Treatment of Anxiety Disorders

Assessment and Risk Stratification

The American Academy of Pediatrics recommends direct questioning about suicidal thoughts and behaviors for effective suicide risk assessment, including asking specific questions about thoughts of death, suicide plans, past attempts, and access to lethal means 1
A structured approach to assessing suicidal ideation should include questions such as "Have you ever thought about killing yourself or wished you were dead?" and "Have you ever done anything on purpose to hurt or kill yourself?" as suggested by the American Academy of Pediatrics 1
Assessing suicide plans, access to means, intent, motivating factors, and previous attempts is crucial in evaluating suicidal ideation, as suggested by the American Academy of Child and Adolescent Psychiatry 2
The following risk factors should be considered: current mental state (depression, anxiety, agitation, psychosis, hopelessness), psychiatric diagnoses (mood disorders, substance use disorders), living situation (alone, homeless, isolated), male gender, increasing age, substance use, and internet use patterns 1, 2
The following risk stratification can be used:

Cognitive Behavioral Therapy (CBT) focused on suicide prevention is a first-line treatment for patients with recent suicidal behavior, reducing suicide attempts by approximately 50% compared to treatment as usual, as recommended by the American Psychological Association 3
Problem-solving therapies are effective for reducing suicidal ideation in patients with a history of self-directed violence 3
Dialectical Behavior Therapy (DBT) may be considered for patients with borderline personality disorder, although evidence is insufficient to make a strong recommendation 3
Medications such as clozapine, ketamine infusion, and lithium may be considered for patients with suicidal ideation or attempt history, as recommended by the American Psychiatric Association 3, 4

Safety takes precedence over confidentiality when suicide risk is present, and explaining to the patient that information will be shared to ensure their safety is crucial, as recommended by the American Academy of Pediatrics 1
Safety planning-type interventions are strongly recommended for individuals at risk of suicide, including identification of warning signs and triggers, development of internal coping strategies, creation of healthy distracting activities, listing social supports and professional resources, and implementing means restriction planning, as recommended by the British Journal of Psychiatry and the American Academy of Pediatrics 5, 6
Periodic caring communications, such as texts or letters, should be sent to patients for 12 months following hospitalization 3
Frequent follow-up appointments should be scheduled, especially after discharge, and self-guided digital interventions with cognitive behavioral content may be considered 3
Establish frequent follow-up appointments, within 24-48 hours, as recommended by the American College of Physicians and the Annals of Internal Medicine 4, 3

Self-administered scales, such as the PHQ-9 and Columbia-Suicide Severity Rating Scale (C-SSRS), can be useful as screening tools, but tend to be oversensitive and underspecific, as noted by the American Academy of Pediatrics 1
The following assessment tools can be used:

Relying solely on one assessment tool or method should be avoided, as recommended by the American Medical Association 3
Insufficient treatment duration is a common pitfall, as BPD requires longer-term treatment, with benefits lasting up to 24 months after treatment completion, and short interventions are often inadequate, as noted by the American Academy of Child and Adolescent Psychiatry 2
Neglecting suicidality is another pitfall, as always assessing and addressing suicidal ideation is essential as part of the treatment plan, with a strong recommendation from the British Journal of Psychiatry 5