KEY POINTS FOR PRACTICE
• When assessing risk of suicide in the general population and those with psychiatric emergencies, the Columbia-Suicide Severity Rating Scale is the most useful for predicting suicidality.
• Cognitive behavior therapy is the only therapy intervention for suicide prevention with sufficient evidence of reducing risk.
• Caring contact via text or mail after hospitalization reduces suicide attempts but may not be beneficial after emergency department discharge.
• Although a single ketamine infusion reduces acute suicidal ideation, repeated ketamine or esketamine infusions do not appear to reduce suicide risk.
From the AFP Editors
The mortality rate from suicide increased from 14 deaths per 100,000 people in 2001 to 18 deaths per 100,000 people in 2021. The suicide mortality rate in males (29 per 100,000) exceeds the rate in females (7 per 100,000). Firearms are responsible for 55% of suicide deaths, whereas 25% are due to suffocation. The US Department of Veterans Affairs and US Department of Defense (VA/DoD) published updated guidelines on evaluation and management of patients at risk for suicide.
RISK ASSESSMENT
The VA/DoD guideline notes that there is insufficient evidence to recommend for or against suicide risk screening programs. Screening does not seem to lead to increased suicide behavior. One study suggests that a multicomponent intervention including universal screening reduced suicide attempts and deaths.
For universal screening or evaluation of high-risk populations, the Columbia-Suicide Severity Rating Scale (C-SSRS) may be the most useful tool. In the general population, answering yes to any degree of thinking about suicide in the past month or a history at any time of preparing, attempting, or aborting suicide predicts suicidality with a positive likelihood ratio of greater than 10 (large increase), although less than one-half of suicide deaths are predicted. In patients seeking emergency psychiatric care, a positive C-SSRS score has a likelihood ratio greater than 2 (small increase) at 7 and 31 days. Any positive response to question 9 of the Patient Health Questionnaire-9 (PHQ-9) has some utility in predicting suicide and suicide attempt.
Suicide risk can be suggested by reported self-harm thoughts and behaviors, psychiatric conditions, psychiatric treatment, psychiatric symptoms, social determinants of health, adverse life events, availability of lethal means, and physical conditions. Although risk stratification is expected in care, there is no evidence of a tool that reliably stratifies risk. Current machine learning models are not better than the C-SSRS.
NONPHARMACOLOGIC INTERVENTIONS
Therapy
Cognitive behavior therapy (CBT) for suicide prevention is suggested, based on weak evidence of benefit, to reduce risk in patients with suicidal behavior within the past 6 months or any history of self-directed violence. Patients who undergo CBT for suicide prevention are at least 50% less likely to report a repeat suicide attempt in follow-up. Problem-solving therapy, CBT focused on problem-solving to cope with stressful life experiences, appears to reduce suicidal ideation over 3 months.
Other therapies, including acceptance and commitment therapy, the Attempted Suicide Short Intervention Program, dialectical behavior therapy, mentalization-based treatment, mindfulness-based interventions, motivational interviewing, and psychodynamic therapy lack consistent evidence of reducing future suicide behavior. The VA/DoD found insufficient evidence to recommend for or against the Collaborative Assessment and Management of Suicidality, a therapeutic framework aimed at decreasing suicidal ideation and increasing hope, to reduce suicidal ideation.
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