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.

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 New Research Agenda for Suicide Prevention

By Thomas Insel

More than 38,000 Americans died by suicide in 2010, the most recent year for which we have national data. This makes suicide, once again, the tenth leading cause of death for all ages; the second leading cause of death for young adults ages 25 to 34.¹ Despite changes in recent decades that might reasonably have been expected to reduce suicide rates—increased awareness about mental disorders, the availability of treatment, and community-based public health efforts aimed directly at preventing suicide—U.S. rates of suicide deaths have not decreased. In fact, suicide has proven stubbornly difficult to understand, to predict, and to prevent.

This grim reality contrasts with the successes achieved in other areas of medicine and prevention. Death rates from heart disease, cancer, traffic accidents, and homicides are all declining. For heart disease and cancer, research has identified risk factors as well as new pathways to prevention and treatment. Changes in automobile design along with road safety measures have contributed to an ongoing reduction in traffic deaths. Homicides now number less than half the annual total of deaths by suicide in this country.

Why is suicide different? There are a number of public health approaches, from redesigned bridges and buildings to firearm safety, that need the kind of aggressive engineering and policy approaches we have seen with automobile safety. And, learning from heart disease and cancer, we can do better detecting and helping individuals at risk. Despite our best efforts, it remains very difficult to predict who will attempt suicide and, thus, difficult to intervene. The presence of mental illness is a risk factor, but it is not universally present or identified in those who attempt suicide. Treatment can be effective, but too many high-risk individuals are not getting the effective care they need. Suicide remains one of the top five sentinel events (unanticipated events resulting in serious injury or death) for health care systems.² To reduce suicide, we need to know how to target our efforts: to be able to reliably identify who is at risk, how to reach them, and how to deter them from acting on suicidal thoughts.

In a blog post last September, I talked about a newly updated National Strategy for Suicide Prevention and the research agenda being developed by a task force of the National Action Alliance for Suicide Prevention . This week, the Research Prioritization Task Force (RPTF) released A Prioritized Research Agenda for Suicide Prevention: An Action Plan to Save Lives.

The stated goal of the Research Agenda is to reduce suicides by 20 percent in five years and 40 percent in the next ten (assuming all recommendations are fully implemented). The Research Agenda bases its recommendations on the impact of currently known interventions and the potential number of suicide attempts and deaths prevented. For instance, it was estimated that in 2010 there were 735 suicides from motor vehicle carbon monoxide inhalation.³ One model illustrated the hypothetical effect of shut-off devices in cars linked to carbon monoxide sensors, a technology that could be inexpensive per vehicle and is currently feasible. The results suggest that installing devices the way we install seat belts could prevent most suicides from carbon monoxide poisoning in automobiles.

What are we doing to jumpstart this agenda? Two new initiatives will focus on priorities of the Research Agenda. First, NIH recently announced  funding opportunities calling for research on violence with particular focus on firearm violence. This call for proposals was developed in response to the Presidential memorandum  in January 2013 directing science agencies within the U.S. Department of Health and Human Services to fund research into the causes of firearm violence and ways to prevent it. The resulting research will help us understand the risk factors for firearm violence and prevention opportunities, directed at self as well as others.

In 2010, suicide was the third leading cause of death for adolescents. It remains a challenge to predict individual risk, and once a young person screens positive for suicide risk, there are few, if any, strategies to guide matching of individuals to the appropriate intervention. As a second initiative, NIMH released a request for applications  to support research that addresses both issues: developing and testing screening approaches for use in emergency departments (EDs) to identify children and adolescents at risk for suicide; and developing methods to help assign youth who screen positive to appropriate interventions. Given the numbers of young people who may be at risk, and the high number of them who visit the ED, developing effective screening and assessment approaches to gauge the level of risk can give providers the tools they need to better use limited resources.

A friend who lost his son to suicide told me that every suicide has at least 11 victims: the person who dies and at least ten others who will never be the same. This is a problem that sooner or later, unfortunately, touches us all. Developing the Research Agenda was a 3-year effort by the RPTF, chaired by Phillip Satow, chair of the board at the Jed Foundation , and myself. The RPTF called on more than 60 national and international research experts and more than 700 individuals representing stakeholders in this research to identify priorities. We believe the Research Agenda gives us a roadmap to save lives.

References

¹ Centers for Disease Control and Prevention, Web-based Injury Statistics Query and Reporting System, http://webappa.cdc.gov/sasweb/ncipc/leadcaus10_us.html .

² The Joint Commission. Sentinel Event Alert. Issue 46, November 17, 2010. http://webappa.cdc.gov/sasweb/ncipc/leadcaus10_us.html .

³ National Action Alliance for Suicide Prevention: Research Prioritization Task Force. (2014). A prioritized research agenda for suicide prevention: An action plan to save lives. Rockville, MD: National Institute of Mental Health and the Research Prioritization Task Force. 

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This post was originally posted on the NIMH Director's Blog.