Management of Suicidal Ideation in Clients with Depression

Immediate Assessment and Safety Planning

The American Academy of Internal Medicine recommends performing a thorough suicide risk assessment focusing on frequency and intensity of suicidal thoughts, access to lethal means, social support, and previous suicide attempts 1
A collaborative crisis response plan should be developed, including identification of warning signs of crisis, self-management coping skills, social support contacts, and crisis resources, as suggested by the American Academy of Internal Medicine 4
Medication should be monitored by a third party who can report any changes in mood, increases in agitation, or unwanted side effects, according to the Journal of the American Academy of Child and Adolescent Psychiatry 5

The American Academy of Internal Medicine suggests considering switching from duloxetine to an SSRI, which has better evidence for treating depression with suicidal features 1
Lithium may be beneficial for patients with mood disorders and suicidal ideation, as it has been associated with reduced suicidal behaviors and deaths, according to the American Academy of Internal Medicine 1
The Journal of the American Academy of Child and Adolescent Psychiatry recommends avoiding tricyclic antidepressants due to their greater lethality in overdose 5
Benzodiazepines should be used cautiously, as they may increase disinhibition or impulsivity in some individuals, as noted by the Journal of the American Academy of Child and Adolescent Psychiatry 5
Ketamine infusion may be considered as an adjunctive treatment for rapid short-term reduction in suicidal ideation if symptoms are severe, according to the Annals of Internal Medicine 6

The American Academy of Internal Medicine recommends initiating cognitive behavioral therapy (CBT) focused on suicide prevention, which has been shown to reduce suicidal ideation and cut the risk of suicide attempts by half compared to treatment as usual 1
Dialectical behavior therapy (DBT) may be considered, as it combines elements of CBT, skills training, and mindfulness techniques to help develop skills in emotion regulation, interpersonal effectiveness, and distress tolerance, according to the American Academy of Internal Medicine 2
Problem-solving therapy can help improve coping with life stressors, as suggested by the American Academy of Internal Medicine 4

The Journal of the American Academy of Child and Adolescent Psychiatry recommends scheduling definite, closely spaced follow-up appointments and contacting the patient if appointments are missed 7
Periodic caring communications, such as postal mail or text messages, should be sent for 12 months following any hospitalization related to suicide risk, according to the Annals of Internal Medicine 6
Self-guided digital interventions with cognitive behavioral-based therapeutic content may be considered for additional support, as noted by the Annals of Internal Medicine 6

The Journal of the American Academy of Child and Adolescent Psychiatry advises against relying solely on no-suicide contracts, as there is no empirical evidence supporting their efficacy 8
Coercive communications, such as "unless you promise not to attempt suicide, I will keep you in the hospital," should be avoided, according to the Journal of the American Academy of Child and Adolescent Psychiatry 8
It should not be assumed that a patient who agrees to a no-suicide contract is no longer at risk, as noted by the Journal of the American Academy of Child and Adolescent Psychiatry 8
Medications with high lethality in overdose should be avoided given the presence of suicidal thoughts, according to the Journal of the American Academy of Child and Adolescent Psychiatry 5