Caring for the Suicidal Patient: Article Summary

Guest Editorial:
Caring for the Suicidal Patient
Isaac Sakinofsky

Chapter 1:
The Current Evidence Base for the Clinical Care of Suicidal Patients: Strengths and Weaknesses
Isaac Sakinofsky

Based on the evidence from a systematic meta analysis, this article outlines:

• The place of suicide as a public health problem by talking about the magnitude of the problem nationally, internally, and globally;
• Describes the methodology by which studies of care of suicidal persons have been assessed in this supplement; and
• Considers whether improved clinical care can reduce suicide.

Dr. Sakinofsky concludes that there is evidence that optimal clinical care can make a difference and reduce suicide. However, there is currently no magic cure that replaces excellent clinical care, which remains the centrepiece of treatment of suicidal persons.

Chapter 2:
Suicidal Behaviour in Children and Adolescents Part 1: Etiology and Risk Factors  
Margaret M Steele, Tamison Doey

Chapter 3:
Suicidal Behaviour in Children and Adolescents Part 2: Treatment and Prevention
Margaret M Steele, Tamison Doey

Chapter 4:
Clinical Management of Suicidality in the Elderly: An Opportunity for Involvement in the Lives of Older Patients
Adrian Grek

Most Canadian doctors will not often encounter the problem of geriatric suicide. Between 1981 and 2000, the suicide rate declined steadily in Canada, more steeply for the old than for the young.  However, it is important to help physicians identify particular subgroups of aged patients whom doctors should be screening for suicidal risk.

This paper is a systematic review of controlled studies in the literature that looks for evidence to address the following questions:

• What are the risk factors for suicide in older patients?
• Which interventions are known to reduce the risk of suicide in older patients? 

The review included e randomized controlled trials (RCTs), controlled cohort studies, and case–control studies. Wherever possible, Dr. Grek reviewed papers dealing with suicide rather than suicide attempts or suicide ideation.

The reviewed studies, which used varying methodology, highlighted the following risk factors for suicide in the elderly:

• Male gender
• Mental illness (particularly depression)
• Physical illness, and
• Interpersonal discord

The data also indicated that conscientious, systematic treatment of depression in elderly individuals reduces the rate of suicide in the elderly.

Chapter 5:
Managing Suicidality in Schizophrenia
David C Mamo

Schizophrenia is a devastating neuropsychiatric condition. Even with successful treatment, most people with this illness continue to live with some symptoms that can isolate them for normal social interaction. This devastating condition is associated with a very high risk of suicide attempts (4% to 30%)and completed suicide (4% to 13%).

Directed at front-line clinicians, this paper provides a systematic overview of the literature on managing suicidality in schizophrenia.

Not surprisingly, the review indicated that suicidality in schizophrenia is high. Early detection relies on the clinician identifying:

• Signs of depression, despair, and hopelessness, and
• The nature and severity of the psychotic experience itself, particularly in individuals recently diagnosed with schizophrenia who have high cognitive function and educational background.

Based on the review, effectively managing suicidality in individuals with schizophrenia involves a combination of traditional bedside clinical skills, selecting of psychosocial techniques to address depression and psychosocial stressors based on individual needs, and selective treatment with medication directed primarily at an individual’s psychotic and depressive symptoms.

Chapter 6:
Treating Suicidality in Depressive Illness Part I: Current Controversies
Isaac Sakinofsky

Chapter 7:
Treating Suicidality in Depressive Illness Part 2: Does Treatment Cure or Cause Suicidality?
Isaac Sakinofsky

This paper is Part two of a review looking at the evidence for the treating suicidality in persons suffering from depressive illness. (See article above).  It deals with the grave charge that antidepressant treatment may actually cause suicidal thoughts and actions.

The controversy around this issue is ongoing. However, based on the literature review, the paper outlines a number of results and conclusions including that:

• There is fairly good evidence that lithium reduces completed suicide and attempt rates in people with bipolar disorder and recurrent unipolar depression.
• Antidepressants and psychological treatments may reduce suicidal ideation in depressed patients.
• Most meta analyses have shown nonfatal suicidal behaviours who take antidepressants (except fluoxetine) are found more often in a minority of children and adolescents.

Chapter 8:
Effectiveness of Psychosocial Treatments on Suicidality in Personality Disorders
Shelley McMain

Until recently, only a handful of studies examined the effectiveness of psychosocial treatment for individuals with Personality Disorders (PDs), and even fewer considered the effects of such treatment on suicidal behaviour. This omission is surprising considering that both suicidal and nonsuicidal self-injury are highly associated with PDs.

This article reviewed the empirical evidence for the effectiveness of psychosocial treatments in reducing self-injurious behaviours. Two fundamental questions were addressed:

1. Are these treatments effective? and,
2. Is there evidence for the superiority of one treatment over another?

In general, research on clinical management of suicidality in patients with PDs is in its infancy and many important questions remained unanswered. However, findings from studies to date do allow for some conclusions to be drawn. The evidence clearly suggests that psychosocial treatments can be effective.  Of the studies reviewed, the vast majority yielded positive findings. Four long-term treatment models—Dialectical Behaviour Therapy (DBT), mentalization-based day treatment, Schema-Focused Therapy, and Cognitive Behaviour Therapy—have been shown to lower the rates of suicidal behaviours in patients with borderline personality disorder. The efficacy of DBT in particular has been established across several well-controlled trials.

While no studies have identified why some treatments have shown to be more effective, the key elements of these treatments provide a basis for specific recommendations for clinical practice including:

• When suicidal behaviour is present, it should be a priority target in treatment, and
• Brief treatments, such as skills training, may be considered if the focus of treatment is outlined (such as self-harm behaviour).

Chapter 9:
Psychopharmacologic Management of Suicidality in Personality Disorders
Robert J Cardish

Chapter 10:
The Aftermath of Suicide: Managing Survivors’ Bereavement
Isaac Sakinofsky

Losing someone close to suicide is more common than expected. One survey showed that 7% of participants had experienced a loss due to suicide during the previous year. Although grief after suicide has much in common with other forms of complicated bereavement, individuals may experience unique reactions such as shame, self-blame, and a perpetual search for meaning. And the quality of treatment trials of suicide survivors and others with complicated grief reactions is poor, with a few exceptions.

This paper consider bereavement management in:

1.      Those who have recently experienced the loss of a close family member or friend by suicide,
2.      Fellow patients on a ward or caregivers, and
3.      Therapists and other primary caregivers.

Although there are a plethora of programs for survivors of suicide, few have been subjected to rigorous evaluation of their efficacy.  This literature review showed that emerging treatment methods with manualized complicated grief therapy (a form of cognitive-behavioural therapy) seem promising in adults.  There are also indications that interpersonal therapy may be effective (when the deceased is a child), and bereavement groups for children who have lost adult relatives may be useful.  Professionals may be traumatized by the suicide of a patient.  It is important to be sensitive to the professional’s feelings of hurt and doubts about his/her competency as a professional, as well as document in detail events surrounding the suicide while they are fresh, for administrative and legal purposes.

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