A.

SOMATIC THERAPIES
For the purposes of this practice guideline, psychiatrists should be familiar with specific
psychotropic medicines that have been found to be useful in the care of the suicidal patient.
In general, somatic therapies such as antidepressants, antipsychotics, or mood-stabilizing
agents will be targeted to specific axis I and/or axis II psychiatric disorders. However, early
use of supplemental medicines, including sedative-anxiolytics or low doses of second-
generation antipsychotics, may also be helpful to rapidly address agitation, anxiety, and
insomnia, which are additional risk factors for suicide.

1. Antidepressants
A mainstay of the treatment of suicidal patients suffering from acute, recurrent, and chronic
depressive illness is the administration of antidepressant medication in an adequate dose.
Antidepressants also have demonstrated efficacy in the treatment of anxiety disorders. They
have also been used successfully in treating suicidal patients with comorbid depression and
substance use disorders. Remarkably, however, there is relatively limited evidence that
antidepressant treatment reduces risk. On the basis of a large number of short-term
randomized, placebo-controlled trials for acute major depression that were subjected to meta-
analysis, antidepressant treatment has not been shown to reduce rates of suicide or suicide
attempts. Studies using data on antidepressants from Food and Drug Administration clinical
trial databases also do not show differences in rates of suicide or suicide attempts with
antidepressant treatment. However, reductions in risk might not be observed as readily over
short time periods or in studies in which suicidality was used as an exclusion criterion.
Furthermore, long-term studies with relevant data are rare and too small to support any
conclusions. However, since the late 1980s, suicide rates in several countries, regions, or
subpopulations have fallen appreciably, coinciding with the increasing clinical use of
nontricyclic and non–monoamine oxidase inhibitor (non-MAOI) antidepressants in adequate
doses and perhaps providing indirect evidence for a role of antide-pressant treatment in the
treatment of suicidal behaviors.
After publication of several case reports suggesting that SSRI antidepressants might be
associated with increased risks of aggressive or impulsive acts, including suicide, a number
of investigators retrospectively analyzed clinical trial data to determine whether suicidality
and/or suicide rates are increased with SSRI treatment. These studies did not show evidence
that suicide or suicidality is increased by treatment with specific types of antidepressants. At
the same time, these medications are prescribed in order to treat disorders that may have
anxiety, agitation, and suicidality as part of the illness course, making it difficult to
distinguish the etiology of symptoms that emerge in the course of treatment. Thus, as
treatment begins, it is important to determine baseline levels of symptoms and then to
observe patients for symptoms such as anxiety, agitation, or sleep disturbance as well as for
the development of mixed states or psychosis, all of which may increase their subjective
sense of distress and increase suicide risk. In addition, antidepressant therapy typically
involves a substantial delay before clinically obvious improvements occur. During initial,
partial recovery, it is possible that suicidal impulses as well as the energy to act on them may
increase. Patients should be forewarned of this likely delay in treatment effects and should be
given encouragement and monitored especially closely in the initial days and weeks of
treatment. If full response to treatment is not observed, adjustments in medication dosage or a
change to a different antidepressant medication may be necessary. Nontricyclic, non-MAOI
antidepressants are relatively safe and present virtually negligible risks of lethality on
overdose. Nevertheless, it is wise to request that conservative quantities of medication be
dispensed for suicidal patients, especially for patients who are not well known. Although the
tricyclic antidepressants and MAOIs are much more toxic in overdose and more limited in
their use, they may still be valuable in treating individuals with suicidal behaviors and
depressive disorders who have not responded to treatment with SSRIs or other newer
antidepressants. Overall, from a clinical perspective, the strong association between clinical
depression and suicide and the availability of reasonably effective and quite safe
antidepressants support their use, in adequate doses and for an adequate duration, as part of a
comprehensive program of care for potentially suicidal patients, including long-term use in
patients with recurrent forms of depressive or severe anxiety disorders.

2. Lithium
There is strong and consistent evidence in patients with recurring bipolar disorder and major
depressive disorder that long-term maintenance treatment with lithium salts is associated with
major reductions in risk of both suicide and suicide attempts. A recent metaanalysis of
available studies of suicide rates with versus without long-term lithium maintenance
treatment found a highly statistically significant decrease in suicidal acts (i.e., suicide or
suicide attempts) of almost 14-fold. For suicide, lithium maintenance treatment was
associated with an 80%–90% decrease in risk, whereas the reduction in suicide attempt rates
was more than 90%. Although suicide rates during lithium treatment are still greater than
those in the general population, maintenance therapy with lithium for bipolar disorder
patients is associated with substantial and significant reductions in suicide risk, compared to
non-lithium-treated bipolar disorder patients. As with antidepressants, the potential lethality
of lithium in overdose should be taken into consideration when deciding on the quantity of
lithium to give with each prescription. However, given the long-term benefits of lithium in
reducing risks of suicidal behaviors, the potential for overdose effects should not preclude
treatment of suicidal patients with lithium when it is clinically indicated.
3. “Mood-stabilizing” anticonvulsant agents
Despite the increased use and antimanic efficacy of specific anticonvulsant and antipsychotic
agents (e.g., divalproex, olanzapine), their long-term effectiveness in protecting against
recurrent mood episodes is less well established. Moreover, there is no established evidence
of a reduced risk of suicidal behavior with any other “mood-stabilizing” anticonvulsants.
Although treatment with these agents may be associated with some decrease in suicidal
behaviors, lithium treatment is still associated with a greater diminution in rates of suicidal
acts than treatment with carbamazepine or divalproex. Consequently, when deciding between
lithium and other first-line agents for treatment of patients with bipolar disorder, the efficacy
of lithium in decreasing suicidal behavior should be taken into consideration when weighing
the benefits and risks of treatment with each medication.
4. Antipsychotic agents
Analogous to the use of antidepressants for patients with depression, the antipsychotic
medications have been the mainstay of somatic treatment for suicidal patients with psychotic
disorders. First-generation antipsychotic agents are highly effective in treating delusions
and hallucinations as well as agitation, aggression, and confusion and may also have some
beneficial actions in major affective disorders. Their potential effects in limiting suicidal risk
in psychotic patients are unknown, although annual rates of suicide associated with
schizophrenia have not fallen appreciably since their introduction. Particularly in highly
agitated patients, the beneficial effects of first-generation and modern antipsychotics may
serve to reduce suicide risk. However, use of older neuroleptic agents may also be associated
with adverse effects, including extrapyramidal neurological side effects and possible
worsening of depression as a result of induction of akathisia. Given the fact that treatment of
psychotic disorders with second-generation antipsychotic agents is associated with lower
risks of some, particularly extrapyramidal-neurological, adverse effects, use of first-
generation antipsychotics in individuals with suicidal behaviors currently is usually reserved
for those needing the enhanced treatment adherence afforded by depot forms of medication or
those whose psychosis has not responded to a second-generation anti-psychotic, or when
economic considerations are compelling. In the United States, the second-generation
antipsychotic medications, such as aripiprazole, clozapine, olanzapine, quetiapine,
risperidone, and ziprasidone, are now used to treat the majority of individuals with
schizophrenia or schizoaffective disorder. In addition to their use as first-line agents in the
treatment of schizophrenia, the second-generation antipsychotic agents may also be indicated
for use in individuals with other psychotic disorders as well as in patients with bipolar
disorder, particularly during manic episodes. Among the second-generation anti-psychotic
agents, clozapine has generally been reserved for use when psychotic symptoms havenot
responded to other antipsychotic medications. As for effects on suicide attempts and suicide,
clozapine is the best studied of any of the antipsychotic agents. Reductions in the rates of
suicide attempts and suicides have been reported in specific studies of patients with
schizophrenia treated with clozapine as well as in registry studies, which may include patients
with other psychotic diagnoses. Earlier studies could not eliminate the possibility that suicide
rates were decreased by a nonspecific effect of increased clinical contact due to hematologic
monitoring during clozapine therapy. However, significant reductions in suicide attempts and
hospitalization for suicidality were also seen in a more recent blinded study comparing
clozapine and olanzapine. The reduction of suicide attempts in both groups, compared to the
rate in the year preceding the study, suggests that olanzapine may also offer some protection
against suicide attempts. These findings suggest that use of clozapine might be considered
earlier in the treatment of individuals with schizophrenia or schizoaffective disorders. At the
same time, the potential benefits of treatment with clozapine need to be weighed against the
potential for adverse effects with long-term clozapine treatment, including agranulocytosis,
myocarditis, weight gain, and glucose dysregulation. Further study is needed to determine
whether clozapine can reduce suicide risk in patients with other diagnoses or whether other
second-generation antipsychotic drugs may reduce suicide risk in schizophrenia in
comparison with one another or with first-generation antipsychotic drugs.
5. Antianxiety agents
Since anxiety is a significant and modifiable risk factor for suicide, utilization of antianxiety
agents may have the potential to decrease this risk. More specifically, before accompanying
depression has resolved, acute suicide risk may be associated with severe psychic anxiety,
panic attacks, agitation, and severe insomnia. Although these symptoms may be reduced by
aggressive short-term benzodiazepine treatment (lasting 1–4 weeks), research on suicide risk
with antianxiety treatment is quite limited, with no clinical trial of antianxiety treatment
showing short- or long-term antisuicide effects. However, a recent anal ysis o f data obtained
in contro lled trials of treatments for anxiety disorders showed no significant differences in
rates of suicidal behavior between those treated with active agents and those taking placebo.
To minimize severe recurrent (rebound) anxiety/agitation, long-acting benzodiazepines may
be preferable to short-acting ones. At the same time, long-acting benzodiazepines may be
more likely to cause daytime sedation. Psychiatrists should also keep in mind that
benzodiazepines occasionally disinhibit aggressive and dangerous behaviors and enhance
impulsivity, particularly in patients with borderline personality disorder. For patients treated
with benzo-diazepines on a chronic basis, discontinuation of the benzodiazepine may be
associated with an increase in suicide risk. As alternatives to benzodiazepines, second-
generation antipsychotic medications or anticonvulsant medications such as divalproex or
gabapentin may be helpful, although no specific research information on their potential to
limit anxiety is available. Persistent, severe insomnia is also a modifiable risk factor for
suicide and can be addressed with the use of benzodiazepines or sedating second-generation
antipsychotics. Choice of a sedating antidepressant can also be considered for depressed
patients with prominent insomnia.
6. ECT
ECT is sometimes used to treat patients who are acutely suicidal, and available evidence
suggests that ECT reduces short-term suicidal ideation. The efficacy of ECT is best
established in patients with severe depressive illness, but ECT may also be used in treating
individuals with manic or mixed episodes of bipolar disorder, schizoaffective disorder, or
schizophrenia, under certain clinical circumstances. ECT is especially likely to be considered
for patients for whom a delay in treatment response is considered life-threatening. Such
patients may include individuals who are refusing to eat because of psychosis or depressive
symptoms as well as those with catatonic features or prominent psychosis. ECT may also be
indicated for suicidal individuals during pregnancy and for those who have already failed to
tolerate or respond to trials of medication. Although ECT is often raised as a possible
treatment for chronically suicidal individuals with borderline personality disorder, ECT in
such patients should target comorbid disorders that may be present, particularly comorbid
major depressive disorder. In the absence of another indication for use, ECT is not indicated
for the treatment of suicidality in borderline personality disorder. For further details on the
clinical use of ECT, including the pre-ECT evaluation, the informed consent process, the
numbers of treatments generally given, and the technical aspects of ECT administration, the
reader is referred to APA’s 2001 report, The Practice of Electroconvulsive Therapy:
Recommendations for Treatment, Training, and Privileging: A Task Force Report of the
American Psychiatric Association. Since there is no evidence for long-term or sustained
reduction of suicide risk after an acute course of ECT, close clinical supervision and
additional treatment with psychotropic medications are usually required during subsequent
weeks and months.

B. PSYCHOTHERAPIES
In addition to pharmacotherapies and ECT, psychotherapies play a central role in the
management of suicidal behavior in clinical practice. Although few rigorous studies have
directly examined whether these interventions reduce suicide morbidity or mortality per
se, clinical consensus suggests that psychosocial interventions and specific
psychotherapeutic approaches are of benefit to the suicidal patient. Furthermore, in recent
years, studies of psychotherapy have demonstrated its efficacy in treating disorders such as
depression and borderline personality disorder that are associated with increased suicide risk.
For example, cognitive behavior therapy, psychodynamic therapy, and interpersonal
psychotherapy have been found effective in clinical trials for the treatment of these disorders.
A small randomized, controlled trial of psychoanalytically oriented partial hospital treatment
for individuals with borderline personality disorder showed a beneficial effect on suicide
attempts and self-harming behaviors during treatment and follow-up. These observations as
well as clinical experience lend support to the use of such psychotherapeutic approaches in
the treatment of suicidal ideation and behaviors. A number of other specific and nonspecific
interventions have been assessed in small methodologically sound, randomized, controlled
trials involving individuals with suicidal ideation or attempts as well as other forms of
deliberate self-harm. Dialectical behavior therapy has been studied for effects in a narrow
range of potentially suicidal patients, particularly chronically suicidal or self-harming women
with personality disorders. By targeting deficits in specific skills, such as emotional
regulation, impulse control, anger management, and interpersonal assertiveness, dialectical
behavior therapy may be effective in reducing suicide attempts when applied over longer
time frames, especially for patients with personality disorders. There is also some preliminary
evidence that cognitive and behavioral psychotherapy may reduce theincidence of suicide
attempts in depressed outpatients. However, other forms of cognitive behavior therapy that
include a problem-solving component have shown mixed results, suggesting the need for
additional study. Other nonspecific interventions have been studied in relatively small
samples and have similarly shown mixed results. Most of these studies are limited in the size
and scope of the patient population and provide only narrow support for an effect on suicidal
behaviors.
RELEVANT INTERVENTIONS FOR HEALTH SYSTEM AND SOCIETAL RISK
FACTORS
1. Mental health policies
In 2013, WHO launched the comprehensive Mental Health Action Plan 2013−2020. The plan
encourages countries to work towards their own mental health policies with a focus on four
key objectives:
1. Strengthen effective leadership and governance for mental health.
2. Provide comprehensive, integrated and responsive mental health and social care services in
community-based settings.
3. Implement strategies for promotion and prevention in mental health.
4. Strengthen information systems, evidence and research for mental health.
The suicide rate is an indicator and its decrease is a target in the action plan.

2. Policies to reduce harmful use of alcohol

Policy options and interventions to reduce harmful use of alcohol have been published in
WHO’s Global strategy to reduce the harmful use of alcohol. At the same time, these offer
measures for effective suicide prevention and include the
following:
1. Leadership, awareness and commitment.
2. Health services’ response.
3. Community action.
4. Drink-driving policies and countermeasures.
5. Availability of alcohol.
6. Marketing of alcoholic beverages.
7. Pricing policies.
8. Reducing the negative consequences of drinking and alcohol intoxication.
9. Reducing the public health impact of illicit alcohol and informally produced alcohol.
10. Monitoring and surveillance.In populations with a lower prevalence of heavy drinking,
strategies such as awareness-raising can be implemented through general media campaigns,
school health promotion activities or information targeted at vulnerable individuals through
health professionals. The alcohol culture of specific regions should be considered carefully
before strategies are selected in order to ensure that the strategies are effective in the context.
A functioning legal system is also a prerequisite for enforcing these strategies effectively
3. Access to health care
Adequate, prompt and accessible treatment for mental and substance use disorders can reduce
the risk of suicidal behaviour. Implementing health literacypolicies and practices throughout
health systems and institutions, and especially at community health centres, is a key way to
improve access to health-care services in general and mental health care in particular.
Practicesinclude clear messaging to users on available services, appropriate use of language
by health-care providers, and clearer pathways for patients through the system. In particular,
mental health literacy should be included in health literacy strategies and policies.
4. Restriction of access to means
The most common means of suicide worldwide are self-poisoning with pesticides, hanging
and jumping. Restricting access to the means of suicide is effective in preventing suicide –
particularly impulsive suicide – as it gives those contemplating suicide more time to
reconsider. Implementation of strategies to restrict means can occur both at national level,
through laws and regulations, and at local level, for instance by securing risk environments.
5. Responsible media reporting
Responsible reporting of suicide in the media has been shown to decrease suicide rates.
Important aspects of responsible reporting include: avoiding detailed descriptions of suicidal
acts, avoiding sensationalism and glamorization, using responsible language, minimizing the
prominence of suicide reports, avoiding oversimplifications, educating the public about
suicide and available treatments, and providing information on where to seek help. Media
collaboration and participation in the development, dissemination and training of responsible
reporting practices are also essential for successfully improving the reporting of suicide and
reducing suicide imitation. These improvements were demonstrated in Australia and Austria
following active media involvement in the dissemination of media guidelines.Use of the
Internet and social media has a potential role as a universal suicide prevention strategy. Some
websites that promote mental health are already showing promising results in promoting
help-seeking behaviours, but there is little evidence of effectiveness in preventing suicides.
The best examples of online suicide prevention strategies are online chats with professionals
for suicidal people, self-help programmes and online therapy. A website in the United
Kingdom has clipsof young people speaking about suicide attempts. These allow young
people to feel empathy with others in similar situation. Alternatives, when computers are not
available, include text messaging and the growing use of social media services on mobile
devices for individual support and therapy.
6. Raising awareness about mental health, substance use disorders and suicide
Stigma and negative attitudes surround mental disorders and help-seeking among the public.
Awareness campaigns (see also Boxes 3 and 6) aim to reduce the stigma related to mental
disorders and help-seeking for suicide, and to increase access to care. There is little evidence
linking awareness campaigns to a reduction in suicide, but they have had a positive impact
oncommunity attitudes, thus increasing the opportunity for public dialogue on these issues.
Effective mental health awareness campaigns focus on only one or two disorders, using
different types of exposure (e.g. television, print media, Internet, socialmedia, posters) in
order to reinforce the messages, appropriately adapting messages, combining several
strategies, and organizing programmes at local level by targeting specific populations
RELEVANT INTERVENTIONS FOR COMMUNITY AND RELATIONSHIP RISK
FACTORS
1. Interventions for vulnerable groups A number of vulnerable groups (see also Boxes 4 and
6) have been identified as having a higher risk of suicide. While rigorous evaluation is
lacking, some examples of targeted interventions are included below.
• Persons who have experienced abuse, trauma, conflict or disaster: On the basis of evidence
from studies that have investigated these relationships, interventions should be targeted at
groups that are most vulnerable following conflict or a severe natural disaster. Policy-makers
should encourage preservation of existing social ties in affected communities.
• Refugees and migrants: Risk factors vary between groups, so it may be more effective to
develop interventions tailored to specific cultural groups rather than treating all immigrants as
if they are the same.
• Indigenous peoples: A review of intervention strategies in Australia, Canada, New Zealand
and the USA found that community prevention initiatives, gatekeeper training and culturally
tailored educational interventions were effective in reducing feelings of hopelessness and
suicidal vulnerability. Most effective were interventions with high levels of local control and
involvement of the indigenous community to ensure that the interventions were culturally
relevant.
• Prisoners: A review of risk factors among prisoners in Australia, Europe, New Zealand and
the USA showed that prevention interventions should aim to improve mental health, decrease
alcohol and substance abuse, and avoid placing vulnerable individuals in isolated
accommodation. All individuals should also be screened for current or past suicidal
behaviours.
• Lesbian, gay, bisexual, transgender and intersex (LGBTI) persons: Efforts to reduce the
suicide risk among LGBTI persons should focus on addressing risk factors such as mental
disorders, substance abuse, stigma, prejudice, and individual and institutional discrimination.
• Postvention support for those bereaved or affected by suicide: Intervention efforts for
individuals bereaved or affected by suicide are implemented in order to support the grieving
process and reduce the possibility of imitative suicidal behaviour. These interventions may
comprise school-based, family-focused or community-based postventions. Outreach to family
and friends after a suicide has led to an increase in the use of support groups and bereavement
support groups, reducing immediate emotional distress such as depression, anxiety and
despair.
2. Gatekeeper training
Individuals at risk of suicide rarely seek help. Nevertheless, they may exhibit risk factors and
behaviours that identify them as vulnerable. A “gatekeeper” is anyone who is in a position to
identify whether someone may be contemplating suicide. Key potential gatekeepers include :
• primary, mental and emergency health providers;
• teachers and other school staff;
• community leaders;
• police officers, firefighters and other first responders;
• military officers;
• social welfare workers;
• spiritual and religious leaders or traditional healers;
• human resource staff and managers.
Gatekeeper training programmes aim to develop participants’ knowledge, attitudes and skills
for identifying individuals at risk, determining the level of risk, and then referring at-risk
individuals for treatment (see also Box 6). All training content should be culturally adapted
and should include local information about accessibility to health care. Adapted programmes
have shown promising results when tailored to specific populations, such as Aboriginal
groups. Studies show that 25−50% of women who display suicidal behaviour saw a health-
care provider in the preceding four weeks; therefore gatekeeper training provides an
opportunity to begin interventions with these individuals.Gatekeeper training is a best
practice for which no conclusive link has so far been made with reduced rates of suicide or
suicide attempts. See also Box 5 for a programme targeted to gatekeepers and their own
health.
3. Crisis helplines
Crisis helplines are public call centres which people can turn to when other social support or
professional care is unavailable or not preferred. Helplines can be in place for the wider
population or may target certain vulnerable groups. The latter can be advantageous if peer
support is likely to be helpful.Helplines in the USA have been shown to be effective in
engaging seriously suicidal individuals and in reducing suicide risk among callers during the
call session and subsequent weeks. A study of telephone and chat helpline services in
Belgium suggests that these strategies might also be cost-effective for suicide prevention.
Helplines have proved to be a useful and widely implemented best practice. However, despite
reducing suicide risk, the lack of evaluation means that there is no conclusive association
with reducing suicide rates.
RELEVANT INTERVENTIONS FOR INDIVIDUAL RISK FACTORS
1. Follow-up and community support
Recently discharged patients often lack social support and can feel isolated once they leave
care. Follow-up and community support have been effective in reducing suicide deaths and
attempts among patients who have been recently discharged. Repeated follow-ups are a
recommended low-cost intervention that is easy to implement; existing treatment staff,
including trained non-specialized health workers, can implement the intervention and require
few resources to do so. This is particularly useful in low- and middle-income countries. The
intervention can involve the use of postcards, telephone calls or brief in-person visits
(informal or formal) to make contact and encourage continued contact. Involving available
community support – such as family, friends, colleagues, crisis centres or local mental health
centres – in aftercare is important as these can regularly monitor people and encourage
treatment adherence.
2. Assessment and management of suicidal behaviours
It is important to develop effective strategies for the assessment and management of suicidal
behaviours. WHO’s mhGAP Intervention Guide recommends assessing comprehensively
everyone presenting with thoughts, plans or acts of self-harm/suicide. The guide also
recommends asking any person over 10 years of age who experiences any of the other
priority conditions, chronic pain or acute emotional distress, about his or her thoughts, plans
or acts of self-harm/suicide. A careful assessment should be carried out through clinical
interviews and should be corroborated by collateral information. Education and training of
health workers, with a focus on emergency care staff, is needed to ensure that psychosocial
support is provided to those in need and that there is systematic follow-up and community
support. In addition to contributing to the management of individual risk factors, assessment
and management of suicidal behaviours also addresses risk factors in relationships.
3. Assessment and management of mental and substance use disorders
Training health workers in the assessment and management of mental and substance use
disorders is a key way forward in suicide prevention. A large number of those who die by
suicide have had contact with primary health care providers within the month prior to the
suicide. Educating primary health care workers to recognize depression and other mental and
substance use disorders and performing detailed evaluations of suicide risk are important for
preventing suicide. Training should take place continuously or repeatedly over years and
should involve the majority of health workers in a region or country. It is important to
consider local risk factors and to tailor the training programme to these in order for the
programme to be successful within countries and cultures.The WHO mhGAP Intervention
Guide, which is directed primarily at the training of non-specialized health workers, provides
guidance on the assessment and management of the following priority conditions: depression,
psychosis, epilepsy/seizures, developmental disorders, behavioural disorders, dementia,
alcohol use disorders, drug use disorders and self-harm/suicide. It is important, however, to
take into consideration the fact that multiple factors are related to the poor assessment and
management skills of health workers – such as low mental health literacy and experience,
stigma, lack of cooperation with psychiatrists and poor interviewing skills. Addressing these
issues, for instance through education curricula and training, may therefore be important for
improving assessment and management.