Suicide Prevention: Identify and Treat at Risk Patients (FL INITIAL Autonomous Practice - Differential Diagnosis)

An interview to gather information during a suicide assessment must be done privately. The clinician must approach the situation with empathy and compassion. Table 4 includes a list of questions clinicians can use when inquiring about different aspects of suicide. Clinicians should follow these steps:

• Elicit the presence or absence of suicidal ideation
• Elicit the presence or absence of a suicide plan
• Assess the degree of suicidality, including intent and lethality (Jacobs et al., 2010)

Suicidal assessment scales have limited value. These self-reported scales can help facilitate conversation between patients and providers; however, the American Psychiatric Association states they have limited clinical utility (Jacobs et al., 2010). The existing suicide assessment scales have elicited high false positives, false negatives, and low predictive values. 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, and previous psychiatric hospitalization.

Clinicians should begin by assessing current signs and symptoms of psychiatric disorders (Jacobs et al., 2010). They should pay close attention to signs of a depressive disorder and note any high-risk characteristics (Table 5).

Gender: Men are four times more likely to commit suicide than 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. 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 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 (CDC, 2016). Rates among immigrants are higher than those among citizens (WHO, 2020). Protestants and Jews have higher suicide rates in the United States than Catholics and Muslims. Overall, the level of orthodoxy and social integration is a more accurate predictor of suicide than religion alone (Sadock et al., 2015).

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 (CDC, 2016).  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, married or single. Some individuals commit "anniversary suicides" when their family member or loved one dies (Sadock et al., 2015).

Occupation: The risk of suicide increases as a person's socioeconomic status increases. Employment is 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 increased during economic recessions and decreased during economic booms (Sadock et al., 2015).

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 contributing to suicide include loss of mobility, disfigurement, and chronic pain. Especially when these impact personal relationships and occupational status. Persons on hemodialysis are also at an increased risk (Sadock et al., 2015).

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 (Sadock et al., 2015). Furthermore, schizophrenia accounts for 10 percent, and dementia or delirium accounts for the remaining five percent. Over one-quarter of those who commit suicide depend on alcohol at the time (Sadock et al., 2015).

Substance Abuse: Substance abuse may contribute to suicide. When suspecting substance use disorder, please consider the following:

• Ask first about socially acceptable substances such as caffeine or tobacco products. This question helps to establish a level of comfort for the rest of the interview. Always ask "how many" and "how often," e.g.," You mentioned you drink the occasional latte. How many of those during a week?" "So you have three Grande lattes, with four shots, six days a week, is that correct?"
• Next, inquire about alcohol use. Be sure to ask specifically about beer, wine, and spirits, as many cultures do not consider beer to be alcohol.
• Next, inquire about over-the-counter substances, including diet aids, cough and cold preparations, and herbal supplements.
• Ask about the misuse of prescription items such as sleep medications, pain preparations, medications for attention deficit disorder, or weight loss.
• Next, ask about marijuana, which is legal for use in some states or settings. Be sure to quantify how much and how often.
• Next, ask about illicit drugs. Be consistently non-judgmental and focus on the information needed for accurate health assistance. Street drugs such as heroin, cocaine, hallucinogens, methamphetamine, and inhalants should be asked about here.
• Remember to ask how much, how often, the length of use, and the last time each substance was used. Route of administration is also important, and be sure to ask whether the person has shared substances, especially injected drugs and needles.
• If prior substance use disorders are mentioned, ask about participation in Alcoholics Anonymous (AA), Narcotics Anonymous (NA), other twelve-step programs, addiction treatments, detoxifications, or periods of abstinence from the substance. Of special interest is the length of the longest period without the substance without using other illicit substances or alcohol to help maintain it.
• Ask the person what benefits they obtain from their substance of choice. This question will be very helpful information when treatment for their substance use disorder begins.
• And finally, ask what negative consequences have arisen from their substance use. Should they need coaching, look for items in each of these three key areas;
  • Physical risks include sickness, accidents, fractures, burns, and car wrecks.
  • Psychiatric problems – focusing problems, anxiety, depression, suicidal thoughts, psychosis.
  • Relationship problems – work, social relationships, legal difficulties, financial worries.

Alcohol use disorder is a known contributor to suicide risk and 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 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 have cocaine as a factor.

More detail on identifying and treating 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 and prior substance use disorder treatment (Sadock et al., 2015). 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 (Sadock et al., 2015). Do not forget that a previous suicide attempt is one of the strongest risk factors for another attempt. Clinicians should contact the patient's current primary care or psychiatric provider (Jacobs et al., 2010).

Clinicians should also inquire about the patient's family history. Family dysfunction is linked to suicide and other self-harming behaviors (Sadock et al., 2015). 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 (Jacobs et al., 2010).

Next, the clinicians should assess the patient's psychosocial situation (Jacobs et al., 2010). 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 (Jacobs et al., 2010).

Finally, clinicians must appreciate the patient's psychological strengths and weaknesses. These may include coping skills, personality traits, thinking style, and development needs. Patients are at an increased risk of exhibiting polarized thinking, closed-mindedness, perfectionism, and excessively high self-expectations (Jacobs et al., 2010).

Admission to an inpatient psychiatric hospital is usually indicated after a suicide attempt or an aborted suicide attempt (Jacobs et al., 2010). 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 a stable, supportive living situation (Jacobs et al., 2010).

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 patient's will is state-specific. Follow the law in your state.

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.

Patients will be encouraged to undergo education and supportive psychotherapy during the early stages of recovering from a suicide attempt. Depressive disorders, the most common underlying condition in patients who attempt suicide, should be managed. Counseling may be effective in treating depression 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 more effective than a placebo, and the total number of sessions was not associated with the degree of clinical benefit (Williams & Nieuwsman, 2020). Psychotherapy and medications are generally comparable for mild to moderate major depression (Williams & Nieuwsman, 2020).

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. Cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) are the two most common therapies.

Cognitive-behavioral therapy helps change thought patterns and behaviors to improve mood. It is believed that how one thinks and behaves contributes to depression (Sharf, 2012).

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 (March et al., 2004).

For those individuals with mild depression, the use of self-guided self-help therapy may be considered. This therapy may involve using a structured workbook or guidance by a clinician. If this option is attempted, the patient should inform the staff if there is no response, worsening, or suicidal ideation. Research suggests a small but significant benefit to this type of treatment (Cuijpers et al., 2011).

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 (Jorm et al., 2011).

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 depression, leading to suicidal risk (Sadock et al., 2015). Common medications to consider as causes of depression include:

• Beta-blockers
• Calcium channel blockers
• Corticosteroids
• H2 blockers
• Sedatives
• Chemotherapy agents

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 (Sadock et al., 2015). 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 depression, will worsen anxiety.

One of the most common co-existent conditions is anxiety disorder (Sadock et al., 2015). 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 disorders, and schizophrenia.

In addition to mental illness, depression often co-exists with many medical diseases (Stahl, 2014). Depression may result from medical diseases, or depression may exacerbate the medical disease. Common medical illnesses 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 identifying and treating depression is available in the course Depression.

Psychopharmacology studies and uses medications that treat psychiatric disorders (Stahl, 2014). Psychopharmacology aims to help regain proper balance in the brain's chemistry and restore optimal functioning (Sadock et al., 2015). The use of medications for the mind is, in most instances, directed towards controlling symptoms. Psychiatric medications are not like antibiotics. Medications alone seldom result in a permanent "cure" of mental or emotional troubles. This medication means that most psychiatric-type medications will need to be taken or be available over an extended period while other treatments or therapies 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 had no positive response in 6-12 weeks (Gartlehner et al., 2007).

Follow-up on the effectiveness of antidepressant use is critical because the FDA suggests that all agents with antidepressant properties may increase the risk of suicide – especially in patients under 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 time before they work (Gabbard, 2014).  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 by the neurotransmitter they primarily affect. Antidepressant groupings include:

• Monoamine Oxidase Inhibitors
• Norepinephrine Dopamine Reuptake Inhibitor
• Selective Serotonin Reuptake Inhibitors
• Serotonin Modulators
• Serotonin Norepinephrine Reuptake Inhibitor
• Tricyclic Agents

Monoamine Oxidase Inhibitors: Monoamine oxidase is an enzyme that breaks down neurochemicals such as serotonin, dopamine, and norepinephrine (Higgins & George, 2013). Medication that inhibits the degradation of these neurotransmitters promotes higher levels of mood by increasing the quantity of available neuroactive chemicals.

MAOIs are effective in many anxiety and mood disorders, especially depression (Stahl, 2014). However, due to the risk of hypertensive crisis, practitioners must be very selective in whom they prescribe MAOIs. The client must understand potential risks and follow a strict, low-tyramine diet.

MAOIs are useful in treating "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 (Stahl, 2014).

MAOIs are effective yet not a first-line drug due to a range of severe food-drug and drug-drug interactions accompanying them (Sadock et al., 2015).

Norepinephrine Dopamine Reuptake Inhibitors: Bupropion is an antidepressant distinctly different from the others. Chemically, its structure resembles amphetamines and can increase available levels of the "brain reward" neurotransmitter dopamine. A spotty past has led to some hesitancy among prescribers.

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 (Sadock et al., 2015). Selective serotonin reuptake inhibitors (SSRIs) can effectively increase the amount of serotonin available within the brain (Stahl, 2014). Increased levels of serotonin occur quickly after initiation of medication therapy. Initial medication response may be seen in about two weeks; however, the full effect may not be observed for up to eight weeks from the initiation of treatment (Stahl, 2014).

The overall efficacy of 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, even though they operate by a slightly different mechanism. Special caution is indicated when liver damage is present due to how the body metabolizes these agents.

Fluoxetine (Prozac®) is dosed at 20 mg in the morning and can be increased to 80 mg daily. 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 at 90 mg once a week (Stahl, 2014).

Fluoxetine can increase 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 (Stahl, 2014).

Sertraline (Zoloft®) is started at 25-50 mg orally daily, and the dose can be increased gradually to a maximum of 200 mg daily. 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 (Stahl, 2014).

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 with 10 mg per day to a maximum of 50 mg orally daily, and the extended-release form (Paxil® CR) is dosed at 12.5 mg once to a maximum of 62.5 mg orally daily.

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, tremors, and diaphoresis. Sexual dysfunction is most problematic with paroxetine among the SSRIs. Fluvoxamine (Luvox®) is approved for obsessive-compulsive disorders but is frequently used off-label in treating depression and anxiety (Stahl, 2014). The starting dose for adults is usually 50 mg once a day and has multiple drug interactions, including benzodiazepines (Stahl, 2014).

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 (Stahl, 2014).

Escitalopram (Lexapro®) is dosed at 10 mg daily 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) can potentially prolong the QT interval and may be fatal. They should be used cautiously in those with underlying heart disease and those prone to becoming hypokalemic (Stahl, 2014).

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) also tend to have a weak uptake effect. The safety and tolerability of the SNRIs are similar to the SSRIs, although monitoring is warranted for an uncommon sustained rise in blood pressure (Stahl, 2014).

Venlafaxine (Effexor®) comes in an immediate-release form and an extended-release form. The extended-release form is dosed with 37.5 to 75 mg daily and can be titrated up to 225 mg daily. The immediate-release form is started at 75 mg, divided two to three times daily, and titrated up to a maximum of 375 mg daily. 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 daily, it mainly affects serotonin levels, but at higher doses, it affects dopamine and norepinephrine levels. Discontinuation syndrome is high with this medication (Stahl, 2014).

Desvenlafaxine (Pristiq®) is a new drug in this class and is dosed 50 mg daily for adults. It may be titrated up to 400 mg once daily, 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 (Stahl, 2014).

Milnacipran (Savella®) is dosed 12.5 mg once a day on the first day and titrated upwards to 200 mg a day divided every 12 hours. It should be used cautiously in those with moderate to severe renal and hepatic impairment. Those who take it may suffer from nausea, headache, dizziness, sleep disturbance, and constipation (Stahl, 2014).

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 need to be reduced 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 (Stahl, 2014).

Duloxetine (Cymbalta®) is dosed at 20 mg twice a day to start and may be increased to 30 mg twice daily 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 (Stahl, 2014).

Duloxetine has multiple indications. It is approved for the treatment of depression in addition to diabetic peripheral neuropathy, fibromyalgia, and generalized anxiety disorder. Those with depression often use this drug in addition to one of these co-morbid conditions (Stahl, 2014).

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 from either grouping, and because of those differences, it should be considered an option for clients with treatment-resistant depression who are not responsive to SNRI or SSRI medications (Stahl, 2014).

Mirtazapine is dosed at 15 mg at bedtime and may be increased every 1-2 weeks up to 45 mg daily in adults. It is given at bedtime because sedation is a major side effect. Another common side effect is weight gain. Other side effects include dry mouth, constipation, and dizziness (Stahl, 2014).

Tricyclic Antidepressants: Cyclic antidepressants were discovered in the 1950s. The first cyclic antidepressants were named "tri" because their chemical structure resembled three interlocked rings drawn out in the scientific notation. Several other cyclic formulations have been discovered since the three-ringers; however, the tradition carries the name tricyclic forward for the general grouping despite its current descriptive inaccuracy (Hirsch & Birnaum, 2010).

Cyclic antidepressants are less common than the current first-line SSRI and SNRI agents. This use, in part, is due to a wider neurotransmitter effect, with more brain chemicals being shifted and a resultant broadening of potential side effect profiles (Hirsch & Birnaum, 2010).

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.

Cyclic antidepressants have been associated with occasional cardiac problems. Before prescribing any of the cyclic agents, it is highly recommended that a baseline electrocardiogram (ECG) and cardiac history be conducted. The ECG may not be warranted in younger clients (less than 40) with a negative cardiac history (Hirsch & Birnaum, 2010).

 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 (Uher et al., 2021).  Individuals who respond early to treatment with antidepressants are more likely to go into remission (Ciudad et al., 2012). Up to three months of treatment is generally recommended to determine if the treatment was effective (Papakostas et al., 2009). The treatment regime should be reevaluated for those with minimal effect after 4-6 weeks (McIntyre, 2010).

Medications must be continued for at least 6-12 months 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 treating substance abuse. Acute medical interventions focus on the individual's specific medical needs at the time of diagnosis. However, the consensus of the medical and mental health community is that acute treatment alone is rarely enough. 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 used at the bedside throughout medical recovery while 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. For example, the ability to hold a meaningful session during a routine office visit 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 success, it must be followed up with a structured support system that focuses on maintaining the person vulnerable to substance use issues.

One of the prized brief intervention tools when dealing with clients is motivational interviewing. Motivational Interviewing (MI) is based on an empathetic, respectful view of the client's life struggles, with simple techniques for promoting behavioral change. Originally, MI was developed for dealing with problem drinkers, yet it 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, and emphasizing personal responsibility and the ability to make meaningful choices.

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 to prevent the patient from harming themselves. 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 another clinician or closed-circuit television (Jacobs et al., 2010).

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 occur 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 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 the standards and regulations of regulatory agencies.

A trained staff member monitors patients in seclusion for self-destructive behaviors on a one-to-one or face-to-face status. This monitoring can be done via video and audio equipment and 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:

1. An order for the seclusion must be obtained from a provider within one hour.
2. The RN communicates with the family or legal caregiver about the need for seclusion and the procedure that will be followed.
3. The RN explains to the patient the need for seclusion and attempts to solicit cooperation.
4. The RN arranges for assistance from qualified staff to help with the seclusion, as well as for the care of the patient.
5. The RN ensures continuous observation and treats the patient with dignity and respect.
6. The RN attends to the psychological and physical needs of the patient at regular intervals.
7. The RN documents the use of the seclusion and all assessments.
8. The RN maintains competence and education on the use of seclusion.

More information on seclusion is available in the course Restraint Use, Evidence-Based Practice.

When the patient agrees, education should be provided to their involved family members. Family members must understand that psychiatric disorders are real and difficult illnesses requiring 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 decrease firearm-related suicides by 32% among minors and 6.5% among adults (Shenassa et al., 2003). A recent study published in 2013 reached the same conclusion: restricting access to firearms reduces suicides and ultimately saves lives (Lewiecki & Miller, 2013). 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 treatment plan (Jacobs et al., 2010). 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 adequate treatment of the patient, especially those that are medically complex.