Screening and Management of patients at risk for suicide: DoD & VA Guideline

The U.S. Department of Defense (DoD) in collaboration with the U.S. Department of Veteran Affairs (VA) has released clinical practice guideline for screening, evaluation, treatment and management of patients at risk for suicide. The guideline is published in the Annals of Internal Medicine.

Key recommendations include:

Screening

• With regard to universal screening, we suggest the use of a validated screening tool to identify individuals at risk for suicide-related behaviour.


• With regard to selecting a universal screening tool, we suggest the use of the Patient Health Questionnaire-9 item 9, to identify suicide risk.

Evaluation

• We recommend an assessment of risk factors as part of a comprehensive evaluation of suicide risk, including but not limited to current suicidal ideation, prior suicide attempt(s), current psychiatric conditions (e.g., mood disorders, substance use disorders) or symptoms (e.g., hopelessness, insomnia, and
  agitation), prior psychiatric hospitalization, recent biopsychosocial stressors, and the availability of firearms.


• When evaluating suicide risk, we suggest against the use of a single instrument or method (e.g., structured clinical interview, self-report measures, or predictive analytic models).


• While it is an expected standard of care, there is insufficient evidence to recommend for or against the use of risk stratification to determine the level of suicide risk.

Non-pharmacologic Treatments

• We recommend using cognitive behavioural therapy-based interventions focused on suicide prevention for patients with a recent history of self-directed violence to reduce incidents of future self-directed violence.


• We suggest offering Dialectical Behavioral Therapy to individuals with borderline personality disorder and recent self-directed violence.


• We suggest completing a crisis response plan for individuals with suicidal ideation and/or a lifetime history of suicide attempts.


• We suggest offering problem-solving based psychotherapies to:
  
  
  
  • Patients with a history of more than one incident of self-directed violence to reduce repeat incidents of such behaviours.
  
  
  • Patients with a history of recent self-directed violence to reduce suicidal ideation.
  
  
  • Patients with hopelessness and a history of moderate to severe traumatic brain injury.
  
  
  
  

Pharmacologic Treatments

• In patients with the presence of suicidal ideation and major depressive disorder, we suggest offering ketamine infusion as an adjunctive treatment for short-term reduction in suicidal ideation.


• We suggest offering lithium alone (among patients with bipolar disorder) or in combination with another psychotropic agent (among patients with unipolar depression or bipolar disorder) to decrease the risk of death by suicide in patients with mood disorders.


• We suggest offering clozapine to decrease the risk of death by suicide in patients with schizophrenia or schizoaffective disorder and either suicidal ideation or a history of suicide attempt(s).

Post-acute Care

• We suggest sending periodic caring communications (e.g., postcards) for 12-24 months in addition to usual care after psychiatric hospitalization for suicidal ideation or a suicide attempt.


• We suggest offering a home visit to support re-engagement in outpatient care among patients not presenting for outpatient care following hospitalization for a suicide attempt.


• We suggest offering the World Health Organization Brief Intervention and Contact treatment modality the following presentation to the emergency department for a suicide attempt, in addition to standard care.

Technology-based Modalities

• There is insufficient evidence to recommend for or against technology-based behavioural health treatment modalities for individuals with suicidal ideation. These include self-directed digital delivery of treatment protocols with minimal or no provider interaction (e.g., compact disc, web-based), and provider-delivered virtual treatment.


• There is insufficient evidence to recommend for or against the use of technology-based adjuncts (e.g., web or telephone applications) to routine suicide prevention treatment for individuals with suicidal ideation.

Population & Community -based Interventions

• We suggest reducing access to lethal means to decrease suicide rates at the population level.


• There is insufficient evidence to recommend for or against community-based interventions targeting patients at risk for suicide.


• There is insufficient evidence to recommend for or against community-based interventions to reduce population-level suicide rates.


• There is insufficient evidence to recommend for or against gatekeeper training alone to reduce population-level suicide rates.


• There is insufficient evidence to recommend for or against buddy support programs to prevent suicide, suicide attempts, or suicidal ideation.

"Suicide is a public health problem, with worsening trends in recent decades," James Sall, from the Veterans Health Administration and Texas A&M University, and colleagues wrote. "Nationwide, suicide rates increased 25% from 1999 to 2016. During that same time, the U.S. Department of Defense (DoD) active component suicide rate increased from 10.7 to 21.5 suicide-related deaths per 100,000 service members."

Sources: VA/DoD clinical practice guideline for the assessment and management of patients at risk for suicide

D'Anci KE, et al. Ann Intern Med. 2019;doi:10.7326/M19-0869.

Sall J, et al. Ann Intern Med. 2019;doi:10.7326/M19-0687.