What Is in Your Treatment Toolbox? Clinical Interventions to Prevent Suicidal Behavior

By Dr. Jane Pearson, National Institute of Mental Health & Action Alliance; Dr. Joel Sherrill, National Institute of Mental Health; and Colleen Carr, National Action Alliance for Suicide Prevention Secretariat

Community behavioral health providers are expected to know how to treat suicidal patients. As so often is the case, though, the practice demands are ahead of the research. New studies are testing the best ways to treat and prevent suicidal behavior, but how do you treat these behaviors without a full toolbox?

Medication Interventions

Many individuals with suicidal ideation will receive medications to address symptoms and “underlying” psychiatric conditions. However, most medication takes weeks to provide relief from psychiatric symptoms.

Currently, the only medication with a specific FDA indication relevant to suicide is clozapine. Clozapine is indicated for reducing the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder. However, agranulocytosis, a rare side effect of clozapine, results in the need for frequent monitoring of white blood cells, which limits its use in practice.

Although not FDA-indicated, lithium medication has been associated with lowering suicide risk in individuals with bipolar disorder. Research has found that individuals who remained adherent to lithium treatment were at lower risk for suicide, but placebo-controlled studies of lithium are still needed to isolate the medication versus compliance benefits in reducing suicide risk.

Ketamine, originally used as an anesthetic, is a repurposed medication that is showing promise as a fast-acting treatment for severe depression and suicidal ideation. Additional research is needed to determine the safety, feasibility, dose and duration for the use of Ketamine, but it does open up the potential for future fast-acting medication treatments for suicidal ideation that could be used in acute care settings.

In addition to tracking possible untoward side effects, there is also a need to test suicidal events as outcomes in medication research studies focused on treating mental disorders. In the past, many industry-sponsored trials excluded suicidal individuals from efficacy trials.

Psychotherapy Interventions

Several research reviews have found that outpatient psychotherapies (e.g., cognitive behavior therapy; dialectical behavior therapy; problem solving therapy) reduce suicidal thinking and re-attempts among high-risk adult patients. One review notes that psychotherapy recipients had, on average, a 32 percent reduction in the likelihood of a suicide attempt compared with usual care within a year.

Another study from the Danish health care registry followed recipients of psychotherapy and those not receiving psychotherapy for up to 20 years. Those who received psychotherapy were 16 percent less likely to attempt suicide and 25 percent less likely to die by suicide.

Modeling the future

In 2014, the Action Alliance’s Research Prioritization Task Force modeled optimal implementation of evidence-based psychotherapy delivered to the U.S. population of adults seen in emergency care for suicide attempts. The model estimated that more than 109,000 suicide attempts and more than 13,000 suicide deaths could be averted over 5 years by delivering effective psychotherapy to adults seen in emergency care settings for self-harm. This demonstrates enormous potential for successful intervention. In the meantime, we must continue to invest in suicide research.

Unanswered Questions

Research challenges include the need to better understand developmental and contextual factors:

• Youth, adult, older adult;
• Transitional, work and health contexts such as discharge from military and COPD onset;
• Co-occurring psychopathology (e.g., substance use);
• Social context (LGTBQ; domestic violence; recent loss);
• Prior suicidal behavior;
• Treatment history and
• Current setting–including immediate (referred from inpatient or emergency care)–in intervention research.

We need to know how to better match potential interventions to the patient’s needs. New treatment targets (e.g., isolation; anhedonia; insomnia; agitation; psychosis) might also be more efficiently addressed.

While suicide research around effective interventions is rapidly increasing, there remain many questions left to answer. For lives to be saved, effective research must be translated into practice.

As community behavioral health providers on the front line, you are the lifeline for patients at risk for suicide and those recovering from an attempt.

(See Section IX in the Research Agenda for citations for all research mentioned above. )

This post has been cross-posted on the National Council for Behavioral Health site.

What We Know (and What We Don’t) About Predicting Suicide Risk

By Dr. Jane Pearson, National Institute of Mental Health & Action Alliance; Dr. Lisa Colpe, National Institute of Mental Health; and Colleen Carr, National Action Alliance for Suicide Prevention Secretariat

Screening for suicide risk is common to most suicide prevention efforts and clinical practices that aim to identify at-risk individuals. To reduce suicide’s burden, there are a number of research-supported screening and risk detection tools to employ, but there is no doubt that further research is necessary to better understand the various factors that put people at risk of suicide.

The Continuum of Suicide Risk
Ideas about screening reflect our assumptions about a continuum of suicide risk—it is assumed there is a progression of suicide ideation, plans and eventual behavior (i.e., suicide attempts, suicide death). For example, multinational surveys have found that about a third of individuals who think about suicide make a plan and about a third go on to attempt suicide. Meanwhile, another subgroup reports having made an attempt with little or no ideation or planning.

Active versus Passive Ideation
Current approaches to assessing risk are heavily weighted toward identifying active ideation with a plan versus passive ideation (e.g., desire for death). However, some studies have found that passive ideation is just as strongly associated with morbidity as active ideation.

Screening Approaches
Many stakeholders consider screening for suicide risk an essential step in reducing suicides—and there are many opportunities to screen. Holding an annual depression screening day in the workplace or a school screening event following a suicide are two community examples. Screenings can be standalone, web-based for use in public settings or clinical tools (e.g., PHQ-9) integrated into primary care or other intake procedures to detect and monitor depression with suicide ideation. In fact, research looking at a large set of electronic health record data found a six-fold increased risk for suicide attempt (includes 709 attempts and 46 deaths) if someone responded ‘every day’ to the question, “Over the past two weeks, how often have you been bothered by thoughts that you would be better off dead, or hurting yourself in some way?” on PHQ-9.

Screening within Health Systems
Screening practices are ahead of research. The Joint Commission recommends screening in all medical care settings to prevent suicide attempts and deaths. However, health care settings vary with regard to the proportion of patients at risk and the steps necessary to get identified patients to adequate care. In any setting, risk detection alone will not reduce suicide. Assessment, adequate intervention and ongoing monitoring must support screening and detection efforts to have the desired impact of reduced suicidal behavior.

Promising Research
Research links neurocognitive science with risk detection and screening. For example, the Suicide Implicit Association Task (IAT) has shown to improve prediction of who will attempt suicide in the future. It examines reaction times to ‘life’ and ‘death’ words and can be administered on the computer in 5-10 minutes. It is currently being studied in emergency department environments with both youth and adults.

Recent research has also identified specific genetic markers for suicidal behavior, but the studies require replication before having a role in clinical practice.

How Can Risk Detection Contribute to Achieving a 20% Reduction in Suicide?
There are a number of ways to model how our nation could achieve a 20% reduction in suicides. One strategy is to stratify risk and identify those in the high-risk group due to risk factors and those in the low-risk group due to risk and protective factors. If we can identify those in the high-risk group and intervene so we move more individuals into the lower part of the triangle (see graphic), we can begin to reduce suicide’s burden on our nation.

On January 29, the National Council launched a six-part webinar series highlighting the National Action Alliance for Suicide Prevention’s Prioritized Research Agenda for Suicide Prevention: An Action Plan to Save Lives. This series is a collaborative effort between the National Council for Behavioral Health,National Action Alliance for Suicide Prevention and the National Institute of Mental Health. Subsequent webinars will describe how this current understanding influences detecting those at risk, clinical care and services, as well as highlighting a number of the pressing research needs to reduce the burden of suicide. For more information about this webinar series, see Linda Rosenberg’s recent blog post announcing this collaboration.

This post has been cross-posted on the National Council for Behavioral Health site.

The Four Factors that Lead to (and Protect Against) Suicide

By Dr. Jane Pearson, National Institute of Mental Health & Action Alliance; Dr. Elizabeth Ballard, National Institute of Mental Health; and Colleen Carr, National Action Alliance for Suicide Prevention Secretariat

The ultimate answer to “Why do people become suicidal?” is complex, and as depicted in the figure below, research has focused on several long- and short-term risk factors that interact to place an individual at increased suicide risk.

1. Social Determinants

Healthy connectedness with family members, neighborhoods, cultural groups and society can serve as a protective factor against suicide. Conversely, social isolation is associated with increased risk. Social networks can be leveraged to promote protective influences across all ages. Young people’s attachment to their family and schools can serve as a protective factor with “school-connected” teens exhibiting a decreased risk for suicidal behavior over time. Interventions that increase healthy connections have been related to reduced suicide risk in older Japanese adults.

At the same time, certain types of social networks can relate to increased suicide risk, both in person and via media influences. Social networks can contribute to a “contagion” of suicidal behavior, potentially through imitation, idealizing and/or by ‘normalizing’ suicidal behavior. Media reporting of high-profile suicides also carries a concern for increased suicidal behavior.

2. Clinical Factors

Research has identified a host of clinical suicide risk factors. Psychiatric risk factors for suicide include depression, anxiety, post-traumatic stress and addiction; physical symptoms include pain and insomnia. Suicide has been associated with specific cognitive symptoms such as suicidal thoughts, making a plan, hopelessness, feeling like a burden and impulsiveness. However, it is important to note that the vast majority of people with behavioral health and physical illness diagnoses do not kill themselves.

3. Neurocognitive Factors

There is a connection between suicide attempts and deficits in basic cognitive functions (e.g., attention, memory), executive performance (e.g., conceptual processes, reversal learning), impulse control, decision-making and implicit thought processes (e.g., implicit associations, like preference and self-esteem). The neurocognitive findings associated with suicide risk include motor impulsivity, decision-making, response inhibition, flexibility of response generation, self-monitoring/error-processing, sensitivity to others’ anger, impaired response to positive emotional stimuli, harm avoidance and an inability to delay rewards. Recent research demonstrates that teens who attempt suicide may have impaired decision making on tasks such as the Iowa Gambling Test.

None of these factors has been determined to be entirely specific to suicide—whether or not these factors can be used reliably as clinical predictors remains to be seen.

4. Biomarkers that Reflect Biological Processes

Early research provided some evidence that suicidal behavior is heritable. Twin studies report 36-43 percent heritability; non-fatal suicide attempts have heritability estimates of 17-45 percent, even after controlling for any psychiatric disorders. In addition, children are five times more likely to attempt suicide if a parent has a history of suicide attempts, and it may relate to impulsive aggression. Another example of tragic and toxic parent-child outcomes, between 10-40 percent of individuals who experience suicidal thoughts and behavior have a child abuse history.

Immune factors, patterns of brain activity observed with imaging and genetic variants, have all been studied to identify biomarkers that can help predict risk or resilience. Current research trends include serotonergic functioning, glutamatergic functioning and responsiveness to stress in the HPA (hypothalamic–pituitary–adrenal) axis, which may be linked to childhood traumatic experiences.

At this point in time, there is no biomarker with diagnostic clinical utility.

There is a great deal to be hopeful about with regard to improving our understanding of why people consider and try to kill themselves. For more information and detailed citations on the information presented above, see the full Prioritized Research Agenda for Suicide Prevention: An Action Plan to Save Lives.

On January 29, the National Council launched a six-part webinar series highlighting the National Action Alliance for Suicide Prevention’s Prioritized Research Agenda for Suicide Prevention: An Action Plan to Save Lives. This series is a collaborative effort between the National Council for Behavioral Health, National Action Alliance for Suicide Prevention and the National Institute of Mental Health. Subsequent webinars will describe how this current understanding influences detecting those at risk, clinical care and services, as well as highlighting a number of the pressing research needs to reduce the burden of suicide. For more information about this webinar series, see Linda Rosenberg’s recent blog post announcing this collaboration.

This post has been cross-posted on the National Council for Behavioral Health site.

A Vision for Research

By Phillip Satow, Private Sector Co-lead, Research Prioritization Task Force, National Action Alliance for Suicide Prevention; Representative, National Council for Suicide Prevention; Chair of the Board, The Jed Foundation

At the end of 1998 I lost my son Jed to suicide. Since then, like so many survivors, caregivers, and advocates, I have worked hard to understand this unendurable tragedy. Sixteen years later, I am happy to be part of the creation of A Prioritized Research Agenda for Suicide Prevention: An Action Plan to Save Lives. This blueprint, if implemented, has a high probability of making a significant impact on our knowledge of suicidal behavior and, most importantly, on the suicide rate itself. The Agenda is a product of the Research Prioritization Task Force of the National Action Alliance for Suicide Prevention, a public-private partnership whose mission is to advance the National Strategy for Suicide Prevention. I have the honor of being the private sector co-chair of this task force. The public sector co-chair is Dr. Tom Insel, Director of the National Institute of Mental Health.

Our task force had a vision — a vision of creating a paradigm based on the careful prioritization of suicide research efforts. How else could we allocate our limited resources as effectively as possible to prevent the maximum number of people from taking their own lives?

Our activities in the mental health 501(c)3 world tend to fall into silos. That is, our organizations generally focus their programming and funding within particular DSM categories or illnesses. We know, however, that there are often associated symptoms, co-morbidities, and other complications that caregivers cannot ignore during treatment. For example, substance abuse is associated with many mental illnesses, while symptoms of depression and anxiety disorders may be associated with each of a full spectrum of disorders.

In addition, there is a connection between suicide and emotional illnesses that is stronger than most people realize. Suicide mortality in populations with a mental disorder is about three times that of the general population. Depressed patients have a 20-fold greater lifetime risk for suicide than the general population. Bipolar illness, panic disorder, and schizophrenia are also associated with suicide risk. These associations speak to the interdisciplinary nature of our mission. We all need to understand the brain better than we do if we hope to progress, not only in suicide prevention but in finding better treatments for all illnesses of the brain. Clearly, improving our prospects for suicide research and discovering better approaches to prevent self-harm will benefit all of our respective missions and our common goal of preventing suicide.

Unfortunately the suicide rate has not decreased appreciably in the last 50 years. It’s hard to believe that nearly 700,000 individuals annually report having received medical attention for a suicide attempt each year. Nearly 40,000 people die by their own hand annually. The number of suicide deaths over the years 2000-2009 increased by nearly 26 percent. During the same period, mortality from HIV, asthma, heart disease, and many cancers has declined.

Each year, we spend 40-50 million dollars on suicide research in the United States. The vast majority of these funds come from the National Institute of Mental Health. However, other organizations, like the American Foundation for Suicide Prevention, also fund research. If we added Veterans Administration and Department of Defense expenditures, the total would be somewhat higher.

Doesn’t it make sense that these funds should be directed to the projects most likely to advance our knowledge base and reduce the suicide rate? I am confident that we all agree that there is no lack of ideas emanating from our research community. But how can we feel confident that funds are directed toward establishing research pathways that would truly reduce the burden of suicide in an optimal manner? The question always remains: if funding was increased, if new funding was developed, how should it be allocated?

There has never been a reluctance to recognize the need for a research agenda. However, because of a combination of the lack of sufficient funding, the lack of an appropriate implementation vehicle, and the inability to galvanize the many disciplines required for the effort, we have not been able to systematically address that need until now. The 2002 Institute of Medicine report Reducing Suicide: A National Imperative recognized the importance of interdisciplinary research on suicide. Both the original National Strategy for Suicide Prevention promulgated by Surgeon General Satcher and its 2012 update explicitly call for a research agenda. The long elusive goal of completing a targeting agenda has now been accomplished.

At the urging of Tom Insel, the Task Force established a specific numerical goal for reducing suicide burden. We set a goal of developing an agenda for research that, if fully implemented, has the potential to reduce morbidity and mortality by at least 20 percent in five years and 40 percent in ten years. This goal is aggressive and far-reaching — but doable! The achievement of our task force’s goal in five years could lower the suicide rate to less than 10/100,000 and less than 8/100,000 in ten years.

We also agreed that we needed a broad sampling of stakeholders in our field — survivors, caregivers and researchers — to inform us of their personal aspirational goals for future suicide prevention research. More than 700 people who have been touched by suicide answered our questionnaire. The many hundreds of aspirational goals offered by stakeholders were reduced to 12 that were deemed to be of highest priority.

A literature search was conducted, followed by a portfolio analysis which documented the state of ongoing research studies. Opinion-leading scientific minds weighed in to help design or identify research pathways to achieve the prioritized aspirational goals which represented the "wishes," if you will, of the suicide community.

With research pathways identified, the task force and our advisors and experts established short- and long-term research objectives. The recommended pathways and objectives are central to the final task force product and to the achievement of our underlying goal.

So, why do we think it can be achieved? We conducted a systematic review of available suicide death and attempt surveillance, data which helped to uncover promising areas of future research. We developed several models of interventions to estimate the potential benefit for individuals at risk within boundaried communities (enclosed entities like our criminal justice system, college campuses, integrated health care complexes, and HMOs). There are more than two million suicide attempts in boundaried communities. Developing effective interventions for these environments has the potential to bring about major reductions in attempt rates.

Critical to achieving our goals is funder cooperation and transparency. And we must not forget the amount of hard work that mental and health supporters put into advocating for an increase in federal funding for suicide research.

The implementation plan for the task force's final report is critical. We expect all the key funders of suicide research to familiarize themselves with its content. We hope that future funding will be directed at the objectives that are clearly outlined in the agenda. The task force expects that the details of its work will be broadly disseminated and will appear in widely read scientific journals. We hope that researchers will focus their efforts on priorities consistent with those suggested in the plan. We also hope that future funding will be allocated to studies that incorporate thematic elements highlighted across multiple pathways, for example, the increased use of common data elements, banking and sharing to leverage research investments, fielding practical research designs, and finding service quality improvements to reduce suicide.

Lastly, I expect that stakeholders, whose aspirational goals are targets for achievement, will now have a potential rallying point and that they will find the task force’s research priorities understandable and see them connected to their own aspirations and to potential reductions in suicide burden. They may also appreciate the broad definition of research that the document considers, including services research, outcomes research, and prevention research — research that for many may have a more direct and practical association to suicide prevention programing.

Most importantly, we can’t let the agenda sit on a shelf. The potential to save thousands of lives, including those of so many military personnel and veterans, deserves support. I hope each of you can help foster a groundswell of awareness and support for this unique opportunity to help move the suicide prevention field forward.

This post was cross-posted on the Suicide Prevention Resource Center's Director's Corner.