0
1
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1. Establish and maintain a therapeutic alliance.

  • Suicidal ideation and behaviors can be explored and addressed within the context of a cooperative doctor-patient relationship, with the ultimate goal of reducing suicide risk.

  • Taking responsibility for a patient's care is not the same as taking responsibility for the patient's life.

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2. Attend to the patient's safety.

  • For patients in emergency or inpatient settings, consider ordering observation on a one-to-one basis or by continuous closed-circuit television monitoring until an assessment of risk can be completed or if the patient is deemed to be at significant suicide risk.

  • Remove potentially hazardous items from the patient's room (if inpatient), and secure the patient's belongings.

  • Consider screening patients for potentially dangerous items by searching patients or scanning them with metal detectors.

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3. Determine a treatment setting.

  • Treat in the setting that is least restrictive yet most likely to prove safe and effective (Table 6).

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Table Reference Number
TABLE 6. Guidelines for Selecting a Treatment Setting for Patients at Risk for Suicide or Suicidal Behaviors

  • Take into consideration the estimated suicide risk and the potential for dangerousness to others.

  • Reevaluate the optimal treatment setting and the patient's ability to benefit from a different level of care on an ongoing basis throughout the course of treatment.

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4. Develop a plan of treatment.

  • Consider potential beneficial and adverse effects of each option along with information about the patient's preferences.

  • Address substance use disorders.

  • Provide more intense follow-up in the early stages of treatment to provide support and to rapidly institute treatment.

  • Review with outpatients guidelines for managing exacerbations of suicidal tendencies or other symptoms that may occur between scheduled sessions.

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5. Coordinate care and collaborate with other clinicians.

  • Establish clear role definitions, regular communication among team members, and advance planning for management of crises.

  • Communicate with other caregivers, including other physicians providing treatment for significant general medical conditions or other mental health professionals who may be providing therapy. Establish guidelines for contact in the event of a significant clinical change.

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6. Promote adherence to the treatment plan.

  • Establish a positive physician–patient relationship.

  • Create an atmosphere in which the patient feels free to discuss positive or negative aspects of the treatment process.

+

7. Provide education to the patient and family.

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8. Reassess safety and suicide risk.

  • Repeat suicide assessments over time, because of the waxing and waning nature of suicidality (see Table 1 for settings and circumstances).

  • Repeat suicide assessments in inpatient settings at critical stages of treatment (e.g., with a change in level of privilege, abrupt change in mental state, and before discharge).

  • Reassess suicidality if the patient was intoxicated with alcohol or other substances when initially interviewed.

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9. Monitor psychiatric status and response to treatment.

  • Monitoring is especially important during the early phases of treatment, since some medications may take several weeks to provide therapeutic benefit.

  • An early increase in suicide risk may occur as depressive symptoms begin to lift but before they are fully resolved.

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10. Obtain consultation, if indicated.

  • Consultation may be of help in monitoring and addressing countertransference issues.

  • Consultation may be important in affirming the appropriateness of the treatment plan or suggesting other possible therapeutic approaches.

Table Reference Number
TABLE 6. Guidelines for Selecting a Treatment Setting for Patients at Risk for Suicide or Suicidal Behaviors

References

NOTE:
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