92% of participants will know how to assess, treat, and manage suicidal thought, plans and behaviors.
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92% of participants will know how to assess, treat, and manage suicidal thought, plans and behaviors.
After completing the course, the learner will be able to:
Latin for “self-murder,” suicide is a psychiatric emergency that claims over 47,000 lives every year in the United States. It is a fatal act that represents a person’s desire to die. Suicide is almost always the result of mental illness, usually depression, and it is preventable when recognized early and treated effectively.
Suicide is ranked as the 10th overall cause of death in the United States (Table 1). Suicide accounts for over 42,000 deaths per year while homicide accounts for around 20,000.1 Estimates suggest that there is a 25:1 ratio of suicide attempts to completed suicides. Over the past century, these rates have remained constant, averaging 14.5 per 100,000 persons.
| Heart disease | 647.457 |
| Cancer | 599,108 |
| Accidents (unintentional injuries) | 169,936 |
| Chronic lower respiratory diseases | 160,201 |
| Stroke | 146,383 |
| Alzheimer’s disease | 121,404 |
| Diabetes | 83,564 |
| Influenza and Pneumonia | 55,672 |
| Nephritis, nephrotic syndrome, and nephrosis | 50,633 |
| Intention self-hard harm (suicide) | 47,173 |
In the United States, suicide rates are lowest in New Jersey for both genders; Montana and Wyoming have the highest for men, and Alaska and Idaho have the highest for women.3 International suicide rates range from 25 per 100,000 in Lithuania, South Korea, and Russia to 10 per 100,000 in Portugal and Australia.4 The Golden Gate Bridge, located in San Francisco, California, is the most common suicide site in the world. Over 1,600 suicides have been completed there since it was built in 1937.
Suicide is the deliberate act of taking one's own life; however, there are a variety of terms used to classify the range of suicidal-type behaviors (Table 2).5 Suicide not only ends a patient’s life, but it can also have a devastating impact on the patient’s loved ones and result in litigation against the provider.
| Aborted suicide attempt | Potentially self-injurious behavior with explicit or implicit evidence that the person intended to die but stopped the attempt before physical damage could occur. |
| Deliberate self-harm | Willful self-inflicting of painful, destructive, or injurious acts without the intent to die. |
| Lethality of suicidal behavior | Objective danger to one's life associated with a suicide method or action. Lethality is distinct from and may not always coincide with an individual's expectation of what is medically dangerous. |
| Suicidal ideation | Thought of serving as the agent of one’s own death. The seriousness of suicidal ideation may vary depending on the specificity of suicidal plans and the degree of suicidal intent. |
| Suicidal intent | Subjective expectation and desire for a self-destructive act to end in death. |
| Suicide attempt | Self-injurious behavior with a nonfatal outcome accompanied by explicit or implicit evidence that the person intended to die. |
| Suicide | Self-inflicted death with explicit or implicit evidence that the person intended to die. |
A suicide assessment is a specific type of psychiatric evaluation aimed at determining a person’s suicidal risk and creating a specialized treatment plan. During a suicide assessment, clinicians should conduct a thorough psychiatric evaluation. This information should be obtained from either the patient or their family members and friends.
In the context of a suicide assessment, the purpose of the psychiatric evaluation is to6:
The five domains of suicide assessment are summarized in Table 3.
| Current Presentation of Suicidality | Suicidal or self-harming thoughts, plans, behaviors, and intent. Specific methods considered for suicide, including their lethality and the patient’s expectation about lethality, as well as whether firearms are accessible. Evidence of hopelessness, impulsiveness, anhedonia, panic attacks, or anxiety. Reasons for living and plans for the future. Alcohol or other substance use associated with the current presentation. Thoughts, plans, or intentions of violence toward others. |
| Psychiatric Illness | Current signs and symptoms of psychiatric disorders with particular attention to depressive disorders. Previous psychiatric diagnoses and treatments, including illness onset and course and psychiatric hospitalizations, as well as treatment for substance use disorders. |
| History | Previous suicide attempts, aborted suicide attempts, or other self-harming behaviors. Previous or current medical diagnoses and treatments, including surgeries or hospitalizations. Family history of suicide or suicide attempts or a family history of mental illness, including substance abuse. |
| Psychosocial situation | Acute psychosocial crises and chronic psychosocial stressors, which may include actual or perceived interpersonal losses, financial difficulties or changes in socioeconomic status, family discord, domestic violence, and past or current sexual or physical abuse or neglect. Employment status, living situation (including whether or not there are infants or children in the home), and presence or absence of external supports. Family constellation and quality of family relationships Cultural or religious beliefs about death or suicide. |
| Individual strengths and weaknesses | Coping skills Personality traits Past responses to stress Capacity for reality testing Ability to tolerate psychological pain and satisfy psychological needs |
An interview to gather information during a suicide assessment must be done in a private setting. The clinician must approach the situation with empathy and compassion. Table 4 includes a list of questions that clinicians can use when inquiring about different aspects of suicide. Clinicians should follow these steps6:
| Opening questions | Opening questions |
|---|---|
| Follow-up questions | Is death something you’ve thought about recently? Have things ever reached the point that you’ve thought of harming yourself? |
| Thoughts of self-harm and suicide | When did you first notice such thoughts? What led up to the thoughts (e.g., interpersonal and psychosocial precipitants, including real or imagined losses; specific symptoms such as mood changes, anhedonia, hopelessness, anxiety, agitation, psychosis)? How often have those thoughts occurred (including frequency, obsessional quality, controllability)? How close have you come to acting on those thoughts? How likely do you think it is that you will act on them in the future? Have you ever started to harm (or kill) yourself but stopped before doing something (e.g., holding knife or gun to your body but stopping before acting, going to edge of bridge but not jumping)? What do you envision happening if you actually killed yourself (e.g., escape, reunion with significant other, rebirth, reactions of others)? Have you made a specific plan to harm or kill yourself? (If so, what does the plan include?) Do you have guns or other weapons available to you? Have you made any particular preparations (e.g., purchasing specific items, writing a note or a will, making financial arrangements, taking steps to avoid discovery, rehearsing the plan)? Have you spoken to anyone about your plans? How does the future look to you? |
| Previous suicide attempts | Can you describe what happened (e.g., circumstances, precipitants, view of future, use of alcohol or other substances, method, intent, seriousness of injury)? What thoughts were you having beforehand that led up to the attempt? What did you think would happen (e.g., going to sleep versus injury versus dying, getting a reaction out of a particular person)? Were other people present at the time? Did you seek help afterward yourself, or did someone get help for you? Had you planned to be discovered, or were you found accidentally? How did you feel afterward (e.g., relief versus regret at being alive)? Did you receive treatment afterward (e.g., medical versus psychiatric, emergency department versus inpatient versus outpatient)? Has your view of things changed, or is anything different for you since the attempt? Are there other times in the past when you’ve tried to harm (or kill) yourself? |
| Repeated suicidal thoughts and attempts | About how often have you tried to harm (or kill) yourself? When was the most recent time? Can you describe your thoughts at the time that you were thinking most seriously about suicide? When was your most serious attempt at harming or killing yourself? What led up to it, and what happened afterward? |
| Psychosis | Can you describe the voices (e.g., single versus multiple, male versus female, internal versus external, recognizable versus non-recognizable)? What do the voices say (e.g., positive remarks versus negative remarks versus threats)? (If the remarks are commands, determine if they are for harmless versus harmful acts; ask for examples)? How do you cope with (or respond to) the voices? Have you ever done what the voices ask you to do? (What led you to obey the voices? If you tried to resist them, what made it difficult?) Have there been times when the voices told you to hurt or kill yourself? (How often? What happened?) Are you worried about having a serious illness or that your body is rotting? Are you concerned about your financial situation even when others tell you there’s nothing to worry about? Are there things that you’ve been feeling guilty about or blaming yourself for? |
| Harm to others | Are there others who you think may be responsible for what you’re experiencing (e.g., persecutory ideas, passivity experiences)? Are you having any thoughts of harming them? Are there other people you would want to die with you? Are there others who you think would be unable to go on without you? |
Suicidal assessment scales have limited value. These self-reported scales can help facilitate conversation between patients and providers; however, the American Psychiatric Association states that they have limited clinical utility.6 The existing suicide assessment scales have elicited high false positives, false negative, and low predictive value. Rating scales are no substitute for clinical expertise.
Clinicians should understand high-risk and low-risk characteristics. High-risk characteristics include older than 45 years, male gender, alcohol dependence, violent behavior, previous suicidal behavior, previous psychiatric hospitalization.
| Characteristic | High-risk | Low-risk |
|---|---|---|
| Age | >45 years | <45 years |
| Sex | Male | Female |
| Marital Status | Divorced or widowed | Married |
| Employment | Unemployed | Employed |
| Interpersonal relationships | Conflictual | Stable |
| Family background | Chaotic | Stable |
| Physical Health | Chronic illness, hypochondriac, excessive substance intake | Good health, feels healthy, low substance use |
| Mental Health | Severe depression, psychosis, severe personality disorder, substance abuse, hopelessness | Mild depression, neurosis, normal personality, social drinker, optimism |
| Suicidal ideation | Frequent, intense, prolonged | Infrequent, low intensity, transient |
| Suicide attempt | Multiple, planned, rescue unlikely, specific wish to die, self-blaming, available lethal method | First attempt, impulsive, rescue inevitable, wish for change rather than wish to die, external anger, low lethality method |
| Personal resources | Poor achievement, poor insight, unstable affect | Good achievement, insightful, controllable affect |
| Social resources | Poor rapport, socially isolated, unresponsive family | Good rapport, socially integrated, concerned family |
Clinicians should begin by assessing current signs and symptoms of psychiatric disorders.6 They should pay close attention to signs of a depressive disorder and make a note of any high-risk characteristics (Table 5).
Gender: Men are four times more likely to commit suicide compared with women, regardless of age, race, religion, or marital status. On the other hand, women experience suicidal thoughts and attempt suicide three times as often as men. The reason for this disparity appears to be related to the different ways men and women attempt suicide.
Age: The rate of suicide increases as a person ages. Prior to puberty, suicide is extremely rare. For men, suicide rates are highest at age 45; for women, they are highest after age 55. Elderly persons attempt suicide less often than younger persons, but they are typically more successful. Unfortunately, the suicide rate is rising quickly in younger populations. Today, suicide is the third leading cause of death for those aged 15 to 24 years, followed by accidents and homicides.
Race and Religion: Caucasian men and women are three times more likely to commit suicide than African American men and women. Native American and Alaskan Native youth experience suicide rates much higher than the national average.3 Rates among immigrants are higher than those among citizens.4 In the United States, Protestants and Jews have higher suicide rates than both Catholics and Muslims. Overall, the level of orthodoxy and integration with society is a more accurate predictor of suicide than religion alone.5
Marital Status: Married individuals with children are much less likely to commit suicide than single persons. Single, never-married individuals experience double the suicide rate compared with married persons.3 Divorce increases the risk of suicide; divorced men are three times more likely to commit suicide than divorced women. Homosexual men and women have higher rates than heterosexual persons, whether married or single. Some individuals commit “anniversary suicides” on the day their family member or loved one died.5
Occupation: The risk of suicide increases as a person's socioeconomic status increases. In general, employment serves as a protective factor against suicide; however, certain occupations increase a person’s risk. High-risk occupations include healthcare providers, artists, mechanics, lawyers, and insurance agents. Unemployed persons are more likely to commit suicide than their employed counterparts. Suicide rates increase during economic recessions and decreased during economic booms.5
Physical Health: Over 30 percent of people who commit suicide have seen a healthcare professional within the previous six months. Physical illness, in general, is a significant contributing factor in half of all suicides. Factors that specifically contribute to suicide include loss of mobility, disfigurement, and chronic pain. Especially when these impact personal relationships and occupational status. Persons on hemodialysis are at an increased risk as well.5
Mental Illness: Nearly 95 percent of those who commit or attempt suicide have a diagnosed mental health disorder. Major depression and other depressive disorders account for 80 percent of suicides; those with delusional depression are at the highest risk.5 Furthermore, schizophrenia accounts for 10 percent, and dementia or delirium accounts for the remaining five percent. Over one-quarter of those who commit suicide are dependent on alcohol at the time.5
Substance Abuse: Substance abuse may contribute to suicide. When suspecting substance use disorder, please consider:
Alcohol use disorder is a known contributor to suicide risk as well as depressive and bipolar disorders.
Impaired judgment and muddled perceptions associated with hallucinogens can lead to heightened injury from accidents or self-injuries, although suicide is reported to be rare among hallucinogen users.
Inhalation, also called bagging, places the open-source or saturated cloth into a plastic or paper bag that is then placed over the nose, mouth, or head. The risk of asphyxia with bagging is high due to hydrocarbons displacing oxygen in the lung alveoli. Be alert that a high association with suicide accompanies individuals who bag using the over-the-head method.
Opioid withdrawal is known to cause brief but severe episodes of depression that can lead to suicide attempts and completed suicide. Accidental opioid overdose, particularly among those desperate to avoid withdrawal, is common and should not be mistaken for a suicide attempt.
Over 6% of emergency room visits for suicide attempts having cocaine as a factor.
More detail on the identification and treatment of substance abuse is available in the course: Substance Abuse.
The best predictor of a suicide attempt is a previous suicide attempt. Around 40 percent of those who commit suicide have attempted in the past. The chances of a second attempt are highest within three months of the first attempt.
Clinicians should consider previous psychiatric hospitalizations along with prior treatment for substance use disorders.5 Specific psychiatric symptoms that increase a person's risk of suicide include aggression, violence toward others, impulsiveness, hopelessness, agitation, psychic anxiety, anhedonia, global insomnia, and panic attacks.
Clinicians should obtain a thorough history of the patient’s previous suicide attempts, aborted suicide attempts, and self-harming behaviors.5 Do not forget, a previous suicide attempt is one of the strongest risk factors for another attempt. When possible, clinicians should contact the patient’s current primary care or psychiatric provider.6
Clinicians should also inquire about the patient’s family history. Family dysfunction is linked to suicide and other self-harming behaviors.5 Clinicians must assess for a family history of suicide or psychiatric disorders. Clinicians should also document a history of familial conflict or separation, parental legal trouble, family substance abuse, domestic violence, and physical or sexual abuse.6
Next, the clinicians should assess the patient’s current psychosocial situation.6 What are their current stressors? Have they experienced any recent interpersonal losses, financial difficulties, or changes in socioeconomic status? The clinician should document acute crises, chronic stressors, employment status, living situation, family constellation, and cultural or religious beliefs about suicide.6
Finally, clinicians must appreciate the patient’s psychological strengths and weaknesses. These may include coping skills, personality traits, thinking style, and development needs. Patients at an increased risk of exhibit polarized thinking, closed-mindedness, perfectionism, and excessively high self-expectations.6
Admission to an inpatient psychiatric hospital is usually indicated after a suicide attempt or an aborted suicide attempt.6 Admission may be necessary if the patient expresses suicidal ideation, has previous attempts and has a diagnosed psychiatric disorder. Outpatient treatment is most beneficial for those with chronic suicidal ideation or who have a stable supportive living situation.6
| Inpatient treatment recommended | After a suicide attempt or aborted suicide attempt if:
|
| Inpatient treatment might be necessary | In the presence of suicidal ideation with:
|
| Outpatient treatment recommended | After a suicide attempt or in the presence of suicidal ideation/plan when:
|
After a person has attempted suicide, they often require inpatient psychiatric treatment. Sometimes patients will agree to this treatment, while others will not. The Involuntary Treatment Act governing the psychiatric detainment against the will of the patient is state specific. Follow the law in your state.
Risk management is an important aspect of clinical practice, particularly related to the assessment and treatment of patients at risk for attempting or committing suicide. To mitigate risk, the provider should maintain a positive, collaborative relationship with the patient and remain attentive to what information is documented in the medical record.6
Thorough and appropriate documentation is essential to prevent malpractice lawsuits. Documentation should always occur6:
This documentation should include6:
In their publication Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors, the American Psychiatric Association defines six key components of the management of suicidal behavior6:
First, the healthcare provider must focus on developing a strong therapeutic alliance with the patient.6 The clinicians should begin by building trust and establishing mutual respect. Only within a trusting relationship will patients feel comfortable discussing and addressing their suicidal ideation and behaviors. The ultimate goal of the patient-provider relationship is reducing the risk of suicide.6
Next, the clinician must attend to the patient’s safety.6
After developing a therapeutic alliance and attending to the patient’s safety, the clinician must select the most appropriate treatment setting. The patient should always be treated in the least restrictive yet safest most effective setting.5 Table 6 provides the guidelines for determining when a patient needs inpatient psychiatric treatment.6
Psychiatric specialists and primary care providers must coordinate their care to offer the best treatment to patients with suicidal behaviors. These patients are often complex, requiring an interdisciplinary team of healthcare professionals such as social workers, case managers, and psychiatric nurses.
During the early stages of recovering from a suicide attempt, patients will be encouraged to undergo education and supportive psychotherapy. Depressive disorders, the most common underlying condition in patients who attempt suicide, should be managed. Counseling may be effective in the treatment of depression and/or substance abuse.
Talk therapy can be used to treat depression either alone or in combination with medications. In a large meta-analysis, psychotherapy was determined to be more effective than a placebo, and the total number of sessions was not associated with the degree of clinical benefit.7 For mild to moderate major depression psychotherapy and medications are generally comparable.7,8
Psychotherapy helps to address the causative factors and the maintaining factors in depression. It is most effective in moderate-to-severe depression after a medication has stabilized the disease. The two most common therapies are cognitive behavioral therapy (CBT) and interpersonal therapy (IPT).
Cognitive-behavioral therapy helps change thought patterns and behaviors to improve mood. It is believed that the way one thinks and behaves contributes to their depression.9
Talk therapy is effective in certain groups of people. Talk therapy is recommended for those with mild to moderate depression. In severe depression, it is recommended to stabilize the patient on medications before implementing talk therapy. A combination of talk therapy and medications is ideal for adolescents with depression.10
For those individuals with mild depression, the use of self-guided, self-help therapy may be considered. This may involve the use of a structured workbook or guidance by a clinician. If this option is attempted, the patient should let the staff know if there is no response, any worsening or any suicidal ideation. Research suggests that there is a small, but significant benefit to this type of treatment.11
The use of relaxation techniques such as relaxation imagery, progressive muscle relaxation and autogenic training is better than no treatment but less effective than psychotherapy.12
In the early phases of treatment, specialists will monitor the patient closely and prescribe specific treatments for symptoms such as anxiety, insomnia, and hopelessness.
Some medications can cause depression5 leading to suicidal risk. Common medications to consider as causes of depression include:
The use of these medications should be evaluated.
The most serious complication of depression is suicide. Along with substance abuse, depression is the most common mental disease that afflicts those who commit suicide.5 Depression is associated with higher rates of substance abuse. It is unclear if depression causes substance abuse or if substance abuse causes depression. There is likely a complex interaction between the two conditions.
Depression often co-exists with other mental health conditions. Healthcare professionals need to be on the lookout for other conditions. Identifying other conditions is important because it can significantly impact treatment options. For example, certain antidepressant medications are indicated for both anxiety and depression. Other antidepressant medications, while treating the depression, will make the anxiety worse.
One of the most common co-existent conditions is anxiety disorders.5 Anxiety disorders may include generalized anxiety disorders, social phobia, obsessive-compulsive disorder, panic disorder, and post-traumatic stress disorder. Other mental health conditions that may co-exist with depression include substance and alcohol abuse, personality disorders, bipolar disease, eating disorders, adjustment disorder and schizophrenia.
In addition to mental illness, depression often co-exists with many medical diseases.13 Depression may be the result of the medical diseases or depression may exacerbate the medical disease. Common medical illnesses that are seen in combination with depression include heart disease, cancer, stroke, Parkinson's disease, dementia and diabetes.
A variety of treatments are available to manage depression. Common treatments include lifestyle changes, psychotherapy, medications, electroconvulsive therapy and light therapy.
More detail on the identification and treatment of depression is available in the course: Depression.
Psychopharmacology is the study and use of medications that treat psychiatric disorders.13 The goal of psychopharmacology is to help regain proper balance in the chemistry of the brain and restore optimal functioning.5 The use of medications for the mind is, therefore, in most instances, directed towards the control of symptoms. Psychiatric medications are not like antibiotics. Medications alone seldom result in a permanent “cure” of mental or emotional troubles. This means in effect that most psychiatric type medications will need to be taken or be available over an extended period of time while other treatments or therapy seek a resolution to the problem causing the symptoms.
Medications for depression are not as effective as medications for many other conditions. A recent analysis showed that 38% of those treated with antidepressants did not have a positive response in 6-12 weeks.14
Follow-up of the effectiveness of antidepressant use is critical because the FDA suggests that all agents that have antidepressant properties may increase the risk of suicide – especially in patients under the age of 25.
Many different medication choices are available for the management of depression. Medications used to manage depression work mainly by altering the chemicals in the brain, particularly serotonin, norepinephrine and dopamine. Medications take a period of time before they work.15 The effect may be noticed as early as one to two weeks, but it typically requires four to six weeks before a significant effect is noticed.
Antidepressant Medication: Several classes of antidepressant medication exist, grouped together by the neurotransmitter they primarily affect. Antidepressant groupings include:
Monoamine Oxidase Inhibitors: Monoamine oxidase is an enzyme that breaks down neurochemicals such as serotonin, dopamine, and norepinephrine.16 Medication that inhibits the degradation of these neurotransmitters promotes higher levels of mood by increasing the quantity of available neuroactive chemicals.
MAOIs have been found to be effective in a broad range of anxiety and mood disorders, especially depression.13 However, due to the risk of hypertensive crisis, practitioners must be very selective in whom they prescribe MAOIs. The client must be able to understand potential risks and follow a very strict, low-tyramine diet.
MAOIs are useful in the treatment of “atypical” depression (e.g., depression with hyperphagia, hypersomnia, leaden paralysis, or rejection sensitivity). Clinicians should also consider the MAOIs for use in clients exhibiting treatment-resistant depression.13
| Name (Generic) | Brand Name | Elimination Half-life (hours) | Dietary Restrictions |
|---|---|---|---|
| Phenelzine | Nardil® | 1.5-4 | Yes |
| Tranylcypromine | Parnate® | 1.5-4 | Yes |
| Selegiline (transdermal patch) | Emsam® | 1.2 | No – however, caution advised if exceeding recommended dosages |
MAOIs are effective yet currently not a first-line drug due to a range of severe food-drug and drug-drug interactions that accompany them.5
| Food Interactions (Tyramine containing foods) | Drug Interactions |
|---|---|
|
|
| Interaction symptoms are similar and represent the effects of excessive catecholamine neurotransmitters in the body: Hypertension, Tachycardia, Tremors, Hyperthermia, and Seizures. | |
Norepinephrine Dopamine Reuptake Inhibitors: Bupropion is an antidepressant distinctly different from the others. Chemically its structure resembles that of amphetamines and has the ability to increase available levels of the “brain reward” neurotransmitter dopamine. A spotty past has led to some hesitancy among prescribers.
| Name (Generic) | Brand Name | Starting dose, mg/day | Usual dose, mg/day |
|---|---|---|---|
| Bupropion | Wellbutrin® | 75-150 | 300-450 |
| Bupropion SR | Wellbutrin® SR | 100 | 300-400 |
| Bupropion XL | Wellbutrin® XL | 150 | 300-450 |
Selective Serotonin Reuptake Inhibitors and Serotonin Modulators: Serotonin abnormalities are linked to many emotional and behavioral disorders, including mood disorders, obsessive-compulsive disorder, and aggressive behaviors.5 The selective serotonin reuptake inhibitors (SSRIs) have the ability to effectively increase the amount of available serotonin within the brain.13 Increased levels of serotonin occur quickly after initiation of medication therapy. Initial medication response may be seen in about two weeks; however full effect may not be observed for up to eight weeks from initiation of treatment.13
Overall efficacy between the SSRIs in relieving depression appears similar. The choice of agent should be determined by matching medication characteristics with individual needs. Serotonin modulators (e.g., nefazodone, trazodone) are similar to SSRIs in effect though they operate by a slightly different mechanism. Special caution is indicated when liver damage is present due to the manner in which the body metabolizes these agents.
| Name (Generic) | Brand Name | Starting dose, mg/day | Usual dose, mg/day |
|---|---|---|---|
| Citalopram | Celexa® | 10-20 | 20-60 |
| Escitalopram | Lexapro® | 10 | 10-20 |
| Fluoxetine | Prozac® | 10-20 | 20-60 |
| Fluvoxamine | Luvox® | 50 | 50-300 |
| Paroxetine | Paxil® | 10-20 | 20-60 |
| Paroxetine CR | Paxil® CR | 12.5-25 | 25-75 |
| Sertraline | Zoloft® | 50 | 50-200 |
| Serotonin Modulators19 | |||
| Nefazodone | Serzone®, Nefadar® | 50 | 300-600 |
| Trazodone | Desyrel® | 50 | 75-300 |
Serotonergic activity in the central nervous system
|
|
Fluoxetine (Prozac®) is dosed at 20 mg in the morning and can be increased up to 80 mg a day. Each titration must occur after a few weeks on the medication. It is not indicated for those less than eight years old. Fluoxetine has a long half-life and is less likely to lead to withdrawal symptoms if abruptly discontinued. A weekly formulation is available that is dosed 90 mg once a week.13
Fluoxetine can increase the levels of warfarin, phenytoin, carbamazepine, TCAs and benzodiazepines. It may lower the therapeutic effect of codeine. It may cause serotonin syndrome when combined with other SSRIs and other antidepressants. It is pregnancy category C. Pregnancy category C means that in animal studies adverse effects on the fetus were found; however, there are no adequate human studies and the potential benefits of the drug may outweigh the potential risks.13
Sertraline (Zoloft®) is started at 25-50 mg orally every day, and the dose can be increased gradually to a maximum of 200 mg per day. It is not indicated for those less than six-years-old. Zoloft® is a common first-line drug for depression and is associated with few side effects. Common side effects include dizziness, fatigue, headache, insomnia, somnolence, diarrhea, nausea, tremor and diaphoresis. It may interact with warfarin, cimetidine, digoxin and diazepam. It is indicated for major depressive disorder, premenstrual dysphoric disorder, panic disorder, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD) and social anxiety disorder.13
Paroxetine (Paxil®) has a short half-life and may lead to discontinuation syndrome when the medication is stopped or doses are missed. It has the strongest anticholinergic effects of any of the SSRIs. For major depression, the standard form is dosed 10 mg per day to start to a maximum of 50 mg orally per day, and the extended-release form (Paxil® CR) is dosed at 12.5 mg once a day to a maximum of 62.5 mg orally every day.
Paroxetine is indicated for major depressive disorder, panic disorder, OCD, social anxiety disorder, generalized anxiety disorder, PTSD, and premenstrual dysphoric disorder. Side effects include somnolence, insomnia, dizziness, headache, nausea, xerostomia, constipation, diarrhea, weakness, tremor and diaphoresis. Sexual dysfunction is most problematic with paroxetine among the SSRIs7,13 Fluvoxamine (Luvox®) is approved for obsessive-compulsive disorders but is frequently used off label in the treatment of depression and anxiety. The starting dose for adults is usually 50 mg once a day and has multiple drug interactions including benzodiazepines.13
Citalopram (Celexa®) is indicated for depression and is dosed at 20 mg once a day, and the dose can be increased to 40 mg once a day after one week. It interacts with macrolide antibiotics, cimetidine, azole antifungal, omeprazole and carbamazepine. Side effects include: sleep disturbance, xerostomia, nausea and diaphoresis.13
Escitalopram (Lexapro®) is dosed at 10 mg once a day and can be increased to 20 mg after one week. It has few interactions but may interact with other SSRIs, cimetidine and alcohol. It is pregnancy category C. The FDA warns that both citalopram (more than 40 mg/day) and escitalopram (more than 20 mg/day) have the potential to prolong the QT interval, and may be fatal. They should be used cautiously in those with underlying heart disease and those who are prone to becoming hypokalemic.13
Serotonin Norepinephrine Reuptake Inhibitors: Combining the “high alert” system arousal effects of increased norepinephrine with the positive mood benefits of serotonin may be a good combination for some clients struggling with depression. The serotonin-norepinephrine reuptake inhibitors (SNRIs) tend also to have a weak uptake effect. Safety and tolerability of the SNRIs are similar to the SSRIs, although monitoring is warranted for an uncommon sustained rise in blood pressure.13
| Name (Generic) | Brand Name | Starting dose, mg/day | Usual dose, mg/day |
|---|---|---|---|
| Desvenlafaxine | Pristiq® | 50 | 50 (no titration) |
| Duloxetine | Cymbalta® | 30 | 60-120 |
| Venlafaxine | Effexor® | 37.5 | 75-300 |
| Venlafaxine XR | Effexor® XR | 37.5 | 75-300 |
| Noradrenergic and Specific Serotonergic Antidepressant18 | |||
| Mirtazapine | Remeron® | 15 | 15-45 |
Venlafaxine (Effexor®) comes as an immediate-release form and an extended-release form. The extended-release form is dosed 37.5 to 75 mg a day and can be titrated up to 225 mg a day. The immediate-release form is started at 75 mg divided two to three times a day and titrated up to a maximum of 375 mg a day. It may interact with other antidepressants, cimetidine, diuretics and alcohol. It should not be used in those with severe uncontrolled hypertension. It is pregnancy category C. At doses less than 150 mg a day, it mainly affects serotonin levels, but at higher doses, it affects dopamine and norepinephrine levels. Discontinuation syndrome is high with this medication.13
Desvenlafaxine (Pristiq®) is a new drug in this class and is dosed 50 mg once a day for adults. It may be titrated up to 400 mg once a day, but positive effects are not proven with higher doses. Common side effects include nausea, headache, dizziness, dry mouth, insomnia, fatigue and bowel disturbance. It may interact with other SSRIs or blood thinners. It is pregnancy category C.13
Milnacipran (Savella®) is dosed 12.5 mg once a day on the first day and is titrated upwards to a maximum of 200 mg a day divided every 12 hours. It should be used cautiously in those with moderate to severe renal impairment and severe hepatic impairment. Those who take it may suffer from nausea, headache, dizziness, sleep disturbance and constipation.13
Levomilnacipran (Fetzima®) is started at 20 mg once a day and increased to 40 mg once a day. The maximum dose is 120 mg a day. Doses needed to be reducing in those with moderate and severe renal insufficiency. Common side effects include nausea but may also be associated with sexual dysfunction, constipation, urinary hesitancy, and elevated heart rate.13
Duloxetine (Cymbalta®) is dosed 20 mg twice a day to start and may be increased to 30 mg twice a day or 60 mg once a day in the adult. The maximum dose is 120 mg a day. It may interact with ciprofloxacin, SSRIs, TCAs, antiarrhythmic agents and anticoagulants. Common adverse effects include: nausea, headache, dry mouth, dizziness, sleep disturbance and fatigue.13
Duloxetine has multiple indications. It is approved for the treatment of depression in addition to diabetic peripheral neuropathy, fibromyalgia and generalized anxiety disorder. This drug is often used by those who have depression in addition to one of these co-morbid conditions.13
Mirtazapine (Remeron®) is an antidepressant without a home. It is neither an SSRI, nor is it an SNRI. Its effects are similar, yet subtly different than either grouping, and because of those differences, it should be considered as an option in clients with treatment-resistant depression who are not responsive to SNRI or SSRI medications.13
Mirtazapine is dosed 15 mg at bedtime and may be increased every 1-2 weeks up to 45 mg a day in adults. It is given at bedtime because one of its major side effects is sedation. Another common side effect is weight gain. Other side effects include: dry mouth, constipation and dizziness.13
Tricyclic Antidepressants: Cyclic antidepressants were discovered in the 1950s. The first cyclic antidepressants were named “tri”-cyclic because their chemical structure somewhat resembled three interlocked rings when drawn out in scientific notation. Several other cyclic formulations have been discovered since the days of the three-ringers; however, the tradition carries the name tricyclic forward for the general grouping despite its current descriptive inaccuracy.20
Cyclic antidepressants find less common use than the current first-line SSRI and SNRI agents. This in part is due to a wider neurotransmitter effect, with more brain chemicals being shifted and a resultant broadening of potential side effect profiles.20
| Name (Generic) | Brand Name | Starting dose, mg/day | Usual dose, mg/day |
|---|---|---|---|
| Amitriptyline | Elavil® | 25-50 | 100-300 |
| Amoxapine | Asendin® | 50 | 100-400 |
| Clomipramine | Anafranil® | 25 | 100-250 |
| Desipramine | Norpramin® | 25-50 | 100-300 |
| Doxepin | Adapin®, Sinequan® | 25-50 | 100-300 |
| Imipramine | Tofranil® | 25-50 | 100-300 |
| Maprotiline | Ludiomil® | 50 | 100-225 |
| Nortriptyline | Pamelor® | 25 | 50-200 |
| Protriptyline | Vivactil® | 10 | 15-60 |
| Trimipramine | Surmontil® | 25-50 | 100-300 |
Common side effects with TCAs include urinary retention, drowsiness, blurred vision, dry mouth, constipation, orthostatic hypotension, lower seizure threshold and sexual side effects. One major concern with TCAs is that they are more lethal in overdose when compared to newer antidepressants.
The cyclic antidepressants have been associated with occasional cardiac problems. It is highly recommended that before prescribing any of the cyclic agents, a baseline electrocardiogram (ECG) and cardiac history be conducted. In younger clients (less than 40) with a negative cardiac history, the ECG may not be warranted.20
Treatment is typically started at a low dose and slowly titrated upwards to the therapeutic range. Some response is typically seen within one to two weeks.21 Those individuals that respond early to treatment with antidepressants are more likely to go into remission.22 Up to three months of treatment is generally recommended to determine if the treatment was effective.23 In those who have minimal effect after 4-6 weeks, the treatment regime should be reevaluated.24
Medications need to be continued for at least 6-12 months for them to have lasting effects. If treatment is discontinued early, there is a high risk of relapse. Most antidepressants need to be weaned gradually. Abrupt discontinuation of antidepressants can result in serious side effects known as the discontinuation syndrome. Medications should be discontinued over about two months for those on treatment for 6-12 months and up to 6 months for those on long term treatment. Gradually tapering the medication is more critical if the patient is on a high dose.
Acute treatment, follow-up, and ongoing maintenance therapies are all essential in the treatment of substance abuse. Acute medical interventions are focused on the specific medical needs of the individual existing at the time of diagnosis. The consensus of the medical and mental health community, however, is that acute treatment alone is rarely enough. Virtually every client with a substance use disorder diagnosis will benefit from consistent follow-up treatment and lasting support to maintain a substance abuse free life.
Several treatment modalities exist for follow-up treatment of substance problems. Individual factors such as time, expense, personality and available support must all be factored into the decision-making process. The therapeutic regimen known as Brief Intervention has gathered a growing following amongst practitioners due to its well-documented efficacy among the substance-dependent, especially in the subset of problem alcohol behaviors.
Brief intervention is a strategy that utilizes short-duration sessions, which can begin at the time of admission. Brief intervention can be woven into treatment planning and be used at the bedside through the course of medical recovery, while also forming an integrated strategy throughout follow-up office visits or referrals. The techniques involved often take around five minutes or less, which makes it a prized therapeutic method useful to even the busiest health professional. The ability to hold a meaningful session during a routine office visit, for example, makes for a happy client and clinician.
Brief intervention sessions focus on finding and emphasizing the specific motivation that will work for that particular client. These short yet structured sessions continue over a regular schedule until the client is motivated to take positive actions to change behaviors that support their substance use problem. While brief intervention has shown good success, it must be followed up with a structured support system that focuses on the maintenance of the person vulnerable to substance use issues.
One of the prized brief intervention tools when dealing with clients is that of motivational interviewing. Motivational Interviewing (MI) is a system based on an empathetic, respectful view of the client’s life struggles, with a set of simple techniques used for prompting behavioral change. Originally, MI was developed for dealing with problem drinkers yet has proven effective across the board for substance use issues. MI focuses on enhancing the client’s self-motivation for change, addressing ambivalence to change, making an emphasis on personal responsibility and the ability to make meaningful choices.
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| Key Skills of Motivational Interviewing |
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Suicidal thinking and behavior are considered a psychiatric emergency, requiring expert evidence-based assessment and treatment. Importantly, suicide can be prevented. Take immediate action to place the patient in a protective environment.
The clinician may need to intervene directly in order to prevent the patient from harming him or herself. For example, the clinician may need to search the patient’s belongings for weapons, lighters, matches, medications, or other toxic substances. The healthcare provider may also determine that the patient needs constant observation by either another clinician or closed-circuit television.6
Careful monitoring of intoxicated individuals is needed as episodes of generally brief yet severe depression may be associated with severe sedative, hypnotic, or anxiolytic intoxication. Suicide or attempted suicide may be present during such intoxication and may be purposeful or accidental self-injury.
Table 6: Guidelines for Determining Treatment Setting helps providers identify a treatment setting. The specific treatment setting will lead to setting specific protocols based on the suicide risk. Seclusion is the safety plan used for imminent risk of self-harm. The nurse must be aware of and compliant with standards and regulations of regulatory agencies.
Patients who are in seclusion for self-destructive behaviors are to be monitored on a one to one or face to face status by a trained staff member. This monitoring can be done via video and audio equipment, as well as by a staff member trained in this area. The staff member must document the patient’s condition, any attempts at less restrictive intervention with results, a behavioral and medical evaluation, the response to the seclusion and the reason to continue seclusion.
Regulations and standards for seclusion include:
More information on seclusion is available in the course: Restraint Use, Evidence-Based Practice.
When the patient agrees, education should be provided to his or her involved family members. Family members need to understand that psychiatric disorders are a real and difficult illness that requires special treatment. Friends and family should also learn about the role of psychological and social stressors that can precipitate or worsen suicidal behaviors.
Preventing access to firearms can actually decrease firearm-related suicides by 32% among minors and 6.5% in adults.26 A recent study published in 2013 reached the same conclusions: restricting access to firearms reduces suicides and ultimately saves lives.27 Handguns are the most common firearm used to commit suicide in the United States. Due to this impulsive nature of suicide, restricting access to firearms, particularly handguns, helps prevent suicides.
Clinicians must develop a plan of treatment.6 The treatment plan begins by ensuring the patient’s safety and selecting the appropriate treatment setting. After acute treatment, the patient should be referred to a psychiatric specialist such as a psychiatrist or a psychiatric nurse practitioner. These specialized clinicians will continue the patient’s care and ensure timely diagnosis and management of any underlying mental health conditions.
Suicidal ideation requires the management of a psychiatrist or psychiatric nurse practitioner. Primary care providers and psychiatric specialists should work together to ensure there is adequate treatment of the patient, especially those that are medically complex.
Population-Specific Data:
There are an estimated 23.4 million living veterans of United States military service. Active servicemen and women are afflicted with high rates of suicidal thinking and behaviors. According to the National Alliance on Mental Illness (NAMI), veterans represent 20 percent of suicides nationally.28
Historically, suicide death rates in the U.S. Army have been below the civilian rate; however, the suicide rate in the U.S. Army began climbing in the early 2000s, and by 2008, it exceeded the demographically-matched civilian rate (20.2 military suicide deaths per 100,000 vs.19.2 civilians). Currently, U.S. military suicide rates range around 18.7 per 100,000.28
Risk, Protective Factors, and Intervention Strategies:
The veteran population is at an increased risk for suicide because they possess many risk factors29, 30:
Most military suicides occur among young men shortly after they are discharged; however, military women commit suicide three times more often than non-veteran women of the same age.31
Suicide risk among veterans has created an enhanced system of intervention for the Veteran’s Administration (VA). Suicide Prevention Education is provided to military personnel and their families at discharge. Suicide risk assessment has been incorporated into all primary care visits. Over the last decade, additional funding and focus on psychiatric services have resulted in increased resources. The VA has acute psychiatric units, extended inpatient psychiatric and substance abuse services, halfway houses, and outpatient psychiatric services.
Veterans Chat enables Veterans, their families, and friends to go online where they can anonymously chat with a trained VA counselor. If the chats are determined to be a crisis, the counselor can take immediate steps to transfer the chatter to the Veterans Crisis Line, where further counseling and referral services are provided, and crisis intervention steps can be taken. This same service is also available to Service members through Military Crisis Line chat.
Locate A Local Suicide Prevention Coordinator: Each VA Medical Center has a suicide prevention coordinator to make sure Veterans receive needed counseling and services. Calls to the Veterans Crisis Line are referred to suicide prevention coordinators.
Learn more about VA and other organizations’ suicide prevention resources and other Veterans' issues:
Parasuicide describes persons who injure themselves but do not intend to die. These patients self-mutilate by cutting their skin with either a razor blade, knife, broken glass, or mirror. Most often, they injure their wrists, arms, thighs, legs, face, breasts, or abdomen.5 These individuals typically have a personality disorder and display introverted, neurotic, and hostile characteristics.
About four percent of psychiatric patients engage in parasuicidal behavior, which is more than 50 times that of the general population.5 The female-to-male ratio is 3:1.5 While the public may characterize self-injurious behaviors as “attention-seeking” and “avoiding responsibility,” for most patients, this is not the case. Instead, these individuals harm themselves to relieve anxiety or tension and create a sense of self-control.
Sometimes, self-injurious behaviors can accidentally become near lethal. Research demonstrates that those who self-harm often underestimate the objective lethality of their attempt if they ever wish to commit suicide.6 Therefore, clinicians must always assess the frequency, severity, and intent of parasuicidal behavior. Each act must be evaluated in the context of the patient’s current life situation.6
Lethal Means; Objects, Substances and Actions Commonly Used in Suicide Attempts: Men more commonly use firearms, hanging, or jumping from high places whereas women more often use poison or medication overdose.5 In states with more stringent gun control laws, suicide by firearms has decreased. Across the world, the most common method of suicide is hanging.4, 5
A 2003 study published in the Journal of Epidemiological Community Health examined the lethality of firearms relative to other suicide methods.26 This study found that suicide attempts by firearms are 2.6 times more lethal than the second most lethal method--suffocation. The percent lethality rate of firearms is the highest (97%), followed by suffocation (90%), jumping from high places (74%), poisoning (7%), and cutting (7%).26
Impulsivity and Lethality of Means: Suicide is commonly an impulsive act by a vulnerable individual. The impulsivity of suicide provides opportunities to reduce the risk of suicide by restricting access to lethal means. In fact, nearly 40% of suicide attempt survivors report contemplating suicide for less than five minutes before they attempt.27
Communication Strategies for Talking with Patients and Their Support People About Lethal Means and Screening for and Restricting Access to Lethal Means Effectively to Prevent Suicide is discussed in this course section Structured Interview to Gather Information: Table 4: Questions During a Suicide Assessment, section Thoughts of Self-harm and Suicide, provides specific questions that can be used.
Healthcare providers must directly ask patients about suicidal thoughts, plans, and behaviors; however, cultural and religious beliefs about death and suicide may prevent a patient from speaking openly about his or her thoughts. In this case, clinicians must seek out collateral sources such as spouses, friends, family members, clergy, or other healthcare providers.6
