Guideline sources The following summarized guidelines for the evaluation and management of suicidal ideation are prepared by our editorial team based on guidelines from the European Society of Medical Oncology (ESMO 2023), the United States Department of Defense (DoD/VA 2022; 2019), the American Society of Anesthesiologists (ASA/ACE/OS/AACE/ASMBS/OMA 2020), the American Psychiatric Association (APA 2020; 2010), the National Health and Medical Research Council of Australia (NHMRC 2019), the American Academy of Neurology (AAN 2019), the American College of Emergency Physicians (ACEP 2017), the American College of Endocrinology (ACE/AACE 2016), the American Association of Family Physicians (AAFP 2015), and the U.S. Preventive Services Task Force (USPSTF 2014). 1 2 3 4 5 6 7 8 9 10 11 12 13 Calculator Calculator Calculator Generalized anxiety disorder-7 s Hamilton anxiety scale HAM A Hamilton d https://web.pathway.md/diseases/recoYSoCgSKYGgUVj 1/6 6/24/23, 3:14 PM Suicidal ideation Pathway Guidelines 1. Screening and diagnosis Indications for screening, general population: As per DoD/VA 2019 guidelines, use a validated screening tool (such as the PHQ-9) for universal screening to identify patients at risk for suicide-related behavior. B As per USPSTF 2014 guidelines, insufficient evidence to assess the balance of benefits and harms of screening for suicide risk in adolescents, adults, and older adults in a primary care setting. I Indications for screening (opioid users): assess the risk of suicide and self-directed violence when initiating, continuing, changing, or discontinuing long-term opioid therapy. A Indications for screening (depression): Obtain a careful and ongoing evaluation of suicide risk in all patients with major depressive disorder, including: specific inquiry about suicidal thoughts, intent, plans, means, and behaviors identification of specific psychiatric symptoms (such as psychosis, severe anxiety, substance use) or general medical conditions likely to increase the likelihood of acting on suicidal ideas assessment of past and, particularly, recent suicidal behavior delineation of current stressors and potential protective factors (such as positive reasons for living, strong social support) identification of any family history of suicide or mental illness. A Assess for the presence of suicidal ideas, homicidal ideas, and psychotic symptoms in patients with depression during the postpartum period. A Indications for screening (psychiatric disorders): assess the risk of suicide and aggressive behaviors in the initial assessment of patients with a possible psychotic disorder. B Indications for screening (Tourette's syndrome): assess for suicidal thoughts and suicide attempts in patients with Tourette's syndrome. A Indications for screening (eating disorders): assess the risk of suicide in patients with an eating disorder. B Indications for screening, obesity: As per ASA/OMA/ASMBS/OS/ACE/AACE 2020 guidelines, assess the risk of suicide by a qualified behavioral health professional in all patients before a bariatric procedure. B As per ACE/AACE 2016 guidelines, assess for suicidal ideation in all patients undergoing weight-loss therapy. B Indications for screening (cancer): assess for suicidal thoughts in all patients with cancer in all phases of illness. B https://web.pathway.md/diseases/recoYSoCgSKYGgUVj 2/6 6/24/23, 3:14 PM Suicidal ideation Pathway 2. Classification and risk stratification Risk assessment: As per VA 2019 guidelines, assess risk factors as part of a comprehensive evaluation of suicide risk, including but not limited to: current suicidal ideation prior suicide attempts current psychiatric conditions, such as mood disorders, substance use disorders current psychiatric symptoms, such as hopelessness, insomnia, agitation prior psychiatric hospitalization recent biopsychosocial stressors the availability of firearms. A Show 2 more As per ACEP 2017 guidelines, do not use currently available risk-assessment tools in isolation to identify low-risk patients safe for discharge for patients presenting to the emergency department with suicidal ideation. Obtain an appropriate psychiatric assessment and use good clinical judgment, taking patient, family, and community factors into account, as the best approach to determine risk. D 3. Diagnostic investigations Screening for borderline personality disorder: consider screening for borderline personality disorder in adult C and adolescent patients with frequent suicidal or self-harming behavior. C 4. Medical management Ketamine: offer ketamine infusion as an adjunctive treatment for short-term reduction in suicidal ideation in patients with suicidal ideation and major depressive disorder. B Lithium: offer lithium alone (in patients with bipolar disorder) or combined with another psychotropic agent (in patients with unipolar depression or bipolar disorder) to decrease the risk of death by suicide in patients with mood disorders. B Clozapine: As per APA 2020 guidelines, offer clozapine in patients with schizophrenia if the risk for suicide attempts or suicide remains substantial despite other treatments. B As per VA 2019 guidelines, offer clozapine to decrease the risk of death by suicide in patients with schizophrenia or schizoaffective disorder and either suicidal ideation or a history of a suicide attempt. B 5. Nonpharmacologic interventions https://web.pathway.md/diseases/recoYSoCgSKYGgUVj 3/6 6/24/23, 3:14 PM Suicidal ideation Pathway Brief interventions: Complete a crisis response plan for patients with suicidal ideation or a lifetime history of suicide attempts. B Offer the WHO brief intervention and contact plan, in addition to standard care, in patients after presenting to the emergency department for a suicide attempt. B Cognitive behavioral therapy: offer CBT-based interventions focused on suicide prevention to reduce incidents of future self-directed violence in patients with a recent history of self-directed violence. A Dialectical behavior therapy: As per VA 2019 guidelines, offer dialectical behavior therapy in patients with borderline personality disorder and recent self-directed violence. B As per NHMRC 2019 guidelines, offer comprehensive dialectical behavior therapy in female patients with borderline personality disorder when reduction in self-harm is a treatment goal. B Problem-solving therapy: Offer problem-solving-based psychotherapy in patients with any of the following: history of > 1 incident of self-directed violence, to reduce repeated incidents of such behaviors history of recent self-directed violence, to reduce suicidal ideation hopelessness and history of moderate-to-severe TBI. B Interventions with no evidence for benefit: Insufficient evidence to recommend for or against the use of the following interventions: technology-based behavioral health treatment methods, including self-directed digital delivery of treatment protocols with minimal or no provider interaction (such as compact disc, Web-based) technology-based adjuncts (such as Web or telephone applications) to routine suicide prevention treatment in patients with suicidal ideation community-based interventions targeting patients at risk for suicide or reducing population-level suicide rates gatekeeper training alone for reducing population-level suicide rates buddy support programs for preventing suicide, suicide attempts, or suicidal ideation. I 6. Therapeutic procedures Electroconvulsive therapy: As per VA 2022 guidelines, offer electroconvulsive therapy, with or without psychotherapy, in patients with severe major depressive disorder and severe suicidality. A As per APA 2010 guidelines, offer electroconvulsive therapy in patients with major depressive disorder with associated suicidal ideation. A 7. Preventative measures https://web.pathway.md/diseases/recoYSoCgSKYGgUVj 4/6 6/24/23, 3:14 PM Suicidal ideation Pathway Restricting access to lethal means: reduce access to lethal means to decrease suicide rates at the population level. B 8. Follow-up and surveillance Post-discharge care: Send periodic caring communications (such as postcards) for 12-24 months, in addition to usual care, after psychiatric hospitalization for suicidal ideation or a suicide attempt. B Offer a home visit to support re-engagement in outpatient care in patients not presenting for outpatient care after hospitalization for a suicide attempt. B References 1. L Grassi, R Caruso, M B Riba et al. Anxiety and depression in adult cancer patients: ESMO Clinical Practice Guideline. ESMO Open. 2023 Apr;8 2 101155. Epub 2023 Mar 14. Open 2. APA. 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