World Suicide Prevention Day

🩺 SUICIDE PREVENTION IN CLINICAL PRACTICE: EVIDENCE-BASED APPROACHES

Suicide prevention in clinical practice relies on three core evidence-based approaches: systematic identification of suicide risk, collaborative safety planning combined with restricting access to lethal means, and structured follow-up after a crisis.

Several U.S. clinical guidelines and recommendations, including the 2024 VA/DoD Clinical Practice Guideline, the recommended standard care framework developed by SAMHSA and the National Action Alliance, and the U.S. Preventive Services Task Force (USPSTF) recommendations, agree on the importance of these components, although their positions differ regarding universal screening.

💬 The belief that asking about suicide may trigger suicidal behavior is false. Avoiding the topic with an at-risk patient is more dangerous than asking about it directly.

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🔎 1. SCREENING AND RISK IDENTIFICATION

The appropriateness of screening the general population for suicide risk remains an unresolved issue. It is important to preserve the differences between guideline recommendations, as treating them as equivalent may mislead readers about the strength of the available evidence.

▪️ VA/DoD, 2024
Position: Suggests using a validated screening instrument to identify individuals at risk for suicide. The guideline does not formulate a recommendation for universal screening of all patients.
Strength of recommendation: Weak for

▪️ USPSTF — Adults, 2023
Position: Evidence is insufficient to assess the balance of benefits and harms of screening specifically for suicide risk. Screening for depression is recommended.
Strength of recommendation: I statement — suicide risk; B recommendation — depression

▪️ USPSTF — Children and Adolescents, 2022
Position: Evidence is insufficient to recommend screening for suicide risk. Screening for depression is recommended for adolescents aged 12–18 years.
Strength of recommendation: I statement — suicide risk; B recommendation — depression in adolescents aged 12–18 years

▪️ SAMHSA / National Action Alliance
Position: At a minimum, recommends targeted assessment for patients with a mental health disorder, a substance use problem, or a history of psychiatric medication use.
Strength of recommendation: Consensus-based standard

🏥 Why is primary care a critical point of intervention?

Approximately half of people who die by suicide have had contact with a primary care provider within the month before their death. This contact represents an important, and sometimes the only, opportunity for intervention. This observation supports targeted assessment, even in the absence of consensus on universal screening.

📝 Screening instruments

• PHQ-9, Item 9: The VA/DoD guideline suggests using this item to identify suicide risk (a weak-for recommendation). Evidence indicates that it can predict both suicide attempts and suicide deaths.
• C-SSRS: The VA/DoD guideline considered the available evidence on its diagnostic accuracy insufficient to support a separate recommendation. Although the instrument is widely used, the guideline does not explicitly endorse it for screening purposes.
• ⚠️ Limitations of available instruments: All currently available instruments have high false-positive rates and low sensitivity for identifying individuals who ultimately die by suicide.

💡 Key clinical principle: Individual risk factors and screening scores cannot reliably predict suicide in a specific patient at a specific point in time. Screening does not replace clinical judgment or direct conversations with patients; rather, it provides a starting point for further assessment.

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⚠️ 2. RISK FACTORS AND WARNING SIGNS

Fazel and Runeson describe suicide as the cumulative result of predisposing and precipitating factors that accumulate throughout a person's life. The categories below are based on the 2024 VA/DoD guideline and additional sources.

🔴 Strongest individual risk factors

• A previous suicide attempt — the strongest single predictor.
• Current suicidal thoughts or intent.
• Psychiatric disorders, including depression, bipolar disorder, schizophrenia spectrum disorders, and substance use disorders — each is associated with at least a threefold increase in the odds of suicide.
• A history of psychiatric hospitalization; risk is particularly elevated after discharge.
• According to a meta-analysis of psychological autopsy studies, approximately 87% of people who died by suicide met the criteria for at least one mental disorder.

🧩 Predisposing factors

• Family history of suicide.
• Childhood abuse or trauma.
• Epilepsy and traumatic brain injury (TBI).
• Chronic pain and chronic medical conditions.
• Sexual and gender minority status (LGBTQ+).
• Impulsivity and aggression as personality characteristics.

🌧️ Precipitating and psychosocial factors

• Relationship loss or another significant interpersonal crisis.
• Hopelessness — one of the most robust psychological predictors.
• Perceiving oneself as a burden to others and social isolation.
• Access to lethal means.
• Major stressful life events, including loss of employment, financial hardship, or loss of social status.

🚩 Acute warning signs

• Talking or writing about wanting to die.
• Attempts to obtain lethal means or seeking access to them.
• Hopelessness, agitation, intense anger, or risky behavior.
• Marked mood changes and sleep disturbances.
• Giving away personal belongings or putting one's affairs in order.

The likelihood of recurrent self-harm is highest within the first 3–6 months after the initial episode. This period represents an important window for active follow-up.

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🛡️ 3. EVIDENCE-BASED INTERVENTIONS

3.1. Safety Planning Intervention (SPI)

Safety planning is a brief, written plan developed collaboratively with the patient. The VA/DoD guideline refers to a similar approach as a crisis response plan and recommends it for individuals experiencing suicidal ideation or those with a lifetime history of suicide attempts.

A safety plan includes:

1️⃣ 🟡 Individually identified warning signs.
2️⃣ 🧠 Internal coping strategies.
3️⃣ 🤝 Social contacts and settings that can provide distraction.
4️⃣ 📞 Specific people the patient can contact for help.
5️⃣ 🏥 Professional support and crisis resources.
6️⃣ 🔒 Counseling on restricting access to lethal means.

📊 Effectiveness of SPI

A comparative cohort study conducted in an emergency department found that the Safety Planning Intervention combined with structured telephone follow-up (SPI+) was associated with the following outcomes over six months, compared with usual care:

• A 45% reduction in suicidal behavior (3.03% vs. 5.29%).
• Twice the odds of attending an outpatient mental health visit (odds ratio, 2.06).

🔐 3.2. Restricting Access to Lethal Means

The VA/DoD guideline suggests reducing access to lethal means as a strategy to reduce suicide rates at the population level (a weak-for recommendation).

Practical measures include:

• Safe storage or temporary removal of firearms, medications, and other identified lethal means.
• Involving family members in reducing access to these means at home.
• During periods of elevated risk, limiting the quantity of prescribed medication and selecting a less toxic alternative when clinically appropriate.

🩺 3.3. Brief Interventions in Acute Care Settings

A systematic review and meta-analysis published in JAMA Psychiatry found that brief interventions delivered in acute care settings reduce subsequent suicide attempts and improve linkage to follow-up care. The findings regarding their effects on depression severity were inconsistent.

💙 3.4. Caring Contacts and Follow-Up

• VA/DoD: Following psychiatric hospitalization, suggests periodic caring contacts (for example, letters or cards) over 12–24 months, in addition to usual care.
• SAMHSA: Recommends the first caring contact within 24 hours or on the next business day.
• Methods of contact: Telephone calls, text messages, letters or cards, or in-person visits.

🚫 3.5. What Should Not Be Used?

"No-suicide" and "no-harm" contracts are not recommended. Their effectiveness has not been established; they may become coercive and create a false sense of security for clinicians regarding risk management.

Instead, clinicians should use a collaboratively developed safety plan or crisis response plan.

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📋 4. RECOMMENDED STANDARD OF CARE

According to the SAMHSA/VA framework, standard care for patients at elevated risk of suicide includes the following components:

1️⃣ Risk assessment and stratification — at intake and periodically thereafter, using a validated instrument.
2️⃣ Safety planning — developing a collaborative safety plan during the same visit and providing contact information for crisis services.
3️⃣ Reducing access to lethal means — involving family members or other significant individuals.
4️⃣ Access to specialized support — connecting the patient with a clinician specifically trained in suicide prevention, for example, through the Zero Suicide model.
5️⃣ Caring contacts and follow-up — ensuring follow-up communication and reassessing the safety plan at every visit until risk decreases.
6️⃣ Management of high or uncertain risk — arranging immediate referral to mental health services.

The therapeutic relationship itself plays an important role in reducing risk.

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🇬🇪 5. APPLICABILITY OF RECOMMENDATIONS IN GEORGIA

When implementing U.S. clinical recommendations in Georgia, local service availability, the legal framework, and epidemiological characteristics must be taken into account.

• 📞 Crisis services: National or regional crisis hotlines, emergency psychiatric services, and referral pathways need to be identified and verified.
• 📝 Screening instruments: The validation status of the Georgian version of the PHQ-9 must be confirmed. Use of a nonvalidated translation represents a separate limitation.
• 🏥 Referral options: Access to psychiatric services and waiting times vary by region. A realistic referral pathway should be established in advance for patients at high risk.
• 🔒 Lethal means: The distribution of lethal means differs across countries. An emphasis on firearms based on U.S. data should not automatically be transferred to Georgia; local epidemiological data should be reviewed.
• ⚖️ Legal and ethical framework: The grounds for involuntary hospitalization and the limits of confidentiality must be clarified in accordance with Georgian legislation.

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✅ CONCLUSION

Suicide prevention in clinical practice involves much more than screening for risk. It requires clinical judgment, open and direct conversations with patients, collaborative safety planning, reducing access to lethal means, and structured follow-up after a crisis.

Recommendations should be applied with careful consideration of their evidentiary basis and limitations. Their implementation in Georgia should be adapted to the local healthcare system and legal environment.

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📚 REFERENCES

1. U.S. Department of Veterans Affairs, U.S. Department of Defense. VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide. Version 3.0. Washington, DC: VA/DoD; 2024.
2. US Preventive Services Task Force. Screening for depression and suicide risk in adults: US Preventive Services Task Force recommendation statement. JAMA. 2023;329(23):2057–2067.
3. US Preventive Services Task Force. Screening for depression and suicide risk in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA. 2022;328(15):1534–1542.
4. National Action Alliance for Suicide Prevention, Suicide Prevention Resource Center. Recommended Standard Care for People with Suicide Risk: Making Health Care Suicide Safe. Washington, DC: Education Development Center; 2018.
5. Fazel S, Runeson B. Suicide. N Engl J Med. 2020;382(3):266–274.
6. Stanley B, Brown GK, Brenner LA, et al. Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry. 2018;75(9):894–900.
7. Doupnik SK, Rudd B, Schmutte T, et al. Association of suicide prevention interventions with subsequent suicide attempts, linkage to follow-up care, and depression symptoms for acute care settings: a systematic review and meta-analysis. JAMA Psychiatry. 2020;77(10):1021–1030.
8. Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012;19(2):256–264.
9. Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry. 2002;159(6):909–916.
10. Arsenault-Lapierre G, Kim C, Turecki G. Psychiatric diagnoses in 3275 suicides: a meta-analysis. BMC Psychiatry. 2004;4:37.
11. Zalsman G, Hawton K, Wasserman D, et al. Suicide prevention strategies revisited: 10-year systematic review. Lancet Psychiatry. 2016;3(7):646–659.
12. Rudd MD, Mandrusiak M, Joiner TE. The case against no-suicide contracts: the commitment to treatment statement as a practice alternative. J Clin Psychol. 2006;62(2):243–251.