Reducing Suicide A National Imperative (2002) / Chapter Skim
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7 Medical and Psychotherapeutic Interventions
7 Medical and Psychotherapeutic Interventions
Pages 229-272
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ASSESSMENT Suicide risk is difficult to assess. Individuals making serious suicide attempts may knowingly withhold their intentions (e.g., Apter et al., 2001; 229
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A prospective study (Pokorny, 1983) of 4800 consecutive patients at a Veterans Administration hospital used 21 known suicide risk factors to identify 803 patients with increased risk of suicide.
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Furthermore, the age, gender, and culture of the suicidal individual must also be considered in choosing assessment scales. Some measures of psychopathology and suicide risk may not be as accurate or appropriate for specific populations, since risk and protective profiles differ across ethnicity, gender, and age.
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In addition to base rate differences, risk factors may vary in meaning, salience, and/or presence across groups. The prevalence of risk factors for suicidal behaviors differs in different samples or population groups, just as the base rates of suicidal ideation and suicide attempts differ.
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PSYCHOACTIVE MEDICATIONS Since 90 percent of suicide occurs in people with mental disorders, it is thought that treating the underlying disorder could reduce suicide risk. For some medications there is evidence that the effects on suicidality may be independent from the effects on the mental disorder.
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From page 234... ...
, this has a serious impact on suicide risk. Research has shown that almost one-half of patients with bipolar disorder are non-adherent to lithium treatment at some point in their lives, and one-third are non-adherent two or more times (lamison and Akiskal, 1983; lamison et al., 1979~.
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None were taking lithium at time of death, but one had discontinued lithium. All of the suicide attempts occurred in patients who were taking carbamazine.
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From page 236... ...
reported that in a multi-centered, randomized clinical trial of 980 patients with schizophrenia or schizoaffective disorder, treatment with clozapine when compared to treatment with olanzapine resulted in significantly fewer suicide attempts and a reduced need for additional medications to control suicidality. Meltzer and Okayli (1995)
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From page 237... ...
Similar analyses with other novel antipsychotic medications have been initiated, and preliminary results suggest that they may also have some beneficial effect in reducing suicide rates. Antidepressant Medications A number of investigators worldwide have recently reviewed outcomes across large populations showing that a decrease in suicides correlates with the increase of antidepressant use in various European countries (Isacsson et al., 1996; Markowitz, 2001; Ohberg et al., 1998; Rich, 1999; Rihmer et al., 1998)
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(1998) found that patients with personality disorders and brief depression, but not major depression, had fewer suicide attempts when treated with paroxetine as compared with placebo.
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Other Classes of Antidepressants In terms of actual suicidal behavior, a prospective long-term, placebocontrolled treatment study of 1141 patients found more suicide attempts, including suicides in the group treated with the norepinephrine reuptake inhibitor maprotiline compared with placebo (Rouillon et al., 1989~. While maprotiline was an effective antidepressant, it was associated with increased suicide attempts.
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From page 240... ...
." It has long been known that affective disorders can carry a significant risk of suicide, and that some small number of patients will deteriorate rather than improve after being treated with any antidepressant or will become at an increased risk for suicide associated with abrupt improvement. Case reports have led some investigators to suggest that there may be a risk of emergent suicidality on SSRIs, in particular, fluoxetine.
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From page 241... ...
Thus, it is not clear that this kind of akathisialike effect can actually lead to suicidal behavior or, for that matter, violent behavior, in patients receiving SSRIs. All of the controlled clinical data do not provide evidence of emergent suicidality, even among patients without mood disorders who are receiving SSRIs (Montgomery et al., 1995; Tollefson et al., 1993~.
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From page 242... ...
Thus, both controlled clinical trials, including large meta-analyses of large groups of patients as well as these postmarketing surveys, provide no support for the concerns of emergent suicidality. Anxiolytic Medications Anxiety is a common symptom in many mental illnesses, including depression, bipolar disorder, and schizophrenia, and acute anxiety and agitation are associated with an increased risk of both suicide and suicide attempts.
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There is no evidence that ECT has a long-term effect on the suicide rate and suicidal behavior (Prudic and Sackeim, 1999~. It is notable that the majority of studies have found a lower mortality rate for ECT treated psychiatric patients versus psychiatric patients with other treatment modalities, but these mortality risk studies are plagued by methodological problems.
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Given that suicidal ideation and behavior is a key symptom of the affective disorders, it would follow that an effective treatment for the disorder would also alleviate one of its symptoms. Additionally, Prudic and Sackeim (1999)
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Psychotherapy often focuses on: · changing long-term social-cognitive suicide risk factors such as hopelessness, low self-esteem and self-efficacy (see Chapter 3) · interpersonal problem-solving deficits (see Chapter 3)
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In general, these studies have produced positive results for both adolescent and adult samples. Four studies of suicidal adolescents and young adults suggest that CBT with problem-solving components and general problem-solving therapy4 reduces suicidal ideation and associated symptomatology such as depressive symptoms, hopelessness, and loneliness for at least 2 years (Harrington et al., 1998; Joiner et al., 2001; Lerner and Clum, 1990; Rudd et al., 1996~.
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The behavioral therapy group showed greater reductions in depression and suicidal ideation, but no between-group differences emerged with respect to suicide attempts over a 9-month follow-up. Patsiokas and Clum (1985)
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At a 6-month follow-up, the brief psychodynamic group showed a significantly greater reduction in the rate of suicide attempts and suicidal ideation. They also reported greater satisfaction with treatment than the control group in this study, which received treatment as usual (usually referral to their general practitioner)
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The studies reviewed in this section therefore indicate that psychotherapy can more effectively reduce depression, hopelessness, suicidal ideation, and suicide attempts compared to treatment as usual. Short-term psychotherapy with CBT and/or problem-solving training components may also positively influence a wider range of suicide risk factors than does solely supportive or insight-oriented therapy.
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Involuntary hospitalization is correlated with many of the common risk factors for suicide, including serious suicide attempts and completed suicide on the unit, a diagnosis of schizophrenia; history of prior attempts of high lethality; and history of living alone or living in a household without younger children (Roy and Draper, 1995~. The immediate priority upon hospitalization is to reduce the suicidal thoughts, anxiety, and other symptoms associated with the suicide attempt.
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The effectiveness of brief hospitalizations is questionable, especially when they entail no psychiatric services or post-discharge services. One randomized controlled trial compared the efficacy of general hospital admission versus discharge in reducing the repetition of suicidal symptoms and suicide attempts over 4 months and found that short-term hospitalization (i.e., a mean of less than 24 hours)
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After Discharge Risk The period directly following discharge from a psychiatric hospitalization is a period of significantly increased risk. There appear to be multiple reasons for this.
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Other risk factors for suicide in recently discharged patients include living alone, hopelessness, relationship difficulties, loss of a job, a history of self harm, and a diagnosis of depression (King et al., 2001; McKenzie and Wurr, 2001~. Patients who maintained care in the community (King et al., 2001)
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Such interventions have produced mixed results with regard to suicidal behaviors: some have demonstrated decreased suicide attempts (Aoun, 1999; Termansen and Bywater, 1975; van Heeringen et al., 1995; Welu, 1977) and even completions (Motto and Bostrom, 2001)
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investigated the relative efficacies of no intervention, emergency room assessment alone, emergency room assessment plus as-needed follow-up care at a volunteer crisis center, and emergency room assessment plus a 3-month follow-up by the same mental health worker who conducted the assessment. Over the 3-month follow-up period, they found that the group who received follow-up by the same mental health worker demonstrated lower rates of suicide attempts and higher treatment adherence.
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, and disease causation influence the expression of mental disorders and response to treatment, including treatment adherence (Hsu, 1999; Marsella, 1988; Marsella and Yamada, 2000~. Clergy/spiritual ministers represent key gatekeepers for suicide prevention.
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FINDINGS · Assessment tools are inadequate to determine acute suicide risk or to predict when a person will attempt or complete suicide. Assessment tools must be validated for various populations since they may not be generally applicable.
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Cognitive-behavioral approaches that include problemsolving training seem to reduce suicidal ideation and attempts more effectively than treatment as usual or supportive therapy. As with drug therapy, research on the long-term effectiveness of these interventions is lacking.
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The most effective psychopharmacological and psychosocial treatment strategies generally involve long-term and/or maintenance treatment. Maintenance treatment with lithium, clozapine, and electroconvulsive therapy, during which patients must regularly see health care professionals, appears more effective in reducing suicidality than only prophylactic treatments; regular contact with health care staff via mail and weeks or months of psychotherapy also appear to reduce suicide.
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1994. The Diagnostic and Statistical Manual of Mental Disorders.
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Results of a randomised controlled trial. British Journal of Psychiatry, 174: 56-62.
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2001. Cognitive risk factors and suicide attempts among formerly hospitalized adolescents: A prospective naturalistic study.
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1996. Epidemiological data suggest antidepressants reduce suicide risk among depressives.
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2000. Symptom reduction and suicide risk in patients treated with placebo in antidepressant clinical trials: An analysis of the Food and Drug Administration database.
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2001. Antidepressants and suicide risk.
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1978. Differential effects on suicidal ideation of mianserin, maprotiline and amitriptyline.
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1997. Risk of suicide attempts after benzodiazepine and/or antidepressant use.
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1991. Reexposure to fluoxetine after serious suicide attempts by three patients: The role of akathisia.
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1996. Effect of prophylactic treatment on suicide risk in patients with major affective disorders.
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1998. Reduction by paroxetine of suicidal behavior in patients with repeated suicide attempts but not major depression.
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And Levin, a happy father and a man in perfect health, was several times so near suicide that he hid the cord, lest he be tempted to hang himself, and was afraid to go out with his gun, for fear of shooting himself. But Levin did not shoot himself, and Jid not hang himself; he went on living.
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From page 272... ...
I E(XC) PPE Early Risk 15.00% 2 13% 100% 5% 34% 15.00% 2 13% 50% 0% 15% Crisis Line 2.00% 2.5 3% 10% 0% 1% 5.00% 2.5 7% 10% 0% 1% 2.00% 10 15% 10% 0% 2% 5.00% 10 31% 10% 0% 5% Gatekeeper 10.00% 2.5 13% 10% 0% 3% 20.00% 2.5 23% 20% 0% 10% REDUCING SUICIDE
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