Suicidality: prevention, detection and intervention

Australian suicide rates are increasing. GPs have a key role in the early detection and management of suicidality and the treatment of commonly associated mood disorders and substance misuse.

Drugs are indicated for moderate to severe depression. They can also be considered for patients who have been unable to access, do not want or have not responded to psychological treatments.

Selective serotonin reuptake inhibitors are less toxic than serotonin noradrenaline reuptake inhibitors. Tricyclic antidepressants are the most dangerous in overdose. Mood stabilising drugs can be prescribed, but in large quantities they are dangerous in overdose.

In depressed adolescents psychological therapies are first-line treatments. When drugs are indicated, in older people selective serotonin reuptake inhibitors are generally well tolerated, but paroxetine and fluoxetine are best avoided.

Suicide accounts for 1.4% of all deaths worldwide.^1,2 In Australia, suicide is the leading cause of death among those aged 16–24 years, while the suicide rates in men aged over 85 years are the highest for any age group.³ In 2015, 3027 Australians died by suicide, more than the national road toll.³ In 2006 the death rate from suicide was 10.2 per 100 000 people. This rose to 12.6 per 100 000 in 2015.3 For every death by suicide, around 25 people will attempt suicide⁴ and many more will engage in non-suicidal self-injury (such as self-cutting). Self-injury is associated with a greater likelihood of suicidal thoughts and behaviours.⁵

Suicide results from a convergence of genetic, biological, psychological, social and cultural factors often combined with an experience of trauma and loss.¹ Despite the rising toll, suicide is still a comparatively rare event. Given the complexity of its causation, it is unsurprising that no single suicide prevention strategy clearly stands out above the others.^1,2 These facts also explain the counterintuitive finding that no single risk factor that is statistically significantly associated with an increase in suicide – such as a history of self-harm or depressed mood – provides any practical assistance in predicting which particular patients might take their own life.^1,6,7 Prevention strategies therefore need to be multifactorial and tailored to the individual patient.

There are suicide risk assessment tools, but these should be used as guides only and not as replacements for clinical decision making.^8,9

Suicide prevention is most likely to be effective if a combination of evidenced-based strategies are used both at the individual and population levels.^1,4

One of the strongest evidence-based strategies for suicide prevention is the education of primary care clinicians.¹⁰ In Australia, GPs are the most frequent providers of mental health care and many patients who attempt suicide visit their GP in the preceding months.¹¹ This makes GPs well placed to help reduce the rate of suicide. Doctors should remember that a therapeutic relationship can be protective.^12-14 

Most suicidal patients will be distressed and many will feel stigmatised and ashamed. Clinicians should offer comfort, reassurance and hope, and avoid judgement.¹⁵ When a patient admits to suicidal thoughts or behaviour, understanding their predicament begins with an exploration of these phenomena (Box 1). This includes the nature of the thoughts or behaviours, any plans, previous suicide attempts and access to means of harm, for example firearms, poisons, and medicines that are dangerous in overdose such as quetiapine, opioids and tricyclic antidepressants. The clinician should then review the circumstances that might be contributing to the patient’s suicidality (Box 2). 

Management plans should be negotiated with the patient. In most cases family, friends or other psychosocial supports should be involved.¹⁵

A key element of any management plan will be to consider the least restrictive environment for safely starting treatment. Most patients can be managed in the community. However, if in doubt (because, for example, the burden of stressors threatens to overwhelm the patient, or if psychosocial supports are unavailable), obtaining a second opinion about whether hospitalisation is necessary through the local acute mental health team, or the emergency department, is sound clinical practice. Patients whose severe depression or psychotic symptoms make them unable to cooperate with community treatment can be compelled to have such an assessment under mental health legislation.

All management plans include reinforcement of protective factors including the involvement of family and friends where possible, provision of emergency contacts, formulation of an individualised self-care plan and encouragement to avoid alcohol and other substances (which increase impulsivity). Every suicidal patient should be seen at least weekly until the acute crisis resolves. Good communication between care providers is essential.

Substance use and depression

Substance misuse (especially alcohol) is a common method of self-medication for depression and anxiety, but it increases the likelihood of suicidal behaviour. The patient’s substance use must be explored in the assessment and addressed in the management plan.

Patients should be encouraged to stop drinking alcohol. Motivational interviewing is the first-line intervention for alcohol misuse. Many online treatments for depression (such as MyCompass) use motivational interviewing principles to help people begin to address substance misuse. Several online treatments specifically for alcohol misuse are currently being developed and evaluated including Shade, Daybreak, Hello Sunday Morning and OnTrack Alcohol and Depression.

Patients appreciate their GP asking about their mental health, although they may not volunteer psychological symptoms. Consider psychological causes when patients present with physical symptoms that are trivial or for which no underlying cause is evident, especially when there is no positive response to reassurance. GPs should be alert to body language or other cues suggesting an underlying mood disorder.

Around 5% of adults will experience an episode of major depressive disorder each year.¹⁶ GPs who wish to assess patients for the symptoms and severity of depression (and associated anxiety) may use well-validated, self-report scales such as the Patient Health Questionnaire (PHQ-9) or the Generalised Anxiety Disorder 7 (GAD7).^17-19 The Patient Health Questionnaire includes a question regarding suicidality which can be a useful springboard for further discussion.²⁰

Early and successful treatment can significantly reduce the length and severity of episodes of depression and associated suicidal thoughts or behaviour. Patients with mild–moderate depression will often respond to psychological therapies. These include cognitive behaviour therapy or interpersonal psychotherapy and may be delivered face-to-face, or via self-guided or clinician-assisted evidence-based e-mental health interventions (Box 3). Patients with moderate–severe depression are likely to also require antidepressants as may those who have not benefited from psychological therapies or cannot or do not want to access them.²⁰ 

There is much evidence that psychological therapies can reduce suicidality and promote well-being in all age groups and across a range of diagnoses including depression, bipolar disorder, schizophrenia and borderline personality disorder.¹

In adolescents, multisystem and family-based treatments are effective.¹ Family-focused interventions are invariably necessary in the treatment of the depressed adolescent. These may include psycho-education and support for parents, family therapy or the treatment of mental illness in a parent. School-based interventions focusing on mental health literacy, suicide risk awareness and skills training (in dealing with adverse life events and stress) can reduce suicidal thinking and attempts, including at 12-month follow-up.¹

Ongoing collaborative care, especially involving specialist mental health and primary healthcare services, has been shown to be feasible, acceptable and effective in reducing suicidal ideation compared to standard care in the general adult population. Similar programs for depressed and suicidal older patients are also effective.¹ 

The choice of antidepressant must consider individual patient factors such as age (Box 4^21,22 and Box 5). It is also guided by efficacy, tolerability, the prominence of certain symptoms, the depressive subtype, adverse effects, the potential for drug–drug interactions and the drug’s safety in overdose. 

Suicidality

There is no specific drug for preventing suicide, although antidepressants reduce the intensity of suicidal thoughts over time in depressed patients. It has been suggested that antidepressants could increase the risk of suicide, but this is unlikely (Box 6).^20,23-30 

Danger in overdose

Tricyclic antidepressants, particularly dothiepin, are the most dangerous of the antidepressants in overdose, followed by serotonin noradrenaline reuptake inhibitors (desvenlafaxine is less toxic then venlafaxine) and then others such as mirtazapine. Selective serotonin reuptake inhibitors are the least dangerous, although citalopram and escitalopram have a significant risk of seizures and QT prolongation³¹ and fluoxetine has a long half-life. If suicidal patients require an antidepressant, we recommend using a drug which is less toxic and that only a week’s supply be prescribed (or dispensed) at a time. 

Lithium can significantly reduce the incidence of suicide attempts and completed suicide in patients with major mood disorders, compared to those not treated with lithium.^16,32

Lithium, valproate, carbamazepine and lamotrigine are dangerous in overdose and lethal quantities may be available on a single prescription. 

Clozapine has been reported to be more effective than olanzapine in the treatment of suicidality in patients with schizophrenia and schizoaffective disorder.³³

For depression and substance misuse, psychological therapies and drugs are key components of treatment. Drugs are especially important for moderate to severe depression. With an empathic approach and awareness of which drugs are most efficacious, tolerable and least dangerous in overdose, GPs are well placed to intervene early to prevent or reduce suicide.

In the past three years Henry Brodaty has been on an advisory committee for Nutricia. He is a consultant for Eli Lilly and Lundbeck in the field of dementia and his centre has been funded to undertake trials for Alzheimer’s disease by Tau Therapeutics, Servier and Sanofi.

Keks N, Hope J, Keogh S. Switching and stopping antidepressants. Aust Prescr 2016;39:76-83. 

Kitching D. Depression in dementia. Aust Prescr 2015;38:209-11.