VA/DoD Update of Suicide Prevention Guidelines

Pauline Anderson

August 30, 2019

A synopsis of new guidance on the assessment and management of patients at risk for suicide, which updates the 2013 clinical practice guideline from the Department of Veterans Affairs (VA) and the Department of Defense (DoD), as well as a systematic review of the literature on which the update is based, were published online August 27 in the Annals of Internal Medicine.

In May 2019, the VA and the DoD approved the update to the 2013 guideline. It provides "health care providers with a framework by which to screen for, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients who may be at risk for suicide," the authors of the synopsis, led by James Sall, PhD, Veterans Health Administration, Washington, DC, and Texas A&M University, Corpus Christi, Texas, write.

The systematic review was led by Kristen E. D'Anci, PhD, senior associate director of the Center for Clinical Evidence and Guidelines, ECRI Institute, Plymouth Meeting, Pennsylvania.

Research in this area is difficult, D'Anci told Medscape Medical News. "This is a patient population that can be difficult to enroll in trials — people in distress may understandably not want to enroll in a clinical trial, some patients may be worried about stigma surrounding mental health concerns, or enrolling a patient in a trial in a time of crisis may not be appropriate," she said.

For these reasons, studies may involve mixed patient populations, and results may be difficult to synthesize, D'Anci said. "The important findings are that there are interventions that may be helpful for individuals at risk," she said.

Literature Search

Suicide is a growing public health problem in the United States — the national rate increased by 30% from 2000 to 2016. Research suggests that the increase in suicidal ideation, suicide planning, and suicide attempts is especially evident among people aged 18 to 25 years.

The end date for the literature search in the previous guideline was November 2011. The new search extended through May 2018.

The current literature search was for studies in the English of adults at risk for suicide. Studies were of nonpharmacologic interventions, such as psychotherapies, crisis response planning, and community support programs; or pharmacologic interventions, such as antidepressants, anxiety medications, lithium, antipsychotics, ketamine, and naloxone.

Comparators of interest were no treatment (for example, placebo or wait list), other active therapies, combination medication, and nonpharmacologic treatments.

Critical outcomes included suicides, suicide attempts, suicidal ideation, overdose, hopelessness, and harms, such as reduction of health-seeking behavior and effect on patient-provider relationship, career, social relationships, and functioning.

Eight systematic reviews (SRs) and 15 randomized controlled trials (RCTs) were included in the analysis. Regarding overall quality, the authors rated five RCTs as poor, eight as fair, and only two as good.

Five SRs and 12 RCTs examined nonpharmacologic interventions for suicide prevention that were provided face to face, via the Internet, or through mobile telephone applications. Of these, four SRs and one additional RCT examined treatment with cognitive-behavioral therapy (CBT) for suicide behavior and prevention.

Evidence Supports CBT

The findings showed moderate-strength evidence supporting the use of CBT over treatment as usual (TAU) in reducing suicide attempts (risk ratio, 0.47; 95% confidence interval [CI], 0.30 – 0.73; P = .0009), suicidal ideation (standardized mean difference [SMD], –0.24; 95% CI, –0.41 to –0.07 in 15 studies and –0.32, 95% CI, –0.53 to –0.11 in eight studies), and hopelessness (SMD, –0.31; 95% CI, –0.51 to –0.10).

Low-strength evidence indicated that CBT did not prevent or reduce suicide. However, the authors note that the rates of suicide were generally low in these studies, which they said limited the ability of the researchers to draw firm conclusions about this outcome.

No harms related to CBT were reported in the evidence.

Dialectical behavior therapy (DBT) combines elements of CBT, skills training, and mindfulness techniques. The aim of this approach is to help patients with borderline personality disorder to develop skills in emotion regulation, interpersonal effectiveness, and distress tolerance.

The review findings suggest that DBT is more effective than client-oriented therapy and wait-list control in reducing suicidal ideation. However, the overall quality of the evidence supporting this outcome was low.

Results showed no differences between DBT and TAU or "expert-led" psychotherapy for suicidal ideation. Similarly, there were no differences between DBT and TAU or other psychotherapeutic interventions for hopelessness, suicide attempts, or death.

One SR included three RCTs that compared the World Health Organization's Brief Intervention and Contact (WHO-BIC) method with an active control condition for suicide prevention. The intervention included an educational session on suicide prevention followed by regular contact with a trained provider by telephone or in person for up to 18 months.

The findings showed that WHO-BIC reduced the incidence of suicide compared with the control condition (odds ratio [OR], 0.20; 95% CI, 0.09 – 0.42; P < .001).

One RCT evaluated the efficacy of a group psychological intervention called Window to Hope among veterans with moderate to severe traumatic brain injury. Its results showed that the intervention improved hopelessness but not suicidal ideation compared with the wait-list control.

There was low-strength evidence supporting crisis response planning, which uses risk assessment, supportive listening, and crisis resources to reduce suicide attempts in patients with active suicidal ideation or a history of suicide attempt.

Ketamine Evidence

The review also included three SRs and three RCTs that evaluated the effectiveness of a range of pharmacotherapies for patients at risk for suicide.

A meta-analysis used individual patient-level data for 167 participants to compare a single intravenous dose of ketamine with placebo or midazolam (multiple brands) for reducing suicidal ideation.

Two additional RCTs examined the efficacy and safety of a subanesthetic dose (0.5 mg/kg of body weight) of racemic ketamine hydrochloride administered over 40 minutes to 60 participants vs 0.02 mg/kg of midazolam administered to 40 participants (or 0.05 mg/kg in 19 participants).

In all studies, suicidal ideation was reduced with ketamine.

"We found moderate-strength evidence supporting use of short-term intravenous ketamine for reducing suicidal ideation," the investigators write.

The only ketamine study that reported on adverse events showed a transient increase in blood pressure during administration. Blood pressure returned to normal within about 15 minutes after the infusion.

The researchers note that the data on ketamine were short-term, with follow-up of only 1 to 7 days in the SR and up to 6 weeks in one small RCT.

The US Food and Drug Administration recently approved esketamine nasal spray (Spravato, Janssen), the s-enantiomer of ketamine, for patients with treatment-resistant depression. Long-term follow-up studies "may better inform future guideline recommendations," note the authors.

Lithium Effective

An SR that included 6674 participants compared the efficacy of lithium with that of other active treatments or placebo in preventing suicide in patients with unipolar or bipolar mood disorders during a period of 4 months to 48 months.

The analysis showed that rates of suicide were statistically significantly lower with lithium than with placebo (OR, 0.13; 95% CI, 0.03 – 0.66). There were no differences between lithium and other active treatments, including amitriptyline (multiple brands), carbamazepine (multiple brands), lamotrigine (Lamictal, GlaxoSmithKline), and olanzapine (multiple brands).

"The data for these comparisons were highly variable and do not suggest that the treatments are equivalent," the investigators write.

Adverse events were not measured in these trials, but the authors note that lithium has a low therapeutic index and requires patient safety monitoring.

Given the need for interventions to mitigate risk for suicide, particularly in the veteran and active military populations, "the lack of evidence to support current nonpharmacologic and pharmacologic interventions and the lack of information on potential harms is significant," write the researchers.

The several gaps found in the literature "merit further study," they add.

Rising Suicide Rates in Vets

In a separate article, a synopsis of the updated guidelines provides healthcare providers with a framework by which to screen for, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients who may be at risk for suicide.

The authors note that 20 veterans die each day by suicide — a rate that is about 20% higher than that of the general population.

The situation appears to be worsening. Suicide rates almost doubled among service members between 1999 and 2016.

Members of the guidelines panel developed three algorithms to highlight current best practices and formulated 22 evidence-based recommendations, which were organized into three categories.

The authors found strong support for assessing risk factors as part of a comprehensive evaluation of suicide risk. Because an effective method has not been identified, they recommend several approaches in the clinical setting, including self-report measures and clinical interviews.

The guideline developers note that there is support for CBT-based interventions that focus on suicide prevention for patients with a recent history of self-directed violence. They point out that there is a lack of evidence of benefit for community-based interventions.

For pharmacologic treatments, the guidelines suggest considering short-term ketamine infusions or lithium alone or in combination with another psychotropic agent. Clozapine (multiple brands) may be used for patients who have previously attempted suicide.

There is also a recommendation for reducing access to lethal means of suicide, such as firearms, poisons, and medications.

Clear Appraisal

In an accompanying editorial, Eric D. Caine, MD, Center for the Study and Prevention of Suicide, Department of Psychiatry, University of Rochester Medical Center, New York, writes that the guidelines "are as good as one will now find in the United States."

The guidelines "offer straightforward algorithms, useful sidebars, and considered recommendations for assessment and management" of suicidal patients, Caine adds. They also provide "clear appraisal of the strength of the recommendations."

He notes that the new guidelines "necessarily reflect the priorities" of the VA and the DoD.

"Although the VA and DoD populations do not reflect the general US population, in many respects they resemble the representation of men among US suicides — 36,782 (78%) of the decedents in 2017 were men," he writes.

But the guidelines are "restricted in their view" in that they neglect findings that broadly based suicide prevention is possible, as shown by sustained reductions in such countries as Finland, Denmark, and the United Kingdom, notes Caine.

"We have much to learn from these nations," he writes. "Fundamental to each has been the view that prevention begins long before someone becomes suicidal, which is akin to dealing with asymptomatic hypertension."

Regarding the systematic review, Caine writes that it is mostly a compilation of prior reviews, and, not surprisingly, its conclusions don't radically differ from those reviews, "which themselves often assembled many of the same studies," he states.

"Taken together, 'evidence-based' studies seem to show, at most, modest benefit for both psychosocial and psychopharmacologic interventions largely involving persons enrolled in randomized controlled trials," he writes.

He points out that the majority of psychotherapy studies in the review included more women than men and that there was little clarity about what recruiting efforts were needed to ensure enrollment or study completion. "We do know that such studies have high attrition rates," he states.

Data for psychopharmacologic trials are similarly "murky," Caine adds. "Many come from industry-sponsored studies, and others come from insurance or larger population databases, such as those collected by the VA," he writes.

The review was funded by the US Department of Veterans Affairs Veterans Health Administration. Development of the guideline was funded by the VA. The DoD and the VA paid travel expenses for their experts to review the evidence on suicide and to develop treatment recommendations. D'Anci reports having received grants from the US Department of Veterans Affairs during the conduct of the study. The guideline authors have disclosed no relevant financial relationships. Caine is supported in part by a grant from the Centers for Disease Control and Prevention.

Ann Intern. Published August 27, 2019. Synopsis, Full text; Systematic review, Full text; Editorial

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