Examples of SSRIs include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft). 

Antidepressant use requires clinical monitoring. This is not only to detect clinical changes/improvement, but also because antidepressants can unmask a previously undiagnosed bipolar disorder, which requires a different treatment approach.

Another medication used to treat patients who are at risk for suicide is lithium maintenance treatment. Long-term maintenance treatment with lithium can reduce the risk of suicide in patients with bipolar disorder. For example, a longitudinal study of youth with bipolar disorder found that lithium treatment was associated with fewer suicide attempts, improved depressive symptoms, less psychosocial impairment, and less aggression.

Clozapine is the only medication approved by the FDA for “reducing suicidal behavior,” and only in patients with schizophrenia. In general, clozapine is used for patients with schizophrenia or schizoaffective disorder who have not been helped by other medications or who have tried to kill themselves and are likely to try again, regardless of their previous response to treatment. Clozapine is available from your medical provider through a restricted distribution and monitoring program.

Another treatment option for those with treatment-resistant depression (depression that has not responded to standard treatments) is ketamine/esketamine, which can be administered by multiple routes including IV in the muscle, intranasally, orally, and under the tongue. Ketamine/esketamine can rapidly and transiently alleviate treatment resistant unipolar major depression, including suicidal ideation. There have been randomized trials in patients with suicidal ideation that indicate a single infusion of ketamine can reduce symptoms within one hour, with benefits persisting for up to one week.

Twenty-five percent of people who die by suicide are misusing or dependent on alcohol or drugs. Those who use opioids regularly are two times more 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.

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.

For more information about effective treatments for opioid use disorder and the relationship between opioid use disorder and suicide risk, please visit www.opioidscreening.org

Cognitive Behavioral Therapy (CBT) is a psychological treatment that addresses faulty or unhelpful thoughts and behaviors. The goal is to build skills to better cope with distress.

Studies show that CBT can reduce suicidal thoughts, attempts, and hopelessness. 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).

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

Several recent studies have found DBT to be an effective treatment for reducing repeat suicide attempts in highly suicidal patients, including adolescents. A cornerstone of DBT is the idea that the patient can build a life worth living, even when the patient has many problems and wishes to die. 

Mindfulness-Based Cognitive Therapy (MBCT) is a form of psychotherapy which 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. In addition, MBCT may help protect against the depressive relapses that are common in those with a history of suicidal thoughts and behaviors.

Collaborative Assessment and Management of Suicidality (CAMS) is a therapeutic approach specifically targeted towards reducing suicide risk. CAMS focuses on identifying risk factors and “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 element is the use of the Suicide Status Form (SSF), which contains open-ended questions about psychological pain, stress, hopelessness, reasons for living, and other such variables. CAMS is a collaboration between the clinician and the patient, who decide together how to manage the client’s suicidality. Clinicians work to understand the struggle of the suicidal patient with empathy and without judgment.

CAMS is an evidence-based approach. Studies, including randomized controlled trials, have shown that this therapeutic approach can reduce suicidal ideation, symptom distress, depression, hopelessness, and emergency department visits for suicidal behavior in a variety of populations. In addition, there is growing evidence that it can treat self-harm and suicide attempts. Evidence for the effectiveness of this approach can be found here.

Interpersonal therapy (IPT) is an evidence-based treatment for depression that can be helpful for some individuals experiencing suicidal ideation. IPT is based on the understanding that personal relationships and life events can both impact and be impacted by mood. IPT aims to improve communication skills and strengthen social support networks. IPT also focuses on developing more realistic expectations and better coping strategies.

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, and that they can help to reduce suicidal behavior. 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).

Electroconvulsive Therapy (ECT) is one of the most effective treatments for patients with treatment-resistant depression or severe depression with psychotic features. It involves applying a brief electrical stimulation to the brain, while a patient is under anesthesia and given a muscle-relaxant to avoid injury. In the United States, most ECT is now given on an outpatient basis. Moreover, since its inception in 1938, the administration of ECT has been modernized focusing on both safety and efficacy. However, patients should be aware of the risks and benefits of this important procedure.

ECT can be used when other treatments (including medication and psychotherapy) have failed to yield adequate responses. ECT is also used for suicidal patients who require a rapid treatment intervention. ECT can rapidly reduce suicidal ideation, though most people treated with ECT will require some form of maintenance treatment (e.g., psychotherapy, medication, additional ECT).

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, as opposed to ECT where electrical stimulation induces generalized epileptic seizures.

Studies find that rTMS can resolve suicidal ideation in some patients with treatment-resistant depression. Bilateral rTMS may be a useful alternative treatment for suicidal ideation when ECT is declined, not tolerated, or not readily available.