Hema Madhuri Mekala, M.D., Simrat Kaur Sarai, M.D., Steven Lippmann, M.D.

Introduction

Suicide is the most common psychiatric emergency (1). Annually, 650,000 people in the United States receive treatment after attempting suicide (1). It is the seventh leading cause of death in this country. About 37,000 individuals commit suicide every year in the U.S. and one million persons worldwide die by suicide (1). The World Health Organization estimates that by 2020, suicide will be the ninth leading cause of death globally (2). About 95% of the people who commit suicide are diagnosed with a psychiatric illness (1). Patients with a history of a suicide attempt are at high risk for a reattempt in the future (2).The prevalence of such individuals with a previous history of suicide having reattempts within one year is 16%–40% (3).  Identifying suicidal ideations and preventing recurrent suicide attempts is a challenging physician obligation that should benefit our patients.

Suicide
                    
Despite identification of risk factors for suicide, there are few specific interventions that are consistently reliable to prevent a reattempt in the future. Following a psychiatric admission, risk for self-harm is highest during the first month and it may decline over time (3). Impulsivity resulting from disappointments is a dangerous confounding factor, especially when co-existent with substance abuse and/or intoxications.

The management of suicidal ideations include pharmacotherapy targeting specific psychiatric conditions, psychotherapy, and a variety of social interventions (3). Psychotherapy reportedly can be more effective in reducing suicidal ideations than medications (1). The therapies most often prescribed to treat these patients include cognitive behavioral therapy, problem solving therapy, dialectical behavior therapy, and psychodynamic psychotherapy (1). Among these, cognitive behavioral therapy is now considered by many to be the most common and maybe the most effective therapy for preventing recurrent suicide attempts (1).

Cognitive behavioral therapy

Cognitive behavioral therapy can have several areas of focus. It should identify risk factors such as previous suicide attempts, family history of suicide, and address current suicidal ideations. The emphasis is on the present issues that currently affect patient function. Within establishing a positive doctor-patient relationship, it also concentrates on the development of better coping skills, focused homework assignments, stressing medicinal or other adherences, and combating potential chemical dependences. Further benefit may come from involving families regarding safety issues, such as removing access to firearms (4,5).
 
Six-month follow-up studies in subjects with suicidal ideations revealed less deaths due to suicide reattempts in those treated with cognitive behavioral therapy (1). Patients who received cognitive behavioral therapy expressed improvements in mood, outlook, problem-solving capacity, and diminished suicidal thinking (1).

Comment

A comprehensive approach is required while evaluating patients since every individual who attempts suicide has different circumstances. Apart from a previous history of suicide attempt, such ideation can also reoccur due to persistent illness, hopelessness, intoxications, impulsivity, resistance, and side effects induced by pharmacotherapies or insufficient medicinal efficacy (6). In summary, there is a need for psychotherapy to target specific risk factors and reduce suicide reattempts. Our patients should be encouraged to participate in cognitive behavioral therapy during follow-up and obtain the advantages of continuing it with medical treatments.

References

1.    Up-to-date. http://www.uptodate.com/contents/suicidal-ideation-and-behavior-in-adults. Last accessed on September 2, 2016.
2.     Chen WJ, Chen CC, Ho CK, et al. Community-based case management for the prevention of suicide reattempts in Kaohsiung, Taiwan. Community Mental Health Journal. 2012; 48(6):786-791.
3.     Ruengorn C, Sanichwankul K, Niwatananun W, et al. Incidence and risk factors of suicide reattempts within 1 year after psychiatric hospital discharge in mood disorder patients. Clinical Epidemiology. 2011; 3:305. 
4.    Stanley B, Brown G, Brent DA, et al. Cognitive-behavioral therapy for suicide prevention (CBT-SP): treatment model, feasibility, and acceptability. Journal of the American Academy of Child & Adolescent Psychiatry. 2009; 48(10):1005-1013.
5.    Lippmann S. Doctors Teaching Gun Safety.  Journal of The Kentucky Medical Association. 2015; 113(4):112.
6.    Neuner T, Schmid R, Wolfersdorf M, et al. Predicting inpatient suicides and suicide attempts by using routine clinical data. General Hospital Psychiatry. 2008; 30(4):324-330.