Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

patients who may be vulnerable to self-harm and suicide

1st line – hospitalization or outpatient monitoring

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ACUTE
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patients who may be vulnerable to self-harm and suicide
1st line – 

hospitalization or outpatient monitoring

Remove means for suicide, ensure the safety of the patient and others, and treat existing psychiatric disorders.​

Determine the appropriate treatment setting.

Patients who indicate a high degree of suicidal intent, have specific plans, or choose methods with high lethality are of particular concern.

Admission to the hospital or observation in a safe place may be indicated, although it may not reduce subsequent attempts at self-harm. The presence of psychosis and/or lack of adequate social support also indicate that admission to the hospital for continued monitoring is likely to be required. On admission, the patient should be monitored according to established suicide protocol, with appropriate levels of supervision, and should not have access to means of self-harm.

If the patient refuses admission, or lacks capacity to accept admission, he or she can be admitted on an involuntary basis following the legal procedures in the location of practice. Clinicians should be familiar with legal issues pertaining to involuntary admission in their jurisdiction.

Admission to an inpatient psychiatric facility is recommended for any pediatric psychiatric patient presenting to the emergency department if they continue to show a desire to die, remain agitated or severely hopeless, or cannot engage in a discussion around safety planning. Admission is also recommended if the patient lacks adequate social support, cannot be adequately monitored or receive follow-up care, or had a high-lethality suicide attempt or an attempt with clear expectation of death.[88]

Outpatient treatment may be more appropriate for patients with chronic suicidal ideation but no history of prior significant suicide attempts. For outpatient treatment to succeed, a strong support network and easy access to outpatient facilities are required.

If any doubt exists about patient safety outside admission to a treatment facility, admission for assessment or until the patient's environment can be more comprehensively evaluated is prudent.

Plus – make a safety plan

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ACUTE
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patients who may be vulnerable to self-harm and suicide
Plus – 

make a safety plan

Treatment recommended for ALL patients in selected patient group

A collaborative discussion with the patient can produce a personalized safety plan that includes strategies for dealing with distress, removal of access to means, and a list of people and organizations to contact should they become distressed or suicidal in the future. This safety plan belongs to the patient, ideally with the clinician (and key others) having a copy. A safety plan can be reviewed regularly as part of routine discussions and at change/transition points. Patients who indicate a high degree of suicidal intent, have specific plans, or choose methods with high lethality should raise more concern and will need more intensive support and/or referral to specialist mental health services.

Consider – treatment of physical injury if suicidal attempt or self-harm

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ACUTE
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patients who may be vulnerable to self-harm and suicide
Consider – 

treatment of physical injury if suicidal attempt or self-harm

Treatment recommended for SOME patients in selected patient group

Any physical injury associated with a current suicide attempt should be treated appropriately.

Consider – psychotherapy

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ACUTE
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patients who may be vulnerable to self-harm and suicide
Consider – 

psychotherapy

Treatment recommended for SOME patients in selected patient group

Psychotherapy is an important part of the recovery process for many patients. No specific intervention has been shown to reduce suicide, and most suicide intervention therapies are tested for effectiveness in preventing suicide attempt.[150]​​ Despite this, the American Academy of Pediatrics recommends that depression in children or adolescents is treated with a referral to a psychotherapist when indicated, as depression increases the risk of suicide.[126]​

In randomized controlled trials, cognitive behavioral therapy (CBT) has been effective in reducing repeated suicide attempts.[150]​​[152]​​[153]​ Candidates for CBT include patients with a psychiatric disorder that is responsive to CBT (e.g., depression).

Dialectical behavioral therapy (DBT) is an intensive and long-term intervention featuring a combination of behavioral, cognitive, and supportive elements developed to treat patients with borderline personality disorder. While patients with personality disorder may have been considered particularly difficult to treat in the past, DBT may be effective in reducing self-harm in adults and adolescents with borderline personality disorder, or features of borderline personality.[153]​​[155][156]

One randomized controlled trial looking at a brief psychotherapeutic intervention specifically designed for application in specialty mental health services with individuals exhibiting ultra-high risk for suicide demonstrated positive results in a small cohort of patients followed over a 2-year period.[158]

One review of randomized controlled trials of psychological and psychosocial interventions after attempted suicide found that psychodynamic interpersonal therapy may also be effective in reducing suicidal ideation, habitual self-harming behavior, and suicide attempts in patients with borderline personality disorder.[150] This review also stressed the importance of the therapeutic alliance as a key factor in the success of a program, and the need for outreach to improve patient attendance and adherence. 

Consider – psychosocial interventions

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ACUTE
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patients who may be vulnerable to self-harm and suicide
Consider – 

psychosocial interventions

Treatment recommended for SOME patients in selected patient group

Additional interventions may include focus on developing long-term personal goals, identifying positive expectations, and broadening perspectives beyond immediate distress. Social supports and group interventions may also help reduce risk of suicide. Structured group problem-solving therapy has demonstrated no success with self-harming patients.[212]

Uncertainty exists about the safety and effectiveness of no-harm contracts (agreements between the patient and the clinician in which the patient pledges, usually in writing, not to harm him- or herself), postcard mailed interventions, assertive outreach (including case management with crisis intervention, problem-solving training, motivational support, assistance to attend scheduled appointments), systematic therapeutic contact, and a variety of brief contact interventions in reducing death by suicide or suicide attempts.[161][162][163][164][165][166] There is putative evidence that a gender difference in response to psychosocial therapy for self-harm may exist.[167]

Plus – mood stabilizer

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ACUTE
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patients who may be vulnerable to self-harm and suicide
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with bipolar disorder
Plus – 

mood stabilizer

Treatment recommended for ALL patients in selected patient group

The long-term effectiveness of lithium in reducing death by suicide and attempted suicide in patients with bipolar and other mood disorders is well established.[170][171] Withdrawal of lithium treatment may be associated with an increased rate of suicide.​[171]

Patients who attempt suicide while taking lithium may require a change in their medication due to the high lethality of lithium taken in overdose. Reports on the relative efficacy of divalproex (a combination of valproate sodium and valproic acid in a 1:1 molar ratio) in preventing suicide attempts or complete suicide compared with lithium are mixed.[172][173] Treatment with divalproex was not shown to increase suicidal ideation or behavior.[174]

In 2018, the European Medicines Agency recommended that valproate and its analogs are contraindicated in bipolar disorder during pregnancy because of the risk of congenital malformations and developmental problems in the infant/child.[213] In both Europe and the US, valproate and its analogs must not be used in female patients of childbearing potential unless there is a pregnancy prevention program in place and certain conditions are met.[213]

See Bipolar disorder in adults (Management).

Plus – antipsychotic and/or mood stabilizer

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ACUTE
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patients who may be vulnerable to self-harm and suicide
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with schizophrenia spectrum disorders
Plus – 

antipsychotic and/or mood stabilizer

Treatment recommended for ALL patients in selected patient group

The long-term effectiveness of lithium in reducing death by suicide and attempted suicide in patients with bipolar and other mood disorders, including schizoaffective disorder, is well established.[170] Withdrawal of lithium treatment may be associated with an increased rate of suicide.​[171]

One study found that treatment with the atypical antipsychotic clozapine is significantly more effective than olanzapine in preventing suicide attempts in patients with schizophrenia and schizoaffective disorder at high risk for suicide.[175] In 2003, the Food and Drug Administration approved clozapine for the reduction of suicide risk in schizophrenia. Antipsychotic medications that treat hostility, impulsivity, and depression while not creating unacceptable adverse effects may be important in decreasing suicide-related risk.[176]

See Schizophrenia (Management) and Schizoaffective disorder (Management).

Plus – selective serotonin-reuptake inhibitor (SSRI)

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ACUTE
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patients who may be vulnerable to self-harm and suicide
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with depression
Plus – 

selective serotonin-reuptake inhibitor (SSRI)

Treatment recommended for ALL patients in selected patient group

Antidepressant treatment for major depressive disorder is associated with a substantial decrease in suicide risk.[177][178][194] Better detection of major depression and increased prescription of antidepressants have been associated with declining suicide rates in Hungary and Sweden.[179][180][181] Similarly, reduction in prescription of SSRIs to treat depression in youths in the US, Canada, and the Netherlands was associated with an increased suicide rate.[182][183]

Commonly-used first-line antidepressants include SSRIs. They are relatively safe in overdose.[184]

In 2004, the Food and Drug Administration issued a black box warning for suicidality associated with pediatric use of antidepressants. Controversy remains about the proportional impact of, and potential for, suicide-promoting effects of antidepressants in people under the age of 25 years.[185][186]​​ ​It is worth noting that the aim of this warning was not meant to discourage use of antidepressants in youth, but rather to encourage close follow-up/monitoring of youth who are prescribed these medications, especially within the first few months of use and after dose changes.[126]​ While analyses suggest a small number of young patients may develop new suicidal ideation or self-harm with SSRI treatment, overall, SSRI treatment substantially decreases suicide rates and suicide attempts;[187][188]​ SSRIs may have less suicide-sparing impact in children and young people than in adults.[189] This risk appears to relate specifically to patients under the age of 25 years during the initial weeks of treatment, suggesting a need for close monitoring of young people, adolescents, and children during this initial treatment period.[195][196][197]​ The results of one large meta-analysis suggest that in adults under the age of 25 years, the risk of both emergence and worsening of suicidality may be raised in weeks 3-6 of treatment (but not in weeks 1-2), which is later than has been suggested by other studies.[198] In young people, suicidal related behaviors arising during antidepressant treatment may be related to higher initiation dose and rapid upward titration, supporting the suggestion that clinicians should use the "start low and go slow" approach to pharmacotherapy.[195]

See Depression in adults (Management) and Depression in children (Management).

Plus – pharmacotherapy ± psychotherapy

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ACUTE
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patients who may be vulnerable to self-harm and suicide
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with anxiety disorder
Plus – 

pharmacotherapy ± psychotherapy

Treatment recommended for ALL patients in selected patient group

The various anxiety disorders may be treated differently, but one review of the acute treatment of anxiety with sedatives/hypnotics in patients with depression did not support using sedatives/hypnotics as an early adjunct to antidepressant treatment to decrease suicide risk.[199] Because there is considerable evidence that sedatives/hypnotics produce depressant and/or disinhibitory effects in a small proportion of people, sedatives/hypnotics may be best avoided in suicidal patients. 

See Generalized anxiety disorder (Management), Phobias (Management), Panic disorder (Management), and Obsessive-compulsive disorder (Management).

Plus – symptom management

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ACUTE
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patients who may be vulnerable to self-harm and suicide
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with borderline personality disorder
Plus – 

symptom management

Treatment recommended for ALL patients in selected patient group

One 2011 meta-analysis concluded that no drug regimen improves the overall symptoms of borderline personality disorder. It concluded that antipsychotics may improve paranoia, dissociation, mood lability, anger, and global functioning, and that antipsychotics and divalproex can decrease anger, anxiety, depression, and impulsivity.[200]

The UK National Institute for Health and Care Excellence does not recommend using drug treatment specifically for borderline personality disorder or symptoms associated with the disorder, such as repeated self-harm. Sedative medications may be appropriate in the short-term for a crisis, which may involve an escalation of self-harm thoughts and acts. Drug treatment may also be appropriate for any comorbid conditions, such as depression or anxiety.[201]

See Personality disorders (Management).

Plus – detoxification and monitoring

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ACUTE
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patients who may be vulnerable to self-harm and suicide
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with substance misuse
Plus – 

detoxification and monitoring

Treatment recommended for ALL patients in selected patient group

One review found no guidelines for admission to the hospital of suicidal, alcohol-dependent people.[202]

Provide patients with alcohol or substance dependence or misuse who are experiencing suicidal ideation or who have exhibited suicidal behavior with immediate attention, specific treatments for the chemical dependence, and/or specific treatments for any comorbid disorders.[202] This may include detoxification treatments or treatments that target symptoms such as anxiety, agitation, insomnia, and panic attacks.[202] This may also include treatment of comorbid mood disorders with antidepressants such as fluoxetine.[203]

Consider referral to an appropriate rehabilitation facility.

Usual environmental precautions (e.g., removing lethal means, monitoring by patient's family and friends) are also recommended.

See Opioid use disorder (Management), Cocaine use disorder (Management), Amfetamine use disorder (Management), and Alcohol use disorder (Management).

Plus – stimulant medication ± psychotherapy

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ACUTE
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patients who may be vulnerable to self-harm and suicide
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with attention deficit hyperactivity disorder
Plus – 

stimulant medication ± psychotherapy

Treatment recommended for ALL patients in selected patient group

One large Swedish longitudinal, register-based pharmaco-etiology study using a within-patient design showed that pharmacologic treatment of ADHD decreased suicidal behavior.[204]

Psychological therapy should be available in all clinical adult ADHD settings as a viable treatment option.

If there has been any substance abuse in the last year, stimulant medication can be used with caution. It is advisable to use longer-acting stimulants, as they have less potential to be abused.[205]

Obtain a careful cardiac history and, in cases where there are symptoms or a history of concern, an ECG and cardiology consultation prior to starting a stimulant.

See Attention deficit and hyperactivity disorder in adults (Management) and Attention deficit and hyperactivity disorder in children (Management).

ONGOING

those left behind after a death by suicide

1st line – grief counseling

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ONGOING
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those left behind after a death by suicide
1st line – 

grief counseling

Suicide affects a web of people connected with the deceased, including spouses, parents, siblings, friends, acquaintances, coworkers, and healthcare providers. Offer these individuals grief counseling, even though grief counseling does not decrease risk of suicide in those bereaved.[206][207]

Suicide postvention services target individuals personally affected by a recent suicide. The intention of postvention programs is to aid the grieving process and reduce the incidence of suicide contagion through bereavement counseling and survivor education.[86] Provision of outreach at the time of suicide to family member survivors has been shown to increase use of services designed to assist in the grieving process when compared with no outreach.[208] Bereavement support group interventions conducted by trained facilitators have been shown to reduce the intensity of complicated grief.[209] Unfortunately, not all those who might benefit can necessarily access this support.[210] Weak evidence shows support groups for children and adolescents bereaved by suicide may reduce subsequent depression and anxiety.[211]

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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