Clinical Practice Guideline for the Prevention and Treatment of Suicidal Behaviour The CPG was revised in September 2020. The review concluded that the recommendations and other relevant clinical content continue to be valid. The procedure for the revision of the CPG can be consulted at: https://bit.ly/2ZEyBJx It is planned to assess the need to update the CPG 5 years after the last revision. CLINICAL PRACTICE GUIDELINTES IN THE NHS MINISTRY OF HEALTH, SOCIAL SERVICES AND EQUALITY MINISTERIO DE SANIDAD, POLÍTICA SOCIAL E IGUALDAD Clinical Practice Guideline for the Prevention and Treatment of Suicidal Behaviour CLINICAL PRACTICE GUIDELINTES IN THE NHS MINISTRY OF HEALTH, SOCIAL SERVICES AND EQUALITY MINISTERIO DE SANIDAD, POLÍTICA SOCIAL E IGUALDAD This CPG is an aid to decision making in health care. It is not mandatory nor does it replace the clinical judgment of healthcare professionals. Edition: 2012 Edited by: Galician Agency for Health Technology Assessment (AVALIA-T). Department of Health. NIPO MICINN: 477-11-053-8 NIPO MSPSI: 860-11-161-2 Legal deposit: C. 1.650-2012 DOI: https://doi.org/10.46995/gpc_481 Lay-out: Tórculo Artes Gráfi cas, SA. "This CPG was fi nanced by the agreement signed by the Carlos III Health Institute, an autonomous body of the Ministry of Science and Research, and the Galician Agency for Health Technology Assessment(AVALIA-T) within the framework of cooperation provided for in the Ministry of Health National Health System Quality Plan, Social and Equality Policy". This guideline must be cited as follows: Working Group of the Clinical Practice Guideline for the Prevention and Treatment of Suicidal Behaviour. Clinical Practice Guideline for the Prevention and Treatment of Suicidal Behaviour. Ministry of Health, Social Policy and Equality National Health System Quality Plan. Galician Agency for Health Technology Assessment (avalia-t), 2012, SNS Clinical Practice Guidelines: Avalia-t 2010/02. MINISTERIO DE SANIDAD, POLÍTICA SOCIAL E IGUALDAD Table of contents Index of tables, graphs and fi gures 8 Background 11 Authorship and Collaborations 13 Questions to be answered 19 SIGN Levels of evidence and grades of recommendations 23 CPG Recommendations 25 I. Evaluation and treatment 25 II. Preventive aspects of suicidal behaviour 32 1. Introduction 39 1.1. Suicidal behaviour 39 1.2. Conceptualisation 39 1.3. Epidemiology of suicide 42 2. Scope and objectives 47 3. Methodology 49 I. EVALUATION AND TREATMENT 51 4. Risk factors associated with suicidal behaviour and suicide risk assessment 53 4.1. Risk factors 53 4.1.1. Individual risk factors 54 4.1.2. Family and context risk factors 59 4.1.3. Other risk factors 60 4.1.4. Precipitating factors 61 4.1.2. Protective factors 62 4.2. Suicide risk assessment 62 4.2.1. Clinical interview 63 4.2.2. Assessment scales: self- and observer-reporting 65 5. Assessment and management of suicidal ideation and behaviour in primary care 77 5.1. Addressing suicidal ideation in primary care 77 5.2. Assessment of suicidal behaviour in primary care 80 5.3. Criteria for referral from primary care 80 6. Assessing and managing patients with suicidal behaviour in the Emergency Department 87 6.1. Classifi cation of patients (triage) in the Emergency Department 88 6.2. Evaluation of patients with suicidal behaviour in emergency department 91 CLINICAL PRACTICE GUIDELINE FOR THE PREVENTION AND TREATMENT OF SUICIDAL BEHAVIOUR 5 6.3. Training medical staff in the emergency department 97 6.4. Hospital admission criteria for patients with suicidal behaviour 98 7. Treatment of suicidal behaviour in specialist care (Mental Health) 105 7.1. Psychotherapeutic interventions in the treatment of suicidal behaviour 105 7.1.1. Cognitive-Behavioural Therapies 106 7.1.2. Interpersonal Psychotherapy 115 7.1.3. Family Therapy 116 7.1.4. Psychodynamic Therapy 117 7.2. Pharmacological treatment of suicidal behaviour 118 7.2.1. Antidepressants 118 7.2.2. Lithium 123 7.2.3. Anticonvulsants 125 7.2.4. Antipsychotic drugs 128 7.3. Electroconvulsive Therapy 131 II. PREVENTION 141 8. General measures to prevent suicidal behaviour 143 8.1. International suicidal behaviour prevention programmes 143 8.2. Enhancing protective factors and resilience 149 8.3. Restricting access to methods for suicide 151 8.4. The media and suicide 152 8.4.1. The communication media 152 8.4.2. The Internet 155 8.5. Training programmes for the prevention of suicidal behaviour 158 8.5.1. Health professionals 158 8.5.2. Non-health professionals 167 9. Screening for suicide risk 179 9.1. Fundamentals of screening 179 9.2. Screening for suicide risk in adults 180 9.3. Screening for suicide risk in childhood and adolescence 181 9.4. Screening for suicide risk in older people 186 9.5. Suicide risk screening in prisons 189 9.6. Possible adverse effects of screening 191 10. Suicidal behaviour in risk groups 195 10.1. Suicidal behaviour in childhood and adolescence 196 10.1.1. Risk and protective factors 196 6 CLINICAL PRACTICE GUIDELINES IN THE SNS 10.1.2. Detecting and assessing suicide risk 202 10.1.3. Psychometric tests 203 10.1.4. Preventive interventions 204 10.2. Suicidal behaviour in older people 208 10.2.1. Risk and protective factors 210 10.2.2. Detection and assessment of suicide risk 213 10.2.3. Psychometric instruments 213 10.2.4. Preventive interventions 215 10.3. Prevention of suicidal behaviour in other risk groups 221 10.3.1. Patients with high dependency or serious somatic illness 221 10.3.2. Patient carers 224 10.3.3. Risk of suicide due to employment type or status 225 10.3.4. Persons who suffer domestic violence 228 10.3.5. Prison population 230 11. Interventions for family, friends and professionals after a suicide 243 11.1. Needs and expectations of family and friends after a suicide 243 11.2. Preventive interventions in families and friends 244 11.3. Community interventions 249 11.4. Interventions for health professionals after the suicide of a patient 250 12. Clinical intervention programmes for suicidal behaviour in Spain 255 13. Legal aspects of suicide in Spain 267 13.1. The penal code and suicide 267 13.2. Treatment of suicidal behaviour during detention 268 13.3. Health responsibilities arising from suicide 269 13.4. Confi dentiality and professional secrecy regarding suicide 270 14. Quality indicators 273 15. Diagnostic and therapeutic strategies 285 16. Dissemination and implementation 289 17. Recommendations for future research 291 Annexes 295 Annex 1. Information for patients and families on suicidal ideation and behaviour 297 Annex 2. Information for families and friends on bereavement after a suicide 317 Annex 3. Abbreviations 337 Annex 4. Glossary 339 Annex 5. Confl ict of interest 344 Bibliography 345 CLINICAL PRACTICE GUIDELINE FOR THE PREVENTION AND TREATMENT OF SUICIDAL BEHAVIOUR 7 Index of tables, graphs and fi gures Tables Table 1. Review of O´Carroll et al. nomenclature, proposed by Silverman et al. 40 Table 2. Classifi cation of modifi able and non-modifi able suicide risk factors 53 Table 3. Assessment of causes precipitating suicidal behaviour and risk of recurrence 63 Table 4. Recommendations for how, when and what to ask about suicidal behaviour 64 Table 5. Clinical attitude during the clinical interview 65 Table 6. Assessment parameters for a patient with suicidal ideation and/or behaviour 66 Table 7. BDI item on suicidal behaviour 68 Table 8. SAD PERSONS scale 69 Table 9. IS PATH WARM scale 69 Table 10. HRSD suicidal behaviour Item 71 Table 11. Self-reported tests for assessing suicide risk or related aspects 71 Table 12. Observer-reported tests for assessing suicide risk or related aspects 72 Table 13. Recommendations for dealing with suicidal ideation 78 Table 14. Recommendations in primary care according to the level of suicide risk 79 Table 15. Data to be collected by the hospital emergency physicianto assess a patient with suicidal behaviour 94 Table 16. Manchester self-harm test questions for suicidal behaviour 95 Table 17. Comparison ofsuiciderisk assessmentby cliniciansand by the Manchester test 96 Table 18. Hospital admission criteria from the American Psychiatric Association 100 Table 19. Variables associated with hospital admission 101 Table 20. Cognitive-behavioural therapy studies (Tarrier et al. meta-analysis) 107 Table 21. Dialectical behaviour therapy studies (Tarrier et al. meta-analysis) 108 Table 22. MACT studies (Tarrier et al. meta-analysis) 109 Table 23. Problem solving therapy studies (Tarrier et al. meta-analysis) 109 Table 24. Other cognitive-behavioural therapy studies (Tarrier et al. meta-analysis) 110 Table 25. Cognitive-behavioural therapy studies included 112 Table 26. Interpersonal therapy studies included 116 Table 27. Psychodynamic therapy studies included 117 Table 28. Studies evaluating antidepressant treatment on suicidal behaviour 119 8 CLINICAL PRACTICE GUIDELINES IN THE SNS Table 29. Use of antidepressants for major depression in childhood and adolescence 122 Table 30. Studies of anticonvulsant treatment in patients with suicidal risk or behaviour 125 Table 31. Studies on the use of anticonvulsants and the risk of suicidal behaviour 127 Table 32. Studies included of patients treated with fi rst generation antipsychotic drugs 128 Table 33. Observational studies of the ECT treatment of suicidal behaviour 133 Table 34. Diagnoses where ECT may be considered a primary indication 135 Table 35. Protective factors associated with suicidal behaviour 149 Table 36. WHO recommendations on reporting suicide in the media 153 Table 37. Studies included in the WHO systematic review on the effect of reporting suicides in the media and the impact of the guidelines 154 Table 38. Training programmes in primary care 161 Table 39. Training programmes in mental health 162 Table 40. Training programmes in the emergency department 165 Table 41. Training programmes in educational centres 168 Table 42.