Treatment of Suicide Attempters and Prevention of Suicide and Attempted Suicide
Keith Hawton
Tatiana Taylor
Introduction
In considering the treatment and prevention of suicidal behaviour account should be taken of recent trends in suicide and attempted suicide, particularly in individual countries. These have been reviewed in other chapters in this section. The term ‘attempted suicide’ is used in this chapter and includes any act of non-fatal self-poisoning or self-injury, irrespective of motive or intention.
Suicide prevention has been incorporated within the World Health Organization Health for All strategy(1) and has received substantial support from the United Nations.(2) Furthermore, in recent years several countries have developed national suicide prevention programmes. Increased suicide rates in young people have probably acted as a stimulus behind this trend. However, suicide rates in most countries remain higher in older populations and prevention programmes must include this increasingly larger sector of society.
Treatment of suicide attempters
Suicide attempts occur for a wide range of reasons. In many cases the primary aim is not death but some other outcome, such as demonstrating distress to other people, seeking a change in other people’s behaviour or temporary escape.(3) This means that a broad range of treatments are required since the needs of individual patients will vary widely (Table 4.15.4.1).
Factors relevant to treatment needs in suicide attempts
(a) Repetition of attempts and risk of suicide
Repetition of attempts is common, with 15 to 25 per cent repeating suicidal acts within a year, and is associated with a greater risk of eventual suicide.(4) The frequency of suicide following attempted suicide varies from country to country,(5) depending on the overall characteristics of the patient population and the rate of suicide in the general population. Prevention of repetition of suicidal behaviour and especially of suicide is a major aim in treating suicide attempters.
(b) Psychiatric and personality disorders
A range of psychiatric disorders are found in suicide attempters.(6) Depression and alcohol abuse are particularly common. In addition, substantial proportions of patients have personality disorders. While treatment directed at the underlying causes of such disorders, where possible, will be important in managing attempted suicide patients, often the disorders themselves will require specific treatment.
(c) Life events and difficulties
Certain problems are particularly common in suicide attempters, including difficulties in interpersonal relationships, especially with partners and with other family members, employment problems, particularly in males, and financial difficulties. Life events, especially disruption in a relationship with a partner, frequently precede suicidal acts.(7)
(d) Poor problem-solving skills
Many suicide attempters have difficulties in problem-solving, particularly in dealing with difficulties in interpersonal relationships.(8) These difficulties are more marked in suicide attempters than in patients with psychiatric disorders who have not carried out a suicidal act.
Table 4.15.4.1 Factors relevant to treatment needs in suicide attempters | ||||||||||
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(e) Impulsivity and aggression
There is a strong link between suicidal behaviour and both impulsivity and aggression. There is also accumulating evidence that hypofunction of brain serotonergic systems is linked to aggression (and possibly impulsivity) and also to suicidal behaviour(9) (see Chapter 4.15.3). It is unclear whether this represents a state phenomenon associated with psychiatric disturbance or a trait phenomenon, but current evidence points towards the latter.
(f) Hopelessness and low self-esteem
Hopelessness, or pessimism about the future, which has been shown to be a key factor linking depression with suicidal acts, is an important predictor of repetition of suicidal behaviour, and a risk factor for eventual suicide.(10) Low self-esteem is another important characteristic associated with suicidal behaviour. There is likely to be a link between low self-esteem and a tendency to experience hopelessness when faced by adverse circumstances.
(g) Motivational problems and poor compliance with treatment
Management of suicide attempters is complicated by the fact that some patients appear to be poorly motivated to engage in aftercare. This is also likely to affect compliance with treatments. The style of organization of general hospital psychiatric services (including continuity of care) and the attitudes of clinical staff may be important factors determining whether patients engage in aftercare.
General overview of treatments
Treatments for suicide attempters include both psychosocial and pharmacological approaches. While these are considered separately below, in some patients both will be appropriate. This might be the case, for example, if a patient suffers from depression with biological features in the setting of employment and financial difficulties, when treatment with an antidepressant might be combined with problem-solving therapy.
Psychosocial treatments
A range of psychosocial therapies have been evaluated in suicide attempters in randomized controlled clinical trials. The efficacy of these approaches has been examined in a systematic review of the worldwide literature.(11) The findings from this review and some further studies are summarized below.
(a) Problem-solving
Meta-analysis of the results of trials that have been conducted so far to evaluate the effectiveness of brief problem-solving therapy (see Chapter 6.3.1) compared with treatment as usual indicates a trend towards reduction of repetition of self-harm episodes, but the total numbers of subjects and trials have precluded a definitive result. However, evidence of other positive outcomes, such as reduced levels of depression and hopelessness and improvement in problems, has been convincingly demonstrated in these studies.(12) This approach is useful, either used alone or in the context of other treatment. It is reasonably easily taught and can be used by clinicians from different professional backgrounds.
(b) Psychotherapy
Cognitive behaviour therapy, combined with care management has recently been shown to be effective in reducing frequency of suicide attempts and in producing other positive outcomes.(13) A brief psychological intervention combined with provision of a treatment manual seems to be less effective in the treatment of patients with repeated attempts.(14)
Two trials have been conducted in which an intensive form of psychological treatment known as dialectical behaviour therapy was evaluated.(15,16) Female patients with borderline personality disorders who had a history of repeated self-harm were offered a year of individual and group cognitive behavioural therapy aimed at addressing the patients’ problems of motivation and strengthening their behavioural skills, particularly in relation to interpersonal difficulties. Compared with routine care this approach seems to result in a reduction in repetition of self-harm as well as a number of other positive outcomes. Further evaluation of this approach is required to determine if it is effective in male patients and in adolescents, and whether it can be delivered in an abbreviated form. While it is a labour-intensive approach, it appears to be helpful for what is a particularly difficult group of patients.
(c) Outreach
Several trials have been conducted to assess the impact of community outreach, either for all patients or for those that have not attended treatment sessions. Some of these studies have included relatively intensive treatment programmes. Overall these studies indicate that some form of outreach may improve outcome in terms of reducing repetition of attempted suicide. In one study, nurse home visits to encourage non-attending participants to attend outpatient appointments resulted in a significantly greater number of appointments attended as compared to the control group and there was a near significant reduction in the rate of repetition of suicide attempts during the year after study entry.(17) In other studies, telephone contact,(18) and contacting patients regularly by post(19) have also produced promising results. Outreach combined with specific treatment may be useful, perhaps reserved for those who are poorly compliant with aftercare.
(d) Provision of emergency cards
In the United Kingdom there has recently been interest in providing suicide attempters with cards which indicate how they might get emergency help at times of crisis. Two initial, relatively small, studies of this approach, one involving adults and the other young adolescents, produced encouraging results but a larger evaluation did not show the cards to be effective.(20) Provision of emergency cards requires there to be a 24 h service to deal with emergency calls. They might be thought helpful in a minority of cases, but there needs to be careful selection of patients who are offered this facility because of risk of it possibly being abused.
Pharmacological treatments
There have been relatively few treatment trials evaluating the effectiveness of pharmacological agents in suicide attempters. This perhaps reflects the problems of compliance with therapy, which were noted earlier, and risk of overdose.
(a) Antidepressants
A trial in the Netherlands in which paroxetine was compared with placebo in patients who were all repeaters of self-harm but who did not suffer from current depressive disorder showed apparent benefits for a subgroup of patients who received paroxetine, namely
those who had a history of between one and four episodes of self-harm. Patients with a history of five or more episodes did not seem to benefit.(21) The findings of this study are clearly of interest (although post hoc subgroup analyses of this kind must be treated with caution). Recently there has been much attention to the risk of antidepressants increasing suicidal ideation and acts in adolescents.(22) Also, it has become clear that there is increased risk with all types of antidepressants during the initial period of treatment.(23) These findings have highlighted the need to be cautious in the use of antidepressants, to provide early follow-up after initiating therapy, and to consider combining antidepressant treatment with other therapies, especially for adolescents (in whom only fluoxetine is currently recommended for the treatment of depression).
those who had a history of between one and four episodes of self-harm. Patients with a history of five or more episodes did not seem to benefit.(21) The findings of this study are clearly of interest (although post hoc subgroup analyses of this kind must be treated with caution). Recently there has been much attention to the risk of antidepressants increasing suicidal ideation and acts in adolescents.(22) Also, it has become clear that there is increased risk with all types of antidepressants during the initial period of treatment.(23) These findings have highlighted the need to be cautious in the use of antidepressants, to provide early follow-up after initiating therapy, and to consider combining antidepressant treatment with other therapies, especially for adolescents (in whom only fluoxetine is currently recommended for the treatment of depression).
(b) Neuroleptics
A trial in which the depot neuroleptic flupenthixol was administered monthly in a dose of 20 mg for 6 months to repeaters of self-harm and compared with placebo in similar patients appeared to show that the active drug was effective in reducing the recurrence of self-harm.(24) While this type of study requires replication, perhaps using one of the atypical oral neuroleptics in patients who frequently repeat self-harm may be worth trying.
(c) Lithium
A systematic review of trials of lithium therapy versus a range of other drugs and placebo in patients with affective disorders has shown convincing evidence that lithium may prevent suicide.(25) It is not known if it may be anti-suicidal in other groups of patients.
Management in clinical practice
Before a treatment plan can be formulated a careful assessment must be carried out. In conducting the assessment the clinician needs to try and establish good rapport with the patient and be sensitive to the patient’s preferences. The key factors that should be covered during the assessment are listed in Table 4.15.4.2. For the purpose of formulating a management plan it is particularly useful to draw up a problem list which summarizes the patient’s current difficulties. This should be done in active collaboration with the patient as far as possible. Qualitative studies have shown that patients appreciate clinicians and other staff keeping them well informed of their mental and physical status and including them in decision-making in regard to their care.(26)
(a) Assessment
During the assessment it is crucial to estimate the risk of suicide or another non-fatal attempt. However, accurate assessment is far from easy. Risk factors for suicide following attempted suicide are shown in Table 4.15.4.3. Because suicide is uncommon, the predictive value of the items is limited. One predictor of suicide risk is the degree of suicidal intent involved in the current attempt (see Table 4.15.4.4). Clinicians should consider the use of the valuable Beck Suicide Intent scale.(27) Factors known to be associated with risk of a further attempt are listed in Table 4.15.4.5. It should be noted that while individuals who score positive on several of these factors will have considerably increased risk of repetition, a substantial proportion of those who repeat will not show these characteristics, i.e. the predictive value of scales to predict repetition is modest.
Table 4.15.4.2 The assessment of attempted-suicide patients | ||||||||||||||||||||||||||||||||||||||
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Table 4.15.4.3 Factors associated with risk of suicide after attempted suicide | |||||||||||
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Table 4.15.4.4 Factors that suggest high suicidal intent | ||||||||||
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Table 4.15.4.5 Factors associated with risk of repetition of attempted suicide | |||||||||||
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(b) Treatment
The treatment plan should be drawn up on the basis of the patient’s needs and risks. Inpatient psychiatric treatment will usually be indicated for patients with severe psychiatric disorders, especially where immediate risk of suicide appears to be high.
(i) Psychiatric disorders
Major psychiatric disorders should be treated in the usual way, but with particular care about use of medication which might be toxic in overdose. Specific treatment should be provided for alcohol and drug abuse; indeed, a suicide attempt is sometimes the first occasion that abuse may come to clinical attention.
(ii) Community therapy
Most patients can be managed in the community. Brief psychological therapy, with a focus on problem-solving will be appropriate for those patients who have clear problems, such as in interpersonal relationships, employment, or social adjustment. Some form of outreach (e.g. home visiting, telephone contact) may be helpful to increase the proportion of patients who engage in treatment, but is not necessary for most patients. Outreach may be essential in the treatment of patients in remote rural areas in developing countries.
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