Intervention, Education - Therapeutic Management of the Suicidal Patient

Intervention

Successful suicide prevention strategies include educating the public and primary care providers about mental illness, its common presentations, the availability of treatment and how to access it. Underdiagnosis and undertreatment remain signifi-cant problems. Antidepressants, lithium, mood stabilizers and ECT, as well as adjunctive benzodiazepines and antipsychotics, can significantly ameliorate underlying psychiatric diagnoses associated with suicide. Psychosocial interventions have much to add, especially for chronic suicidal ideation, but more intensive outpatient strategies may be limited by resources available.

Education

Educating the public and clinicians about the prevalence, symp-toms and available treatment for mood disorders is of crucial im-portance. It is estimated that half to a quarter of mood disorders go undiagnosed and untreated (Grandin et al., 2001; Nierenberg et al., 2001). Many patients will have spoken to significant others about their distress or have recently seen a health care profes-sional. The US Surgeon General issued a call to action in 1999 to prevent suicide. The linchpins of the strategy include aware-ness, intervention and methodology. Recommendations include improving public awareness of suicide, including their prevent-ability, enhancing access to prevention resources, and decreas-ing the stigma of mental illness. Interventions include improved ability of primary care physicians to recognize, treat, or refer the mentally ill; remove barriers; create incentives to treatment; train other professionals, community members and family to rec-ognize or assess risk; develop programs for at risk adolescents; enhance community access to care and support for suicide sur-vivors; and partnering with the media for educated reporting and depictions of mental illness and suicide deaths. Methodol-ogy involves researching effective prevention programs, clinical and culture specific interventions; developing evaluation tools to measure efficacy of interventions; and the reduction of access to lethal means of suicide (US Public Health Service, 1999).

Oquendo and colleagues (1999) examined the aggres-siveness of antidepressant treatment on patients with major depression, with and without suicide attempts. They included 171 inpatients with major depression, 80 “remote” (defined by the authors as an attempt more than 90 days prior to admission) suicide attempters and 91 nonattempters, in their data analysis. Subjectively and objectively, degrees of major depression were not significantly different. Only 15% of the entire sample was taking antidepressants on admission, and of those who were, 35% were deemed adequately dosed. Almost inexplicably, the patients with a history of suicide attempts, and therefore more likely to have future attempts, were less likely to receive adequate anti-depressant therapy. The failure to diagnose and adequately treat major depression warrants ongoing education of all physicians (Oquendo et al., 1999).

Two reports from the NIMH Collaborative Depression Study, 1978–1980 (Keller et al., 1982, 1986), also note under-treatment. Keller and colleagues (1982) described 217 patients entering the naturalistic study. Only 3% with moderate to severe unipolar depression of a month’s duration had been treated with the most intensive dose of tricyclic antidepressants. A quarter of those with psychotic depression received the most intensive therapy and another quarter with psychotic depression received no antipsychotics or antidepressant therapy of any category. The follow-up report (Keller et al., 1986) described treatment of 338 patients in the 2 months after enrollment. Of inpatients, 31% re-ceived no or inadequate antidepressant somatotherapy, and only 49% received the equivalent of at 200 mg of imipramine. Of out-patients, 51% received no or inadequate somatotherapy, and 19% received the equivalent of 200 mg of imipramine. As reviewed by Hirshfeld and colleagues (1997), there is “overwhelming evi-dence” that depression is being undertreated, both before and during the widespread use of SSRIs.