by DG Jacobs · 2010 · Cited by 976 — Before a change in observation status or treatment setting (e.g., A thorough treatment history can serve as a systematic method for gaining information.
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1PRACTICE GUIDELINE FOR THE Assessment and Treatment of Patients With Suicidal BehaviorsWORK GROUP ON SUICIDAL BEHAVIORS Douglas G. Jacobs, M.D., Chair Ross J. Baldessarini, M.D. Yeates Conwell, M.D. Jan A. Fawcett, M.D. Leslie Horton, M.D., Ph.D. Herbert Meltzer, M.D. Cynthia R. Pfeffer, M.D. Robert I. Simon, M.D. Originally published in November 2003. This guideline is more than 5 years old and has not yet been updated to ensure that it reflects current knowledge and practice. In accordance with national standards, including those of the Agency for Healthcare Research and Quality™s National Guideline Clearinghouse (http://www.guideline.gov/), this guideline can no longer be assumed to be current.
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2APA Practice Guidelines AMERICAN PSYCHIATRIC ASSOCIATION STEERING COMMITTEE ON PRACTICE GUIDELINES John S. McIntyre, M.D., Chair Sara C. Charles, M.D., Vice-Chair Daniel J. Anzia, M.D. Ian A. Cook, M.D. Molly T. Finnerty, M.D. Bradley R. Johnson, M.D. James E. Nininger, M.D. Paul Summergrad, M.D. Sherwyn M. Woods, M.D., Ph.D. Joel Yager, M.D. AREA AND COMPONENT LIAISONS Robert Pyles, M.D. (Area I) C. Deborah Cross, M.D. (Area II) Roger Peele, M.D. (Area III) Daniel J. Anzia, M.D. (Area IV) John P. D. Shemo, M.D. (Area V) Lawrence Lurie, M.D. (Area VI) R. Dale Walker, M.D. (Area VII) Mary Ann Barnovitz, M.D. Sheila Hafter Gray, M.D. Sunil Saxena, M.D. Tina Tonnu, M.D. STAFF Robert Kunkle, M.A., Senior Program Manager Amy B. Albert, B.A., Assistant Project Manager Laura J. Fochtmann, M.D., Medical Editor Claudia Hart, Director, Department of Quality Improvement and Psychiatric Services Darrel A. Regier, M.D., M.P.H., Director, Division of Research
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Assessment and Treatment of Patients With Suicidal Behaviors 3CONTENTS Statement of Intent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Guide to Using This Practice Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Development Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Part A: Assessment, Treatment, and Risk Management Recommendations . . . . . . . . . . . . . . 9 I.Executive Summary of Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 A.Definitions and General Principles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 B.Suicide Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10C.Estimation of Suicide Risk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2D.Psychiatric Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 E.Specific Treatment Modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 II.Assessment of Patients With Suicidal Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 A.Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 B.Conduct a Thorough Psychiatric Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 C.Specifically Inquire About Suicidal Thoughts, Plans, and Behaviors . . . . . . . . . . . . . . . . . . . 19 D.Establish a Multiaxial Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 E.Estimate Suicide Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24F.Additional Considerations When Evaluating Patients in Specific Treatment Settings . . . . . . . 47 III.Psychiatric Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 A.Establish and Maintain a Therapeutic Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 B.Attend to the Patient™s Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 C.Determine a Treatment Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 D.Develop a Plan of Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 E.Coordinate Care and Collaborate With Other Clinicians. . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 F.Promote Adherence to the Treatment Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 G.Provide Education to the Patient and Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 H.Reassess Safety and Suicide Risk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 I.Monitor Psychiatric Status and Response to Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 J.Obtain Consultation, if Indicated. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 IV.Specific Treatment Modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 A.Somatic Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61B.Psychotherapies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 V.Documentation and Risk Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 A.General Risk Management and Documentation Issues Specific to Suicide . . . . . . . . . . . . . . 66 B.Suicide Contracts: Usefulness and Limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
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4APA Practice Guidelines C.Communication With Significant Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 D.Management of Suicide in One™s Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 E.Mental Health Interventions for Surviving Family and Friends After a Suicide . . . . . . . . . . .70 Part B: Background Information and Review of Available Evidence . . . . . . . . . . . . . . . . . . . .71 VI.Review and Synthesis of Available Evidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 A.Factors Altering Risk of Suicide and Attempted Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 B.Psychiatric Assessment Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125 C.Special Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .128 D.Somatic Therapies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 30E.Psychotherapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139Part C: Future Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .142 Individuals and Organizations That Submitted Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .144 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145
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Assessment and Treatment of Patients With Suicidal Behaviors 5STATEMENT OF INTENT The American Psychiatric Association (APA) Practice Guidelines are not intended to be con- strued or to serve as a standard of medical care. Standards of medical care are determined on the basis of all clinical data available for an individual patient and are subject to change as sci- entific knowledge and technology advance and practice patterns evolve. These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome for every individual, nor should they be interpreted as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psy- chiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available. This practice guideline has been developed by psychiatrists who are in active clinical prac- tice. In addition, some contributors are primarily involved in research or other academic endeavors. It is possible that through such activities some contributors, including work group members and reviewers, have received income related to treatments discussed in this guide- line. A number of mechanisms are in place to minimize the potential for producing biased recommendations due to conflicts of interest. Work group members are selected on the basis of their expertise and integrity. Any work group member or reviewer who has a potential con- flict of interest that may bias (or appear to bias) his or her work is asked to disclose this to the Steering Committee on Practice Guidelines and the work group. Iterative guideline drafts are reviewed by the Steering Committee, other experts, allied organizations, APA members, and the APA Assembly and Board of Trustees; substantial revisions address or integrate the com- ments of these multiple reviewers. The development of the APA practice guidelines is not financially supported by any commercial organization. More detail about mechanisms in place to minimize bias is provided in a document avail- able from the APA Department of Quality Improvement and Psychiatric Services, fiAPA Guideline Development Process.fl This practice guideline was approved in June 2003 and published in November 2003.
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6APA Practice Guidelines GUIDE TO USING THIS PRACTICE GUIDELINE Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors consists of three parts (Parts A, B, and C) and many sections, not all of which will be equally useful for all readers. The following guide is designed to help readers find the sections that will be most useful to them. Part A, fiAssessment, Treatment, and Risk Management Recommendations,fl is published as a supplement to the American Journal of Psychiatry and contains the general and specific rec- ommendations for the assessment and treatment of patients with suicidal behaviors. Section I summarizes the key recommendations of the guideline and codes each recommendation ac- cording to the degree of clinical confidence with which the recommendation is made. Section II discusses the assessment of the patient, including a consideration of factors influencing sui- cide risk. Section III discusses psychiatric management, Section IV discusses specific treatment modalities, and Section V addresses documentation and risk management issues. Part B, fiBackground Information and Review of Available Evidence,fl and Part C, fiFuture Research Needs,fl are not included in the American Journal of Psychiatry supplement but are pro- vided with Part A in the complete guideline, which is available in print format from American Psychiatric Publishing, Inc., and online through the American Psychiatric Association (http:// www.psych.org). Part B provides an overview of suicide, including general information on its natural history, course, and epidemiology. It also provides a structured review and synthesis of the evidence that underlies the recommendations made in Part A. Part C draws from the pre- vious sections and summarizes areas for which more research data are needed to guide clinical decisions. To share feedback on this or other published APA practice guidelines, a form is available at http://www.psych.org/psych_pract/pg/reviewform.cfm.
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Assessment and Treatment of Patients With Suicidal Behaviors 9PART A: ASSESSMENT, TREATMENT, AND RISK MANAGEMENT RECOMMENDATIONS I.EXECUTIVE SUMMARY OF RECOMMENDATIONS A.DEFINITIONS AND GENERAL PRINCIPLES 1.Coding system Each recommendation is identified as falling into one of three categories of endorsement, in- dicated by a bracketed Roman numeral following the statement. The three categories represent varying levels of clinical confidence regarding the recommendation: [I]Recommended with substantial clinical confidence. [II]Recommended with moderate clinical confidence. [III]May be recommended on the basis of individual circumstances. 2.Definitions of terms In this guideline, the following terms will be used: SuicideŠself-inflicted death with evidence (either explicit or implicit) that the person intended to die. Suicide attemptŠself-injurious behavior with a nonfatal outcome accompanied by evidence (either explicit or implicit) that the person intended to die. Aborted suicide attemptŠpotentially self-injurious behavior with evidence (either ex- plicit or implicit) that the person intended to die but stopped the attempt before physical damage occurred. Suicidal ideationŠthoughts of serving as the agent of one™s own death. Suicidal ideation may vary in seriousness depending on the specificity of suicide plans and the degree of suicidal intent. Suicidal intentŠsubjective expectation and desire for a self-destructive act to end in death. Lethality of suicidal behaviorŠobjective danger to life associated with a suicide method or action. Note that lethality is distinct from and may not always coincide with an individual™s expectation of what is medically dangerous. Deliberate self-harmŠwillful self-inflicting of painful, destructive, or injurious acts without intent to die. A detailed exposition of definitions relating to suicide has been provided by O™Carroll et al. (1).
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10APA Practice Guidelines B.SUICIDE ASSESSMENT The psychiatric evaluation is the essential element of the suicide assessment process [I]. During the evaluation, the psychiatrist obtains information about the patient™s psychiatric and other medical history and current mental state (e.g., through direct questioning and observation about suicidal thinking and behavior as well as through collateral history, if indicated). This information enables the psychiatrist to 1) identify specific factors and features that may gener- ally increase or decrease risk for suicide or other suicidal behaviors and that may serve as mod- ifiable targets for both acute and ongoing interventions, 2) address the patient™s immediate safety and determine the most appropriate setting for treatment, and 3) develop a multiaxial differential diagnosis to further guide planning of treatment. The breadth and depth of the psy- chiatric evaluation aimed specifically at assessing suicide risk will vary with setting; ability or willingness of the patient to provide information; and availability of information from previous contacts with the patient or from other sources, including other mental health professionals, medical records, and family members. Although suicide assessment scales have been developed for research purposes, they lack the predictive validity necessary for use in routine clinical prac- tice. Therefore, suicide assessment scales may be used as aids to suicide assessment but should not be used as predictive instruments or as substitutes for a thorough clinical evaluation [I]. Table 1 presents important domains of a suicide assessment, including the patient™s current presentation, individual strengths and weaknesses, history, and psychosocial situation. Infor- mation may come from the patient directly or from other sources, including family members, friends, and others in the patient™s support network, such as community residence staff or members of the patient™s military command. Such individuals may be able to provide informa- tion about the patient™s current mental state, activities, and psychosocial crises and may also have observed behavior or been privy to communications from the patient that suggest suicidal ideation, plans, or intentions. Contact with such individuals may also provide opportunity for the psychiatrist to attempt to fortify the patient™s social support network. This goal often can be accomplished without the psychiatrist™s revealing private or confidential information about the patient. In clinical circumstances in which sharing information is important to maintain the safety of the patient or others, it is permissible and even critical to share such information without the patient™s consent [I]. It is important to recognize that in many clinical situations not all of the information de- scribed in this section may be possible to obtain. It may be necessary to focus initially on those elements judged to be most relevant and to continue the evaluation during subsequent contacts with the patient. When communicating with the patient, it is important to remember that simply asking about suicidal ideation does not ensure that accurate or complete information will be received. Cultural or religious beliefs about death or suicide, for example, may influence a patient™s will- ingness to speak about suicide during the assessment process as well as the patient™s likelihood of acting on suicidal ideas. Consequently, the psychiatrist may wish to explore the patient™s cul- tural and religious beliefs, particularly as they relate to death and to suicide [II]. It is important for the psychiatrist to focus on the nature, frequency, depth, timing, and per- sistence of suicidal ideation [I]. If ideation is present, request more detail about the presence or absence of specific plans for suicide, including any steps taken to enact plans or prepare for death [I]. If other aspects of the clinical presentation seem inconsistent with an initial denial of suicidal thoughts, additional questioning of the patient may be indicated [II]. Where there is a history of suicide attempts, aborted attempts, or other self-harming behav- ior, it is important to obtain as much detail as possible about the timing, intent, method, and consequences of such behaviors [I]. It is also useful to determine the life context in which they occurred and whether they occurred in association with intoxication or chronic use of alcohol or other substances [II]. For individuals in previous or current psychiatric treatment, it is help- ful to determine the strength and stability of the therapeutic relationship(s) [II].
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Assessment and Treatment of Patients With Suicidal Behaviors 11If the patient reports a specific method for suicide, it is important for the psychiatrist to as- certain the patient™s expectation about its lethality, for if actual lethality exceeds what is expect- ed, the patient™s risk for accidental suicide may be high even if intent is low [I]. In general, the psychiatrist should assign a higher level of risk to patients who have high degrees of suicidal intent or describe more detailed and specific suicide plans, particularly those involving violent and irreversible methods [I]. If the patient has access to a firearm, the psychiatrist is advised to discuss with and recommend to the patient or a significant other the importance of restricting access to, securing, or removing this and other weapons [I]. Documenting the suicide assessment is essential [I]. Typically, suicide assessment and its documentation occur after an initial evaluation or, for patients in ongoing treatment, when sui- cidal ideation or behaviors emerge or when there is significant worsening or dramatic and un- anticipated improvement in the patient™s condition. For inpatients, reevaluation also typically occurs with changes in the level of precautions or observations, when passes are issued, and dur- TABLE 1. Characteristics Evaluated in the Psychiatric Assessment of Patients With Suicidal Behavior 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 illnesses Current signs and symptoms of psychiatric disorders with particular attention to mood disorders (primarily major depressive disorder or mixed episodes), schizophrenia, substance use disorders, anxiety disorders, and personality disorders (primarily borderline and antisocial personality 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 vulnerabilities Coping skills Personality traits Past responses to stress Capacity for reality testing Ability to tolerate psychological pain and satisfy psychological needs
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