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Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors

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Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors American Psychiatric Association American Psychiatric Association Practice Guidelines Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors Work Group on Suicidal Behaviors Douglas G. Jacobs, M.D., Chair Ross J. Baldessarini, M.D. Herbert Meltzer, M.D. Yeates Conwell, M.D. Cynthia R. Pfeffer, M.D. Jan A. Fawcett, M.D. Robert I. Simon, M.D. Leslie Horton, M.D., Ph.D. Steering Committee on Practice Guidelines John S. McIntyre, M.D., Chair Sara C. Charles, M.D., Vice-Chair Kenneth Altshuler, M.D. Grayson Norquist, M.D. Ian Cook, M.D. Stuart W. Twemlow, M.D. C. Deborah Cross, M.D. Sherwyn Woods, M.D., Ph.D. Joel Yager, M.D. Barry J. Landau, M.D. Louis Alan Moench, M.D. Consultants and Liaisons Sheila Hafter Gray, M.D. (Liaison) Daniel J. Anzia, M.D. (Area IV) Andrew J. Kolodny, M.D. (Liaison) R. Scott Benson, M.D. (Area V) Robert Johnston, M.D. (Area I) Lawrence Lurie, M.D. (Area VI) R. Dale Walker, M.D. (Area VII) James Nininger, M.D. (Area II) Roger Peele, M.D. (Area III) Staff Robert Kunkle, M.A., Senior Program Manager Althea Simpson, M.B.A., Project Coordinator Laura J. Fochtmann, M.D., Practice Guidelines Medical Editor Claudia Hart, Director, Department of Quality Improvement and Psychiatric Services Darrel Regier, M.D., M.P.H., Director, Division of Research Developed under the auspices of the Steering Committee on Practice Guidelines. Successive drafts reviewed by APA components and members, as well as other interested individuals and organizations (see p. 97) and two members of the editorial board of The American Journal of Psychiatry. Approved by the APA Board of Trustees in June 2003 and published in November 2003. Part A received by The American Journal of Psychiatry July 3, 2003; accepted July 28, 2003. Copyright © 2003 American Psychiatric Association. ALL RIGHTS RESERVED. No part of this Practice Guideline may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, or by any information storage or retrieval system, without permission in writing from the publisher. Table of Contents Statement of Intent....................................................................................................................................iv Guide to Using This Practice Guideline .................................................................................................... 1 Overview of Guideline Development Process ......................................................................................... 2 Part A: Assessment, Treatment, and Risk Management Recommendations............... 3 I. Executive Summary of Recommendations .................................................................................... 3 A. Definitions and General Principles ........................................................................................ 3 B. Suicide Assessment.................................................................................................................. 3 C. Estimation of Suicide Risk....................................................................................................... 4 D. Psychiatric Management ........................................................................................................ 5 E. Specific Treatment Modalities ................................................................................................6 II. Assessment of Patients With Suicidal Behaviors.......................................................................... 7 A. Overview................................................................................................................................... 7 B. Conduct a Thorough Psychiatric Evaluation......................................................................... 8 C. Specifically Inquire About Suicidal Thoughts, Plans, and Behaviors.................................. 9 D. Establish a Multiaxial Diagnosis........................................................................................... 11 E. Estimate Suicide Risk ............................................................................................................. 12 F. Additional Considerations When Evaluating Patients in Specific Treatment Settings ...... 27 III. Psychiatric Management................................................................................................................ 29 A. Establish and Maintain a Therapeutic Alliance .................................................................. 29 B. Attend to the Patient’s Safety...............................................................................................30 C. Determine a Treatment Setting ........................................................................................... 30 D. Develop a Plan of Treatment............................................................................................... 33 E. Coordinate Care and Collaborate With Other Clinicians .................................................... 33 F. Promote Adherence to the Treatment Plan ....................................................................... 34 G. Provide Education to the Patient and Family .................................................................... 35 H. Reassess Safety and Suicide Risk ......................................................................................... 35 I. Monitor Psychiatric Status and Response to Treatment..................................................... 37 J. Obtain Consultation, if Indicated .......................................................................................... 37 IV. Specific Treatment Modalities ...................................................................................................... 37 A. Somatic Therapies ................................................................................................................. 37 B. Psychotherapies..................................................................................................................... 40 V. Documentation and Risk Management....................................................................................... 40 A. General Risk Management and Documentation Issues Specific to Suicide ..................... 40 B. Suicide Contracts: Usefulness and Limitations ................................................................... 41 C. Communication With Significant Others ............................................................................. 42 D. Management of Suicide in One’s Practice .......................................................................... 42 E. Mental Health Interventions for Surviving Family and Friends After a Suicide .............. 43 Part B: Background Information and Review of Available Evidence............................ 44 VI. Review and Synthesis of Available Evidence............................................................................. 44 A. Factors Altering Risk of Suicide and Attempted Suicide................................................ 44 B. Psychiatric Assessment Techniques ................................................................................ 83 C. Special Issues ..................................................................................................................... 85 D. Somatic Therapies ............................................................................................................87 E. Psychotherapies................................................................................................................. 93 Part C: Future Research Needs ..................................................................................................... 95 Individuals and Organizations That Submitted Comments ................................................................. 97 Acknowledgment ..................................................................................................................................... 97 References................................................................................................................................................. 97 For continuing medical education credit for this and other APA Practice Guidelines,visit http://www.psych.org/cme. Statement of Intent This practice guideline is based on available evidence and clinical consensus and offers rec- ommendations to help psychiatrists in assessing and treating adult patients with suicidal behaviors. This report is not intended to be construed or to serve as a standard of medical care. Standards of medical care are determined on the basis of all clinical data available for an individual patient and are subject to change as scientific knowledge and technology ad- vance and practice patterns evolve. These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome for every individ- ual, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available. This practice guideline has been developed by psychiatrists who are in active clinical practice. In addition, some contributors are primarily involved in research or other academ- ic endeavors.
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