Life after near death: What interventions work for a suicide survivor?

Current Psychiatry. 2009 August;08(08):35-42

August 1, 2009|Psychiatry

Sarah M. Jacobs, MEd;Michael J. Bostwick, MD

Motives and methods of self-harm may suggest an individual's risk for future attempts

Suicide research deploys a single intervention for a diverse group of subjects rather than tailoring the approach to each particular case. A certain intervention may be highly effective for 1 patient because it is well matched to the specific blend of issues driving that patient’s suicidality, yet ineffective for another because it fails to address that individual’s underlying issues. Thus, a single treatment program standardized for research can be simultaneously a success and a failure, depending on which patient is assessed. The overall outcome is statistical insignificance because success is lost in the noise of failure.

Treating the individual. To individualize your treatment approach, it may be useful to recast the case and treatment strategy into Shneidman’s cubic model.⁶ Identifying the uniquely personal drivers behind a patient’s thoughts and actions helps point toward the most effective management approach. Tailored pharmacologic treatments and psychotherapy can be used to help guide the patient away from maximum suicide risk.

Clinical Point

CBT for 18 months has been shown to significantly lower the suicide reattempt rate and reduce depression and hopelessness

A recent study by Brown et al²⁷ found a significantly lower reattempt rate and less severe self-reported depression and hopelessness in patients who received CBT for 18 months after a suicide attempt, compared with controls. Another recent trial found that SA patients who received 18 months of partial hospitalization, mentalization-based therapy, and 18 months of follow-up group therapy had a dramatically lower suicide completion rate at 5 years compared with patients who received treatment as usual.²⁸

Table 2

Symptom-targeted pharmacologic treatment of suicidal patients

Drug class	Impulsive-behavioral dyscontrol	Affective dysregulation	Psychotic features
SSRIs	Self-damaging behavior, impulsivity	Mood lability/mood crashes; anger; temper outbursts
Antipsychotics		Anger, temper outbursts	Cognitive symptoms; perceptual symptoms
Mood stabilizers (lithium, carbamazepine, valproic acid)	Self-damaging behavior, impulsivity	Mood lability/mood crashes, anger, temper outbursts
SSRI: selective serotonin reuptake inhibitor
Source: References 16,17

Box 1

Which strategies reduce subsequent self-harm in suicide attempt survivors?

Treatment of suicide attempt survivors has dramatically increased in the United States since 1990, but the incidence of suicidal thoughts, plans, gestures, or attempts has not significantly decreased.¹⁸ A systematic review of 15 randomized controlled trials using the search methods published by Arensman et al¹⁹ reveals very little difference in the suicide reattempt rate, despite extra treatment beyond the “usual standard of care.”

Intervention strategies shown to significantly decrease the rate of self-harm include home visits, behavioral therapy, and a “green card” strategy (patients were issued a card at the time of discharge explaining that a doctor was always available for them and how that doctor could be contacted).^20-23

No significant difference in reattempt rate was found with other strategies, although benefits such as lower rates of depression and suicidal ideation or higher outpatient visit attendance were observed in some trials.^24-26Click here for a summary of the studies’ methodologies and results.

Outcomes of self-harm

When considering outcomes of SA, it is important to separate the short-term outcome of a single SA from the long-term outcome of suicidality. Short-term outcome depends on the characteristics and management of the acute episode, whereas long-term encompasses ongoing management of suicidality as a trait.

In the short term, surviving a SA depends heavily on the lethality of method and access to acute treatment. It also depends on medical fitness to withstand injury, which may help account for the higher death rate among elderly suicide attempters. A frail or medically ill person is less likely to survive the bodily insult of a SA.

Long-term outcomes are harder to predict. Some patients’ index attempts result from a transient state—an isolated incident that never will be repeated. In others, suicidality is a trait—a chronic maladaptive pattern that is potentially lethal. After an index attempt, the most reliable predictors for eventual death by suicide are:

Clinical Point

Some patients will never reattempt suicide, but in others suicidality is a chronic, maladaptive pattern that is potentially lethal

diagnosed mental illness
high-lethality method on the index SA
number of reattempts.⁴

As time since the index attempt increases, the risk of repeat self-harm and of suicide completion both decrease.²⁹ This raises the tantalizing prospect that if patients can be effectively bridged across the first months and years after the index attempt, they may be more likely to survive their suicidality.

Mood disorders impact long-term outcome, yet only a limited number of studies have found a reduction in suicide rates in response to mood disorder treatment. In a 44-year follow-up study, long-term treatment of depression and bipolar disorder with lithium significantly reduced the suicide rate.³⁰ A meta-analysis of recurrent major affective disorder studies found that subjects on lithium maintenance treatment were 15 times less likely to commit suicidal acts, compared with those not on lithium.³¹

References

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