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Suicidal ideation

What's new

Updated 2024 VA/DoD guidelines for the assessment and management of suicide risk.

Guidelines

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 United States Department of Defense (DoD/VA 2024,2022), the European Society of Medical Oncology (ESMO 2023), the U.S. Preventive Services Task Force (USPSTF 2023), the World Health Organization (WHO 2023), the American Psychiatric Association (APA 2020,2010), the American ...
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Screening and diagnosis

Indications for screening, general population: as per DoD/VA 2024 guidelines, insufficient evidence to recommend for or against suicide risk screening programs to reduce the risk of suicide or suicide attempts.
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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)

  • Choice of screening tool

Classification and risk stratification

Risk assessment
As per DoD/VA 2024 guidelines:
Consider including factors within the following domains when assessing suicide risk:
self-directed violence, thoughts, and behaviors
current psychiatric conditions and current or past mental/behavioral health treatment
psychiatric symptoms
social determinants of health and adverse life events
availability of lethal means
physical health conditions
demographic characteristics
C
Insufficient evidence to recommend for or against the use of a specific tool or method to determine the level of suicide risk.
I

Diagnostic investigations

Screening for borderline personality disorder: as per NHMRC 2019 guidelines, consider screening for borderline personality disorder in adult
C
and adolescent patients with frequent suicidal or self-harming behavior.
C

Medical management

Clozapine: as per DoD/VA 2024 guidelines, consider offering clozapine to reduce the risk of suicide attempts in patients with schizophrenia or schizoaffective disorder and either suicidal ideation or a history of suicide attempts.
C

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  • Ketamine

  • Lithium

Nonpharmacologic interventions

CBT
As per DoD/VA 2024 guidelines:
Consider offering CBT-based psychotherapy focused on suicide prevention to reduce the risk of suicide attempts in patients with a history of suicidal behavior within the past 6 months.
C
Consider offering CBT (including problem-solving-based psychotherapies) focused on suicide prevention to reduce suicidal ideation in patients with a history of self-directed violence.
C

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  • Dialectical behavior therapy

  • Community-based interventions

  • Collaborative interventions

  • Technology-based interventions

  • Safety planning

Therapeutic procedures

Electroconvulsive therapy: as per DoD/VA 2022 guidelines, offer electroconvulsive therapy, with or without psychotherapy, in patients with severe major depressive disorder and severe suicidality.
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  • Transcranial magnetic stimulation

Preventative measures

Restricting access to lethal means: as per DoD/VA 2024 guidelines, consider reducing access to lethal means to reduce the risk of suicide by firearms, jumping, or medication overdose.
C

Follow-up and surveillance

Post-discharge care
As per DoD/VA 2024 guidelines:
Consider sending periodic caring communications (such as postal mail, text messages) in addition to usual care for 12 months following hospitalization related to suicide risk to reduce the risk of suicide attempts.
C
Insufficient evidence to recommend for or against brief contact interventions (such as telephonic interventions, crisis cards, WHO Brief Intervention, and Contact treatment modality) in addition to usual care following discharge from the emergency department to reduce the risk of suicide attempts.
I

Quality improvement

Public health measures: as per DoD/VA 2024 guidelines, insufficient evidence to recommend for or against crisis lines to reduce suicidal ideation or the risk of suicide attempts or suicide.
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