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Suicidal ideation

Key sources
The following summarized guidelines for the evaluation and management of suicidal ideation are prepared by our editorial team based on guidelines from the World Health Organization (WHO 2023), the U.S. Preventive Services Task Force (USPSTF 2023), the European Society of Medical Oncology (ESMO 2023), the United States Department of Defense (DoD/VA 2022; 2019), the American Psychiatric Association (APA 2020; 2010), the American Society of Anesthesiologists (ASA/ACE/OS/AACE/ASMBS/OMA 2020), the National Health and Medical Research Council of Australia (NHMRC 2019), the American Academy of Neurology (AAN 2019), the American College of Emergency Physicians (ACEP 2017), the American College of Endocrinology (ACE/AACE 2016), and the American Academy of Family Physicians (AAFP 2015).
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Guidelines

1.Screening and diagnosis

Indications for screening, general population, USPSTF: insufficient evidence to assess the balance of benefits and harms of screening for suicide risk in adults (including pregnant and postpartum individuals) and older adults.
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  • Indications for screening (opioid users)

  • Indications for screening (depression)

  • Indications for screening (psychiatric disorders)

  • Indications for screening (Tourette's syndrome)

  • Indications for screening (eating disorders)

  • Indications for screening (obesity)

  • Indications for screening (cancer)

2.Classification and risk stratification

Risk assessment: as per VA 2019 guidelines, assess risk factors as part of a comprehensive evaluation of suicide risk, including but not limited to:
current suicidal ideation
prior suicide attempts
current psychiatric conditions, such as mood disorders, substance use disorders
current psychiatric symptoms, such as hopelessness, insomnia, agitation
prior psychiatric hospitalization
recent biopsychosocial stressors
the availability of firearms.
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3.Diagnostic investigations

Screening for borderline personality disorder: consider screening for borderline personality disorder in adult
C
and adolescent patients with frequent suicidal or self-harming behavior.
C

4.Medical management

Ketamine: offer ketamine infusion as an adjunctive treatment for short-term reduction in suicidal ideation in patients with suicidal ideation and major depressive disorder.
B

More topics in this section

  • Lithium

  • Clozapine

5.Nonpharmacologic interventions

Brief interventions
Complete a crisis response plan for patients with suicidal ideation or a lifetime history of suicide attempts.
B
Offer the WHO brief intervention and contact plan, in addition to standard care, in patients after presenting to the emergency department for a suicide attempt.
B

More topics in this section

  • CBT

  • Dialectical behavior therapy

  • Problem-solving therapy

  • Technology-based interventions

  • Safety planning

  • Interventions with no evidence for benefit

6.Therapeutic procedures

Electroconvulsive therapy: as per VA 2022 guidelines, offer electroconvulsive therapy, with or without psychotherapy, in patients with severe major depressive disorder and severe suicidality.
A

7.Preventative measures

Restricting access to lethal means: reduce access to lethal means to decrease suicide rates at the population level.
B

8.Follow-up and surveillance

Post-discharge care
Send periodic caring communications (such as postcards) for 12-24 months, in addition to usual care, after psychiatric hospitalization for suicidal ideation or a suicide attempt.
B
Offer a home visit to support re-engagement in outpatient care in patients not presenting for outpatient care after hospitalization for a suicide attempt.
B

9.Quality improvement

Public awareness campaigns: insufficient evidence to recommend stand-alone media campaigns (to raise awareness and sensitize the general public about suicide and its prevention) for reducing deaths from suicide, suicide attempts, and acts of self-harm.
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