APA’s Newest Practice Guideline Addresses Suicide-Risk Issues

If only psychiatrists could have a crystal ball at their disposal when working with patients at risk for suicide. While that’s an unfulfillable fantasy, psychiatrists now can, with APA’s newest evidence-based practice guideline, fine-tune their ability to assess those who may be at risk for suicide and treat them.

APA’s Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors was approved by APA’s Assembly in May and by the Board of Trustees last month.

The guideline is divided into two major sections: Part A includes recommendations for the assessment and treatment of suicidal behaviors, and Part B provides an overview of suicide and reviews the literature upon which the recommendations in Part A are based.

“The majority of psychiatrists are involved in the evaluation of the risk of suicide in their patients,” Douglas Jacobs, M.D., chair of the Workgroup on Suicidal Behaviors, told Psychiatric News. Jacobs is an associate professor of psychiatry at Harvard Medical School and founder and executive director of Screening for Mental Health Inc.

Members of the work group, which included suicide researchers such as Jacobs, collaborated with members of the Steering Committee on Practice Guidelines, a group of consultants, and APA staff to formulate the guideline.

“The new guideline will be of great help to psychiatrists in their daily work,” said John McIntyre, M.D., chair of the Steering Committee on Practice Guidelines. “Suicide and suicidal behaviors cause severe personal, family, and social consequences and remain among the most challenging issues facing psychiatrists.”

APA practice guidelines are published as supplements to the American Journal of Psychiatry. The guideline is expected to appear in the November issue and will simultaneously appear on APA’s Web site with previously published practice guidelines.

The guideline will also be included in the APPI publication 2004 Compendium of Practice Guidelines, which is slated for release in fall 2004.

Jacobs said that by reviewing the guidelines, psychiatrists will better understand the prevalence rates, risk factors, and protective factors for patients, as well as the psychotherapeutic and pharmacologic treatments for at-risk patients.

“They will also learn that certain risk factors for suicide are modifiable and some are what we call static—this is important to keep in mind when evaluating patients,” he said.

In addition, the guideline provides psychiatrists with tips about how to elicit information about suicidal intent, how best to manage the risk of suicide in patients from a legal standpoint, and under what conditions it may be necessary for the psychiatrist to reveal confidential information about the patient to significant others to keep the patient safe.

Some of the risk factors for suicide, according to the guideline, are aggression, impulsiveness, hopelessness, and psychic anxiety.

The guideline notes that long-term maintenance treatment with lithium is associated with major reductions in both the risk of suicide and suicide attempts in patients with bipolar disorder, while the evidence supporting lowered suicide rates with antidepressants is inconclusive.

Clozapine has been found to reduce the rates of suicide attempts and perhaps even suicide in patients with schizophrenia and schizoaffective disorder.

The guideline cautions psychiatrists not to rely on a suicide-prevention contract (see Original article: page 3). By signing such a document, a patient agrees to contact his or her psychiatrist or other treatment team members before harming himself or herself.

“No studies have shown their effectiveness in reducing suicide,” the guideline states of these contracts. “In fact,” the guideline continues, “studies of suicide attempters and inpatient suicides have shown that a significant number had a contract in place at the time of their suicidal act.”

Jacobs emphasized that the guideline does not serve as the “standard of care” for suicidal patients, but instead offers psychiatrists recommendations about evaluating and treating at-risk patients based on available evidence and clinical consensus. ▪