What screening and management tools should be used to prevent suicide in patients at high risk?

These guidelines, developed jointly by the US. Departments of Veterans Affairs and Defense, highlight the need to identify patients already deemed to be at risk for suicide and categorizing their risk as low, intermediate, or high. High risk patients and many patients at intermediate risk should be hospitalized; in the short term, acute treatment with ketamine, lithium, or clozapine, depending on the underlying cause, can be considered. Cognitive behavioral therapy or dialectical behavior therapy can be used after the acute risk is mitigated. A series of algorithms for <a href="https://annals.org/aim/fullarticle/2748922/assessment-management-patients-risk-suicide-synopsis-2019-u-s-department... identification, evaluation, and management</a> are on the website. (LOE = 5)

Sall J, Brenner L, Millikan Bell AM, Colston MJ. Assessment and management of patients at risk for suicide: synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines. Ann Intern Med. 2019;171:343-353. doi:10.7326/M19-0687  [PMID:31450237]

Practice guideline

Government

Various (guideline)

These guidelines update the previous 2013 guidelines issued jointly by two U.S. groups. They are based on a <a href="https://annals.org/aim/fullarticle/2748923/treatments-prevention-managemen... review</a> of randomized controlled trials and other systematic reviews of strategies for treatment of adults at risk for suicide. The guideline development group comprised clinicians from different disciplines and specialties but did not include a patient representative. The group members had no financial conflicts of interest. Some of the recommendations are more clear than others. The recommendations (there are 22 of them) start by screening of patients for suicide who present with warning signs (and not screening of the general public). The next step is to determine whether the person is at low, intermediate, or high risk of suicide. High risk patients should be hospitalized. Patients at intermediate risk may be managed as outpatients if frequent contact and support systems are available. Patients at low risk should be treated for depression if warranted or decreasing isolation by strengthening social support. The guidelines suggest consideration of ketamine infusion for rapid amelioration of suicide ideation or lithium in patients with unipolar depression or bipolar disorder; clozapine can be considered in patients with schizophrenia or schizoaffective disorder. Cognitive behavioral therapy or dialectical behavior therapy can be used to decrease a second attempt at suicide.