APA guideline: Assess, monitor risk level of suicidal patients

The treatment of patients who have demonstrated suicidal behaviors should involve a thorough psychiatric evaluation, an estimation of the patient’s risk level and appropriate treatment in a safe but minimally restrictive setting, according to the American Psychiatric Association’s guideline for assessing and treating suicidal behavior.

Additionally, a suicide assessment may be indicated for certain individuals who have not committed any act of self-harm but may be at risk, according to the guideline. These situations may include the following:

Patients who have presented to an ED or for crisis evaluation;
During inpatient or outpatient intake assessments;
Before changes in levels of observation, such as discharge from an inpatient facility;
In cases of significant loss or stress, such as divorce, financial loss or legal problems;
In patients who are experiencing a debilitating or life-threatening physical illness.

In assessing a patient for suicide risk, the psychiatrist should seek to draw out any suicidal ideations and obtain detailed information about situations under which a patient would consider suicide. According to the guideline, the clinician should ask about any specific plans for suicide and inquire into the existence of any firearms or weapons in the patient’s possession or home. Psychiatrists should emphasize to the patient or family member the importance of restricting a patient’s access to any weapons or objects that could be used for self-harm.

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The clinician should estimate the patient’s level of suicidality and consider this information when formulating a plan for the patient’s care. Nearly all psychiatric disorders are known to elevate suicide risk, as do medical illnesses. Some factors, such as responsibility for children at home or religiosity, may serve to mitigate suicide risk.

The psychiatrist should then formulate a multiaxial diagnosis, including identification of any physical or psychiatric conditions that may contribute to the extent of suicidality, as well as the patient’s level of functioning.

When developing a treatment plan for a suicidal patient, a clinician should first ensure the immediate safety of the patient. Patients seen in an emergency setting may benefit from one-to-one monitoring or continuous closed-circuit television monitoring until the patient is no longer in crisis. Any potential weapons should be taken from the patient.

In considering a treatment setting for a patient who is suicidal, clinicians should choose the setting that is least restrictive while also maintaining safety and effectiveness. The current guidelines support psychotherapy for patients with suicidal tendencies, along with pharmacologic therapy. Besides antidepressants, the guidelines suggest that the following may be beneficial:

Lithium salts, for patients with major depressive disorder and recurrent bipolar disorder;
Clozapine, for patients with schizophrenia;
Antipsychotics, for patients who are very agitated;
Anti-anxiety medications;
Electroconvulsive therapy, for a short-term decrease in suicidal ideation.

For more information:

American Psychiatric Association. (2003b). Assessing and treating suicidal behaviors: A quick reference guide. Arlington, VA: American Psychiatric Association. Available at: http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide-guide.pdf. Accessed Dec. 8, 2014.