Suicidal Behavior (eBook)

Table of Contents 6
1 Description 10
1.1 Terminology 13
1.2 Definition 14
1.3 Differential Diagnosis 17
1.4 Epidemiology 20
1.5 Course and Prognosis 24
1.6 Comorbidities 27
1.7 Assessment Procedures 30
2 Theories and Models of Suicidal Behavior 35
2.1 Neuropsychiatric Theories 35
2.2 Psychological Theories 36
3 Risk Assessment and Treatment Planning 40
3.1 Assessing Suicide Risk and Protective Factors 41
3.2 Estimating Suicide Risk Level 42
3.3 Resolving Contradictory Risk Factors 43
3.4 Understanding the Time Dimension of Suicide Risk 44
3.5 Documenting Suicidal Risk 46
4 Treatment 48
4.1 Methods of Treatment 51
4.2 Crisis Intervention and the Management of Acute Risk 54
4.3 Safety Planning 61
4.4 Treatment Techniques 67
4.5 Mechanisms of Action 78
4.6 Efficacy and Prognosis 80
4.7 Variations and Combinations of Methods 80
4.8 Problems in Carrying Out the Treatments 84
4.9 Multicultural Issues 87
5 Case Vignette 89
Julie 89
6 Case Example 92
Intake Evaluation and Treatment Plan 92
7 Further Reading 96
8 References 97
9 Appendices: Tools and Resources 106
Appendix 1: Outline for Suicide Consultation 107
Appendix 2: Decision Tree for Intervening with Suicidal Callers 109

4 Treatment (S. 39-40)

While there is substantial evidence that pharmacological treatment of disorders that are risk factors for suicide (such as depression) can be effective, pharmacological studies that have targeted suicide directly have had much more equivocal results. In part, this is because clinical trials of medication have historically excluded those at risk for suicide (as have psychotherapy studies). Evidence for the effectiveness of Lithium in preventing suicide is probably stronger than for any other medication (Cipriani, Pretty, Hawton, &, Geddes, 2005).

Meltzer (1999) has examined clozapine versus olanzapine for patients with schizophrenia or schizoaffective disorder who were at high risk for suicide and found that those receiving clozapine were less likely to attempt suicide or be hospitalized for suicide risk. An area of significant controversy recently has been the relationship between the use of SSRIs and suicide risk. While previously the major debate within the field has focused on whether the significantly increased rates of prescription of SSRIs was responsible for a decrease in national suicide rates in various countries around the world (Safer &, Zito, 2007), fears about the potential role of SSRIs in causing suicide erupted in England and the United States. This concern about suicidality as a possible side effect from the use of SSRIs led the Food and Drug Administration to issue a “black box” warning.

The focus of concern was initially on youths, because the evidence of efficacy for treatment of depression among this group was much more equivocal than the evidence among adults, making the risk/benefit ratio more problematic among youths than adults. Following this warning, prescriptions of SSRIs fell significantly. When the youth suicide rate increased in 2004, after almost a decade of decline, some argued that the decrease in use of SSRIs was to blame. While there may be a subgroup of those who take SSRIs who experience an increase in suicidality (Maris, 2007), this does not mean that they are not safe for most patients, particularly those with serious depression. Gibbons, Brown, Hur, Marcus, Bhaumik, and Mann (2007) report that among male veterans treated with SSRIs, suicide attempts decreased.

However, their effectiveness in preventing death by suicide is still uncertain. A review of the literature by Rudd, Joiner, and Rajab (2001), which focused only on nonpharmacologic interventions, revealed only 25 randomized or controlled studies that targeted suicidality. They divided their review into intervention studies and treatment studies. Intervention studies were those that did not provide any kind of psychotherapy or medication treatment.

These studies made changes in either procedures associated with treatment (letters, phone calls), or facilitated access to mental health services and assessed any subsequent reductions in suicide attempts. Of particular note was a study by 4 Treatment While there is substantial evidence that pharmacological treatment of disorders that are risk factors for suicide (such as depression) can be effective, pharmacological studies that have targeted suicide directly have had much more equivocal results. In part, this is because clinical trials of medication have historically excluded those at risk for suicide (as have psychotherapy studies). Evidence for the effectiveness of Lithium in preventing suicide is probably stronger than for any other medication (Cipriani, Pretty, Hawton, &, Geddes, 2005).