Ninety percent of people who die by suicide have a mental disorder at the time of their deaths. One of the best ways to prevent suicide is by understanding and treating these disorders.
Treatment for Suicide and Suicide Attempts
At this time, there is only one medication, clozapine, approved by the FDA for suicide risk reduction in patients with schizophrenia. There is some evidence from retrospective studies that the atypical antipsychotics, especially clozapine, reduced death by suicide in schizophrenics treated with these medications compared to similar patients not treated with these medications. In addition, there is one long term follow up study of mood disorder patients that shows that treatment with antidepressants, atypical antipsychotics and lithium reduced death by suicide again compared to those who did not receive these treatments. There are meta-analyses of small lithium studies that show that suicide is reduced in those patients with either bipolar disorder or major depression taking lithium, but there are other studies that do not support that claim. So the lithium data for suicide risk reduction are still controversial.
There are two proven psychotherapies for treating those who attempt suicide: cognitive behavior therapy for suicide attempters (CBT for suicide attempters) and dialectical behavioral therapy (DBT) for patients with borderline personality disorder and recurrent suicidal ideation and behaviors. Clearly theses short term interactive therapies make a difference. The goal now is to transport evidence based treatments into community based settings. There are many small studies of various interventions, including promising short term therapies that include the family that show that repeat suicide attempts are reduced under the treatment condition being tested. These need to be replicated and tested in a controlled way before they can be adopted for the greater population.
Treatment for Major Depression
Research shows that teaching health care professionals to recognize and treat depression is an effective way to reduce suicide rates. Because that is a proven fact, we focus here on how depression can be treated, both with medications and with psychotherapy.
If the depression is mild, the doctor may begin with psychotherapy alone and add medication later if the symptoms don’t improve.
Many medications are available to treat depression, the most common of which are antidepressants. About 22 medications are currently approved by the FDA. Since there is no accurate test to match a person’s symptoms and complaints with the right medication, there is no way to know which drug will work best for a particular person. The person who may be depressed should discuss with their doctor the medication choice and how to take it as well as the potential side effects. The doctor needs to be told all the other prescription medications the person is taking as well as nonprescription medications, vitamins and supplements and his/her daily alcohol intake. Alcohol intake should be minimal while taking an antidepressant or any psychotropic medication. Sometimes there is the need to try a few different medications before finding the one that gives the best result with minimum side effects.
When the optimal dose with the best medication is achieved, the antidepressant may take from 4–12 weeks to achieve maximum benefit, but it is possible for one or two symptoms to improve in the first few weeks. In fact, the person may look or sound better than he/she feels early in the treatment and the doctor may see that even if the person doesn't.
When antidepressants are started or when doses are increased, a few patients, especially children, adolescents and young adults, may experience increased anxiety, agitation, restlessness, irritability or anger which may lead to suicidal thoughts or attempts. These should be outlined by the doctor before the treatment begins. If the patient or the family sees this developing, they should immediately call the doctor. The doctor will either add a medication to help the symptoms, decrease the dose or change the medication. Initially the doctor may also prescribe the medications in small amounts to minimize the results of any impulsive or suicidal behavior.
If the person is not feeling better or much improved after 12 weeks on the medication, the doctor may add a second antidepressant, another drug, switch to a different antidepressant or add psychotherapy, if that has not already been instigated.
The doctor may ask the patient to take a depression rating scale so that both the patient and the doctor can see whether things are improving. The treatment should be continued until the patient is no longer experiencing symptoms. Even after that is achieved, the doctor will typically recommend continuing the treatment for another 9–12 months. But, if the person is not feeling better after six months, it is reasonable to request a second opinion.
Beyond medicines, specific types of psychotherapies have been proven effective for treating depression. These are usually short term lasting from 12–16 weeks and they are formalized and interactive. Sessions may take place one to two times a week with a professional who has been specifically trained and certified in the treatment they are using.
The most common types of psychotherapy for depression are cognitive behavior therapy (CBT), interpersonal therapy (IPT), behavioral activation (BH), and cognitive behavioral analysis system of psychotherapy (CBASP). There is clear evidence from research studies that combining antidepressants with any one of these psychotherapies is the best treatment for chronic depression, meaning that they have had a depressive illness for two years or more. Supportive psychotherapy for depression is less well defined. The therapist may be a physician, psychiatrist, psychologist, social worker, psychiatric nurse or a psychotherapist or counselor.
Unfortunately, the nature of depressive illness is that, even after it is successfully treated, it often recurs. Antidepressants and some of the therapies noted above can prevent or reduce the frequency of these recurrences. Continuing treatment for a longer time or coming back to treatment can help. The patient and the doctor should discuss the best way to approach the long term treatment of the illness.
If the depression does not respond to treatment or if it is very severe or if psychotic symptoms appear as part of it, there are additional treatments that should be used. The oldest and best studied is electroconvulsive therapy, a treatment that can be given as an out or inpatient, but requires anesthesia and the delivery of a small electric current to the brain. It is remarkably effective but can have side effects, which the doctors are working to reduce. A similar treatment is transmagnetic stimulation (TMS) which is less dramatic and may not be as effective. Finally for those who suffer from seasonal mood disorder (SAD) the doctor may suggest light therapy in addition to other treatment.
Treatment for Bipolar Disorder
Another high risk group is people with bipolar disorder, which is characterized by mood swings from high (manic) to low (depressed), often with periods of feeling normal between. Those with bipolar disorder are at greatest risk for suicide when they are in a depression or have a mixed mood state. With bipolar disorder the doctor will begin treatment with a mood stabilizer such as lithium, mood stabilizing anticonvulsants or antipsychotics. The use of antidepressants for the depressive phase of the illness is sometimes important, but there is no evidence that antidepressants have long lasting results. Treatment for bipolar disorder should always include a complete physical exam and blood tests before treatment begins.
Treatment for Alcohol and Drug Abuse
When combined with depression, bipolar disorder or any mental disorder, alcohol and drug abuse can increase suicide risk. When being treated the patient should be completely honest about his/her alcohol or drug intake for the safest treatment and the best chance of getting better. Treatment for alcohol and drug abuse is varied but always includes a strong psychosocial component.
All treatments are discussed in more detail in Demystifying Psychiatry: A resource for patients and their families, by Zorumski and Rubin, Oxford Press.