Can We Really Prevent Suicide?

MOOD DISORDERS (SM STRAKOWSKI, SECTION EDITOR) Can We Really P e en Suicide? Maya Schwa z-Li shi z &Gil Zalsman &Lucas Gine & Ma ia A. Oquendo Published online: 21 Sep embe 2012 #Sp inge Science+Business Media, LLC 2012 Abs ac E e y yea , suicide is among he op 20 leading causes o dea h globally o all ages. Un o una ely, suicide is di icul o p e en , in la ge pa because he p e alence o isk ac o s is high among he gene al popula ion. In his e iew, clinical and psychological isk ac o s a e examined and me hods o suicide p e en ion a e discussed. P e en- ion s a egies ound o be e ec i e in suicide p e en ion include means es ic ion, esponsible media co e age, and gene al public educa ion, as well iden i ica ion me hods such as sc eening, ga ekeepe aining, and p ima y ca e physician educa ion. Al hough he ea men o p e en ing suicide is di icul , ollow-up ha includes pha maco he a- py, psycho he apy, o bo h may be use ul. Howe e , p e- en ion me hods canno be es ic ed o he indi idual. Communi y, social, and policy in e en ions will also be essen ial. Keywo ds Suicide .Risk ac o s .Diagnos ic isk ac o s . Dep essi e diso de s .Bipola diso de s .Anxie ydiso de s . Alcohol and o he subs ance abuse .Schizoph enia . Agg ession, impulsi i y, and hos ili y .Hopelessness . He edi y .Childhood auma .Pas a emp s .P e en ion . Means es ic ion .Mediaco e age .Iden i ica ion me hods . Diagnosis .T ea men .Psycho he apy .Pha maco he apy . Elec ocon ulsi e he apy .Mood diso de s .Psychia y In oduc ion The Wo ld Heal h O ganiza ion (WHO) de ines suicide as he ac o killing onesel . The ac mus be delibe a ely ini ia ed and pe o med by he pe son conce ned in he ull knowledge, o expec a ion, o i s a al ou come [1]. Suicide is among he op 20 leading causes o dea h globally o all ages and e e y yea , nea ly one million people die om suicide. Wo ldwide, suicide anks among he h ee leading causes o dea h among hose aged 15–44 yea s, and he second leading cause o dea h in he 10–24 yea s age g oup [2]. The global suicide a e is 16 suicides pe 100,000 inhabi an s: mo e speci ically 18 suicides pe 100,000 males and 11 suicides pe 100,000 emales [2]. Clinical s udies ha e demons a ed ha in mos coun ies, suicide p edomi- na es in males, al hough he e a e impo an excep ions such as China. O no e, he suicide a e inc eases wi h age, al hough suicide a es among young people ha e been inc easing o such an ex en ha hey a e now he g oup a highes isk in a hi d o coun ies, in bo h de eloped and de eloping coun ies. As well, he e a e ma ked di e ences in suicide a es be ween some e hnic g oups and indi idual coun ies, and also wi hin di e en egions o one coun y. A suicide a emp is a sel -in lic ed, po en ially inju ious beha io wi h a non a al ou come o which he e is e idence (ei he explici o implici ) o in en o die [3,4]. I is es ima ed ha o e e y suicide, he e a e 50 suicide a emp s, and hus M. Schwa z-Li shi z Geha Men al Heal h Cen e , Pe ach Tiqwa, Is ael G. Zalsman Geha Men al Heal h Cen e , Pe ach Tiqwa, Is ael and Sackle Facul y o Medicine, Tel A i Uni e si y, Tel A i , Is ael L. Gine Depa men o Psychia y, Uni e si y o Se ille, Se ille, Spain M. A. Oquendo New Yo k S a e Psychia ic Ins i u e and Columbia Uni e si y, New Yo k, NY, USA M. A. Oquendo (*) Molecula Imaging and Neu opa hology Di ision/Depa men o Psychia y, Columbia Uni e si y, 1051 Ri e side D i e, Uni 42, New Yo k, NY 10032, USA e-mail: [email p o ec ed] Cu Psychia y Rep (2012) 14:624–633 DOI 10.1007/s11920-012-0318-3 a emp s a e a sou ce o signi ican mo bidi y. Mo eo e , he You h Risk Beha io Su eillance s udy sugges s ha as many as 7 % o adolescen s in he Uni ed S a es acknowledge ha ing a emp ed suicide. Iden i ying indi iduals a imminen isk o suicidal beha - io is a majo challenge o clinicians. In gene al, suicide is ha d o p edic because he p e alence o isk ac o s is high among he popula ion, while suicide is a e. Indeed, only a mino i y o hose wi h isk ac o s will commi suicide. Fu - he mo e, some o he isk ac o s a e no speci ic and o hose who die by suicide, some a e no in any isk g oup. None he- less, up o 90 % o he people who commi suicide, and a simila a e o hose who a emp suicide, su e om a psy- chia ic diso de (a ec i e illnesses, d ugs/alcohol abuse, psy- chosis o pe sonali y diso de s [5–8]). On he o he hand, among psychia ic popula ions, suicidal beha io is no a e and he a e o a emp s among psychia ic pa ien s anges be ween 15–50 % [9]. Despi e he challenges in iden i ying hose a isk o suicidal beha io , oppo uni ies o p e en ion do exis . In many cases, suicidal pe sons ha e been in con ac wi h gene al p ac i ione s in he mon h p io o hei dea h [10–12], al hough, up o 80 % o hem we e no ea ed o hei psychia ic condi ion a ha ime o dea h [13–15]. This con ac wi h he medical p o ession may a o d an oppo uni y o in e en ion. Risk Fac o s Diagnos ic Risk Fac o s Dep essi e Diso de s Mo e han hal o all clinically dep essed pe sons ha e suicidal idea ion and Majo Dep ession Diso de and Bipola Diso de s a e he psychia ic diso de s mos o en associa ed wi h suicide [16]. Some symp oms o dep ession ha e been iden i ied as pa icula ly impo an in isk o suicidal beha - io : hopelessness, eelings o guil , loss o in e es , insomnia, and low sel es eem [17•]. E ec i e p e en ion and ea men o mood diso de s migh educe he numbe o suicide a emp s, gi en ha mos dep essed pa ien s a he ime o suicide a emp a e inadequa ely ea ed [16]. Thus, ea ing suicidal dep essed pa ien s ac i ely and in ensi ely migh o e an e ec i e way o p e en ing suicidal beha io . Bipola Diso de s Suicidal idea ion is highly p e alen in pa ien s wi h bipola diso de s, and i is es ima ed ha as many as hal o hose who ha e bipola diso de a emp suicide a leas once. The suicide a e among hese pa ien s is mo e han 20 imes highe han ha o he gene al popula ion [5] and he isk o suicide is highes ea ly in he cou se o Bipola Diso de , pa icula ly in he i s yea o he illness. The p esence o dep essi e and dyspho ic–i i able s a es in Bipola Diso de is epo ed o be a isk ac o o suicide [8]. O he wo k sugges s ha hopelessness p edic s suicidal beha io du ing he dep essi e phase, and ha se e i y o dep ession p edic s suicide a emp s du ing mixed episodes [17•]. The e o e, agg essi e and e ec i e managemen o dep essi e phases is essen ial, as dep essi e phases a e high isk pe iods o suicidal beha io . Anxie y Diso de s Anxie y diso de s a e associa ed wi h li e ime suicidal ide- a ion and suicide a emp s, especially in adolescen s and in young adul s [18]. Among anxie y diso de s, Panic Diso de and Pos T auma ic S ess Diso de (PTSD) ha e he s on- ges associa ions wi h suicidal beha io . Howe e , whe he anxie y diso de s alone o whe he p esence o anxie y in he con ex o a mood diso de inc eases isk o suicidal be- ha io emains an open ques ion. Fo example, a link be- ween suicidali y and panic/anxie y diso de s has been epo ed [19,20] a imes, independen ly om he p esence o como bid dep ession, subs ance abuse and pe sonali y diso de s [3]. Howe e , Placidi e al. [21] ound ha como - bid panic diso de s in pa ien s wi h majo dep ession did no inc ease he isk o li e ime suicide a emp s. Mo eo e , non-a emp e s sco ed highe in he anxie y i ems in he Hamil on dep ession scale. I may be ha anxie y symp- oms, like ea o disabili y o dea h, se es as a p o ec i e ac o o suicide. In e ms o PTSD, a e iew by Panagio i e al. [22] ound a ela ionship be ween PTSD and suicidal hough s and beha io s, i espec i e o he ype o auma expe ienced.In many PTSD s udies, suicidali y is associa ed wi h como bid dep ession and subs ance abuse [17•]. The e- o e, he inc eased p opo ion o suicide a emp e s among pe sons wi h a PTSD diagnosis may be due o he como bid dep ession and no o PTSD i sel . Gi en ha anxie y is highly como bid wi h o he men al diso de s, especially mood dis- o de s and subs ance abuse, he ole o se e e anxie y as a ma ke o acu e suicide isk equi es u he s udy. Alcohol and O he Subs ance Abuse Subs ance misuse diso de s inc ease he isk o suicidal beha - io s, alcohol being he mos signi ican isk ac o among he subs ances. Alcohol misuse and abuse p edispose o impulsi - i y, agg ession, dep ession, hopelessness, and o he nega i e ac o s ha inc ease he isk o suicidal beha io . Indi iduals who commi suicide and su e om alcohol and o he sub- s ance abuse diso de s a e o en younge males, di o ced o sepa a ed. They o en su e om ecen ad e se li e e en s, Cu Psychia y Rep (2012) 14:624–633 625 and a e likely o be in oxica ed a he ime o he suicide [23]. In e ms o suicide a emp s, he p esence o alcohol misuse dis- o de s is also a signi ican isk ac o . Mo eo e , when co- mo bid wi h a ec i e diso de s, p esence o alcohol misuse diso de s inc eases isk o suicide a emp s by mo e han wo old [24]. Schizoph enia and O he Psychoses Suicide a emp is p e alen in pa ien s wi h schizoph enia and o he psycho ic diso de s [25] and occu s in as many as 23–31 % o hose a lic ed depending on he global egion. Meanwhile, he li e ime suicide isk o people wi h schizo- ph enia is es ima ed o be abou 5 % [26]. The isk ac o s o suicide in schizoph enia a e pas and p esen suicidal beha io , pas dep essi e episodes, d ug abuse o depen- dence and mo e equen psychia ic admissions [27]. O no e, o he isk ac o s, such as ea o men al disin eg a ion, agi a ion o es lessness, and poo adhe ence o ea men , all inc ease isk o suicidal beha io and may be mo e speci ic o schizoph enia [28]. The g ea majo i y o suicides in schizoph enia occu in he ac i e phase o he diso de , in he con ex o dep essi e symp oms [17•]. Tha suicides a e mos common ea ly in he cou se o he illness sugges s ha p e en ion and ea men should ocus on he ea ly s ages o disease. Pe sonali y Diso de s Pe sonali y diso de s ha e been shown o be ela ed o suicidal and sel -inju ious beha io , bo h among he gene al and he psychia ic popula ion [29]. Mo eo e , many suicide a emp e s mee c i e ia o a pe sonali y diso de [30,31]. Al hough bo de line pe sonali y diso de is he only pe son- ali y diso de ha lis s suicidal beha io as a c i e ion, o he pe sonali y diso de s, such as an isocial and o he Clus e B pe sonali y diso de s [32] also inc ease isk o suicidal be- ha io . Pe sonali y diso de s a e o en accompanied by im- pulsi i y, agg ession, alcohol and subs ance abuse, as well as majo dep essi e episodes, all o which a e known isk ac o s o suicide in hei own igh . O he Risk Fac o s Agg ession, Impulsi i y, and Hos ili y Le els o impulsi i y, hos ili y and agg ession a e highe in suicide a emp e s compa ed o non-a emp e s among peo- ple who su e om majo dep ession [33]. Among bipola pa ien s, pas suicide a emp e s epo mo e li e ime agg es- sion han non-a emp e s [34]. Agg ession is an impo an a iable in he p edic ion o suicidal beha io as well [16]. O no e, al hough impulsi i y con ibu es o he u u e isk o suicidal beha io [35], i appea s o lowe he le hali y o he suicidal ac , since i de imen ally a ec s one’s planning abili y. In suppo o his, olde suicides a e epo ed o ha e lowe le els o impulsi i y andagg essioncompa ed o young suicides. Hopelessness Hopelessness was ound o be associa ed wi h u u e suicide a emp s bo h in he sho and long e m [19,36–38]. Fu - he mo e, in mood diso de s, i p edic s suicidal beha io as pa o a pessimism ac o , which also includes measu es o subjec i e dep ession, suicidal idea ion and easons o li ing [37]. Whe he hopelessness as a ai a he han a symp om o dep ession is o impo emains an open ques ion. He edi y Suicidal beha io is highly amilial [3,39,40] and a amily his o y o suicidal beha io is associa ed wi h suicide a emp s and suicide all h ough he li e cycle and ac oss psychia ic diagnoses [41]. This ansmission is independen o he ansmission o psychia ic diso de s [42,43]. Ins ead, he amiliali y o suicidal beha io appea s o be media ed by he ansmission o a endency o impulsi e agg ession, ai s ha leads he pa ien o a highe endency o ac upon suicidal hough s [44,45]. Childhood T auma Childhood auma is also a isk ac o o suicide a emp . Mo eo e , he amoun o auma expe ienced by he child, co ela es wi h younge age a he i s suicide a emp and an inc eased numbe o suicide a emp s [46]. Pas A emp s and Idea ion A suicide a emp in he pas is a majo isk ac o o suicide [3,16] as well as u u e suicide a emp , especially among people su e ing om a ec i e diso de s [46–52]. Repea ed suicide a emp s inc ease he isk o u u e suicidal beha io , as was demons a ed by Leon e al. [53]. Oquendo e al. [54] ound a 50 % inc ease in he isk o u u e suicidal beha io o each p e ious a emp made by he indi idual. The e idence o suicidal idea ion by i sel as a isk ac o o suicide ac s is mo e nuanced. In a p ospec i e s udy [37], suicidal idea ion alone did no p edic u u e suicide a emp s o comple ion. In con as , o he s udies ha e iden- i ied suicidal idea ion as a p ecu so o a emp ed and comple ed suicide among pa ien s wi h mood diso de s [55–58] and as co ela ed wi h g ea e isk o u u e suicide a emp s (as pa o a pessimism ac o ) among bipola 626 Cu Psychia y Rep (2012) 14:624–633 pa ien s p esen ing wi h a majo dep essi e episode [59]. No su p isingly, suicide a emp e s also a e mo e likely o endo se suicidal idea ion du ing subsequen acu e phases o hospi aliza ions [34,60]. The e o e, i is easonable o iew suicide idea ion as a isk ac o o suicide, ei he as an independen isk ac o , o as pa o a ac o in eg a ing measu es o subjec i e dep ession, easons o li ing, and hopelessness [16]. P e en i e Measu es Since a a ie y o ac o s a e in ol ed in he suicidal ac , mul imodal app oaches co e ing mul iple le els o in e en ion and ac i i ies will be essen ial o any p e en i e s a egy. Thus a , p e en ion s a egies ound o be e ec i e in suicide p e- en ion include means es ic ion, esponsible media co e age and gene al public educa ion, as well iden i ica ion me hods such as sc eening, ga ekeepe aining, and p ima y ca e phy- sician educa ion. Means Res ic ion Suicide a emp s using highly le hal means, such as i ea ms in US men, o pes icides in u al China, India, and S i Lanka, esul in high a es o dea h [10]. The mos equen means o suicide in Eu ope is hanging [61] and in No h Ame ica, i ea ms [62]. Suicide me hods a e necessa ily in luenced by hei accessibili y. In many coun ies, es ic ion o access o common means o suicide has led o lowe o e all suicide a es [63]. Fo example, inc easing i ea m con ol in he US and Canada [64–66], de oxi ica ion o domes ic and mo o ehicle gas [67,68], es ic ions on use o oxic pes i- cides in u al a eas [10], and physical ba ie s a jumping si es [69,70] a e epo ed o be o u ili y in educing suicides. In addi ion, educing access o liga u e and liga u e poin s in p isons and hospi als has educed ins ances o hanging [71] while in oducing sa e an idep essan , selling smalle pack- ages o analgesics o indi idually w apped analgesics, and es ic ing o he sale o ba bi u a es has educed suicides by o e dose [72]. Thus, public policy o educe access o means o suicide has an impo an ole in p e en ion. Responsible Media Co e age Responsible media co e age is key o suicide p e en ion by p o iding he public in o ma ion on men al diso de s and hei ea men , and ways o iden i ying pe sons a isk. Glo i ica ion and d ama iza ion o a suicidal ac can be ollowed by a se ies o suicides, especially among adoles- cen s ("con agion"), hus i is impo an o s ess ha he pe son who los his li e o suicide is ill and no in any way a he o. P og ams o educa e he media abou co e age o suicides a e a ailable h ough ounda ions (Ame ican Foun- da ion o Suicide P e en ion) and emphasize he impo - ance o epo ing suicide as a public heal h issue, in a non-sensa ional way. Media co e age should emphasize he ea able causes o suicide, such as subs ance abuse and men al diso de s. Discussing he a ailable ea men op ions o hese p oblems and he ypes o heal hca e p o ide s who can ea hem may encou age help seeking beha io by hose con empla ing suicide. As well, because many indi iduals conside ing suicide exhibi wa ning signs, educa ing he public abou such signs can help ela i es iden i y and espond quickly and e icien ly o he pe son in need. In addi ion, i is essen ial ha media co e age no link suicide only o ex e nal e en s, like di o ce, a ecen job loss o school ailu e, d ama ic as hey may be. Ins ead, emphasizing he equency o psychia ic condi ions among hose who die by suicide and p o iding educa ion abou possible in e en ions can be help ul o communi ies exposed o highly isible suicides. O no e, media epo s co e ing speci ic suicide me hods we e ound o inc ease suicidal beha - io s in he communi y in some s udies [73,74]. The e o e, i is ad isable o a oid inclusion o speci ic de ails such as he loca ion o me hod o dea h in news epo s. Iden i ica ion Me hods Be o e suicidal beha io can be p e en ed, hose a isk need o be iden i ied. Since no all po en ial suicide a emp e s a e in close con ac wi h a men al heal h p o essional, hose a ound hem (e.g., iends, amily, school s a , mili a y commande s and p ima y ca e gi e s) should be equipped wi h ools o p ope ly iden i y isk and make a imely e e al. Gene al Public Educa ion Public educa ion campaigns a e aimed mos ly a imp o ing suicide isk ecogni ion and help-seeking beha io and e- ducing he s igma o men al illness [75••]. Some campaigns add ess suicidal beha io di ec ly, as was done in he Uni ed S a es Ai Fo ce suicide p e en ion p og am [76], while o he s a ge dep essi e diso de s [77–79]. Howe e , Mann e al. [10] ound no de ec able e ec s o public awa eness campaigns, nei he on educing he a e o suicidal ac s, o on inc easing ea men seeking o an idep essan use. Fu - he , a e iew by Dumensil and Ve ge [80•] examined 15 public educa ion campaigns in eigh coun ies and ound ha hese p og ams imp o ed he gene al public’s knowl- edge o suicide and dep ession and con ibu ed a leas mode a ely o be e social accep ance o people wi h de- p ession and o he men al illnesses. Un o una ely, no s udy clea ly demons a es inc eased ca e seeking o dec eased suicidal beha io a e such campaigns. Howe e , i s ill Cu Psychia y Rep (2012) 14:624–633 627 may be he case ha awa eness campaigns ha e an e ec when combined wi h o he measu es in a mul ile el and mul i ace ed in e en ion p og am [76,81]. This was demon- s a ed in he Nu embe g Alliance agains Dep ession (NAD), a wo yea in e en ion p og am ha included ou le els: (1) T aining o gene al p ac i ione s and suppo h ough di e en me hods; (2) A public ela ions campaign in o ming abou dep ession, (3) Coope a ion wi h communi y acili a o s ( eache s, p ies s, local media, e c.), and (4) Suppo o sel - help ac i i ies as well as o high- isk g oups. The p og am was ound o be e ec i e in lowe ing he a e o suicidal ac s by app oxima ely 20 % (suicide a emp s and comple ed suicide) [81]. The p og am demons a ed he addi i e and syne gis ic e ec o combining all ou in e en ion le els simul aneously. The Eu opean Alliance agains Dep ession (EAAD), an EU- unded ne wo k o pa ne s om 17 coun ies adop ed his mul i ace ed in e en ion app oach, and is cu en ly conduc ing a es in Hunga y, Po ugal, Ge many and I eland. Resul s o his ini ia i e ha e ye o be eleased. P ima y Ca e Physicians T aining On a e age, 77 % o he people who commi suicide we e in con ac wi h a p ima y ca e physician in he yea be o e hei dea h, and abou 45 % came in con ac wi h a p ima y ca e p o ide in he mon h p io o hei dea h [11]. Howe e , unde - ecogni ion and unde - ea men o psychia ic diso de s in p ima y ca e se ing p esen s a challenge o iden i ying hose a isk and while men al diso de s a e p esen in mos cases o suicide, mos suicides a e un ea ed a he ime o dea h [13]. Fo una ely, educa ion o p ima y ca e physicians in ecogni ion and ea men o dep ession may be an e icien means o lowe ing suicide a es [10,63,82]. Indeed, s udies ha examined p og ams o p ima y ca e physician aining ound a ise in he an idep essan p esc ip ion a es and a decline in he suicide a e a e he p og am [81,83]. Ga ekeepe T aining Ga ekeepe s a e igu es wi h he po en ial o in luence he suicidal pe son on a empo a y o ongoing basis (e.g., amily membe s, iends, au ho i y igu es- a pa en , eache o a mili a y commande , educa o s, social wo ke s, nu sing home s a and olun ee s) and can se e as a suppo esou ce. The aining o ga ekeepe s ocuses on ecognizing suicidal hinking and beha io and helping people a isk o access app op ia e se ices [10]. The key elemen s o he aining include: lea ning abou dep ession and suicide, ain- ing in p ac ical elemen s (e.g., how o alk abou suicide, de ec suicide isk, handle an acu e suicidal c isis e c.), in- s uc ion on wha o do i ea men needs a e encoun e ed, and s a egies o ecognizing popula ions ulne able o suicide [75••]. Success o ga ekeepe aining in lowe ing suicide a es has been epo ed in mili a y and school p og ams [76,84]. In a g oup-based andomized ial conduc ed by Wyman e al. [85], Ques ion, Pe suade, Re e (QPR) aining o a andom sample o school s a inc eased hei knowledge o you h isk ac o s o suicide. The p og am also inc eased he s a 's commi men o assis ing s uden s in ecei ing help be o e engaging in po en ially le hal sel -ha m beha io s. The ga e- keepe aining, howe e , did no o e come he s uden s’ eluc ance o seek assis ance om adul s, unde sco ing he need o imp o e he communica ion be ween school s a and di icul - o- each s uden s. Sc eening Sc eeningaims oiden i ya - isk indi iduals and di ec hem o ea men [10]. The Columbia Suicide Sc een® (CSS) ques ion- nai e is a b ie , sel -adminis e ed se o ques ions in ended o iden i y high school s uden s a isk o suicide.In a s udy ha examined he e iciency o he CSS in iden i ying high school s uden s a isk o suicide [86], he algo i hm ha ga e bo h he highes speci ici y and he bes balance be ween sensi i i y and speci ici y (0.75 and 0.83, espec i ely) sc eened o suicidal idea ion o p e ious a emp and sel epo ed unhappiness, wi hd awal, o i i abili y and anxie y. A e iew o s udies o dep ession sc eening in adul s in p ima y heal h ca e se ings pe o med o he US P e en i e Se ices Task Fo ce [87] ound highe de ec ion and diagnosis a es o dep ession h ough he use o sc eening ools. I was also ound ha b ie ques ionnai es, such as he PHQ-2 which ask wo ques ions: (1) “O e he pas 2 weeks, ha e you el down, dep essed o hopeless?”and (2) “O e he pas 2 weeks, ha e you el li le in e es o pleasu e in doing hings?”appea ed o pe o m as well as leng hie ques ionnai es (e.g., he Zung Sel -Dep ession Scale and he Beck Dep ession In en o y). Indeed, sc eening was associa ed wi h a 13 % educ ion in he ela i e isk o emaining dep essed and a 9–pe cen age poin absolu e educ- ion in he p opo ion o pa ien s wi h pe sis en dep ession. Mo eo e , a e iew o e idence on sc eening o suicide isk [88], sugges s ha ocusing on sc eening high- isk g oups (dep essed pa ien s, subs ance abuse s) in p ima y ca e se ings may dec ease suicide a es. Since dep ession is common, a - ec ing abou 121 million people wo ldwide [89], and he bu den o his disease is signi ican -dep ession is he second cause o Disabili y Adjus ed Li e Yea s in he age ca ego y 15– 44 yea s o bo h sexes combined and i is expec ed ha by he yea 2020, dep ession will each ha s a us o all age g oups- he e may be oom o conside dep ession sc eening in p ima y ca e se ings, much like sc eening o hype ension o diabe es. T ea men Suicide is complex in ol ing psychological, social, biological, cul u al and en i onmen al elemen s. The e o e, a combina ion 628 Cu Psychia y Rep (2012) 14:624–633 o ea men and suppo s a egies –psycho he apy, pha ma- co he apy, ollow up ea men and suppo o hose who los a lo ed one o suicide, may p o ide e ec i e measu es agains suicidal beha io . Psycho he apy Se e al e idence based psycho he apies ha e been shown o be o u ili y in he ea men o hose a isk o suicidal beha io . This is he case no only because psycho he apy, wi h o wi hou medica ion, can educe dep essi e symp oms, bu because i can speci ically a ge suicidal idea ion and suicide a emp s [10]. Fo example, Cogni i e Beha io al The - apy (CBT) is an e idence-based me hod o educing suicide a emp a es and imp o ing adhe ence o ea men . This ea - men has been shown o be e ec i e when di ec ly ocused on educing aspec s o suicidal beha io [90–93]. Simila ly, gi en ha suicidal people o en lack psychosocial esou ces, inc eas- ing p oblem-sol ing capaci y h ough P oblem Sol ing The a- py may educe he bu den o unsol ed p oblems, and as a esul , educe hopelessness, dep essi e symp oms and suicidal hough s [94,95]. In e pe sonal he apy, which iden i ies and esol es in e pe sonal di icul ies which cause o exace ba e psychological dis ess has also been ound o dec ease suicidal idea ion [94]. As well, Dialec ical Beha io al The apy (DBT) has been shown o educe sel -inju y and suicidal beha io in indi iduals wi h bo de line pe sonali y diso de [95,96]. Pha maco he apy Gi en he impo ance o psychia ic illness as a con ibu o o suicide isk, p o iding sui able, obus pha maco he apy o psychia ic diso de s is c i ical o suicide p e en ion. An idep essan s Dep ession is he psychia ic condi ion mos o en associa ed wi h suicidal beha io . The li e ime suicide isk a e among dep essed (unipola and bipola ) pa ien s is 10–15 % [74]. An idep essan s a e he ea men o choice o he elie o dep essi e symp oms and suicidal idea ion, which o en accompanies dep ession [97,98]. An idep essan s signi ican ly educe he isk o suicidal idea ion and suicidal beha io in pa ien s wi h majo dep ession [3]. Mo eo e , highe p esc ip- ion a es o an idep essan s co ela e wi h a dec ease in suicide a es [99–101]. Due o hei ela i e sa e y in cases o o e dose, and ela i ely mild side e ec s, SSRIs a e conside ed i s line he apy in p ima y ca e se ings [102]. Howe e , child en, adolescen s and young adul s unde he age o 24 may pa a- doxically expe ience an induc ion o wo sening o suicidal idea ion o beha io . A sys ema ic e iew o andomized con- ol ials aimed a es ablishing he associa ion be ween SSRIs and suicide a emp s [103] ound a mo e han wo old inc ease in he a e o suicide a emp s in pa ien s ecei ing SSRIs compa ed wi h placebo o he apeu ic in e en ions o he han icyclic an idep essan s (TCA). Howe e , he e was no di e - ence in suicide dea hs be ween SSRIs and placebo. Simila ly, a me a-analysis by Gunnel a al. [104] ound weak e idence o inc eased isk o non- a al sel ha m in pa ien s aking SSRI's compa ed wi h placebo, bu no e idence o inc eased suicide isk. Possible explana ions o hese indings a e ha SSRIs can cause agi a ion, anxie y, insomnia and aka hisia a he ini ia ion o ea men , all o which may inc ease suicide isk among young dep essed pa ien s. Po en ial solu ions include close obse a ion o pa ien s wi h mild illness who a e being ea ed in he communi y by gene al p ac i ione s, amily and close iends. Why younge indi iduals a e a isk o wo sening sui- cidal idea ion upon exposu e o an idep essan s is no known bu may be due o he complex na u e o dep ession among child en and adolescen s, which can mask a bipola diso de o pe sonali y ai s. The Food and D ug Adminis- a ion (FDA) has issued a “black box”wa ning on he use o an idep essan s among his age g oup [105], and i is ecommended ha child en and adolescen s aking his class o medica ion be unde close moni o ing o side e ec s. Clea ly, he clinician mus conside he isks and bene i s en ailed in he use o an idep essan s, especially SSRIs, in he ea men o dep ession in pa ien s unde he age o 24. Mood S abilize s Li hium is epo ed o educe bo h a emp ed and comple ed suicides in majo mood diso de s, such as unipola dep es- sion and bipola pa ien s wi h long- e m li hium ea men [106,107]. A me a analysis by Baldessa ini e al. [106] ound ha isk o comple ed and a emp ed suicide we e lowe by app oxima ely 80 %, du ing ea men o bipola and o he majo a ec i e diso de pa ien s wi h li hium. Long e m li hium ea men also may educe he le hali y o suicidal ac s, pe haps by limi ing impulsi i y and agg es- si eness. None heless, a cause o conce n is li hium’s lim- i ed he apeu ic index o ma gin o sa e y, such ha le hal ou comes can occu in he se ing o suicide a emp by o e dose. In e es ingly, he a ali y isk o li hium o e doses is mode a e, much like ha o mode n an idep essan s and second-gene a ion an ipsycho ics [108]. Tha no wi hs and- ing, close pa ien moni o ing and educa ion abou adhe ence o ea men is impo an since ab up discon inua ion o he ea men wi h mood s abilize s can cause a ebound in- c ease in suicidal idea ion [109,110]. An ipsycho ics Clozapine has been shown o ha e an an i-suicidal e ec in schizoph enia [111] compa ed o bo h placebo and o he Cu Psychia y Rep (2012) 14:624–633 629 second gene a ion an ipsycho ics and is he only FDA app o ed d ug o ea men o suicidal beha io . O no e, a s udy by Spi ac e al. [112] sugges s ha his e ec is due, in pa , o a educ ion in impulsi eness and agg ession. Howe e , because suicidal idea ion and beha io in schizoph enia can eme ge as pa o an acu e psychosis, se e e anxie y, agi a ion, o dep ession, seda ing an ipsycho ics o an idep essan s espec i ely, may be use ul. Gi en ha some a ypical an ipsycho ics ha e an idep essan e ec s [113,114] hey may also be o u ili y in schizoph enia accompanied by suicide isk. Elec ocon ulsi e The apy The e is ex ensi e e idence ha ECT is an e ec i e ea - men o acu e suicidali y among se e ely dep essed pa ien s [115]. This ea men can also educe he isk o subsequen suicidal beha io . Thus, al hough in mos coun ies he use o Elec ocon ulsi e he apy (ECT) is ese ed o majo dep essi e episodes ha ha e been shown o be “ ea men esis an ” o adequa e ials o wo o mo e pha maco he a- pies, p esence o acu e suicide isk should clea ly be an indica ion o ECT ega dless o he ea men his o y. Follow-Up A e Suicide A emp Recu en suicidal beha io places a g ea bu den on pa ien s and hei amilies, as well as on he heal h ca e sys em as a whole. Since p e ious suicide a emp s a e a majo isk ac o in p edic ing u he suicidal beha io and suicide [116,117], adequa e ollow-up ca e a e a suicide a emp o pa ien s and hei amilies is c ucial in p e en ion.A ew me hods ha e been ound o be e icien . The G een Ca d S udy [118]isan ini ia i e aimed a inc easing compliance among Delibe a e Sel Ha m pa ien s a e discha ge. The ini ia i e o e ed pa ien s a e delibe a e sel ha m a “li eline”- easy access o on call psychia is s, and encou aged hem o make con ac should di icul ies a ise. A doc o was a ailable a all imes, and he in e en ion included c isis admission i necessa y. This kind o ini ia i e showed a signi ican educ ion o de- libe a e sel -ha m. Fu he mo e, i did no equi e a signi ican amoun o esou ces. Ca e e al. [119] ound ha ongoing con ac a e hospi al discha ge ia pos ca ds lowe ed he numbe o epea suicide a emp s by nea ly 50 %. This model emphasized social connec edness, espec o he pa ien and high quali y medical and psychia ic managemen a e hos- pi al discha ge. The No wegian ini ia i e [120] which p o id- ed ollow-up ca e a e suicide a emp s ia a chain-o -ca e ne wo k also is epo ed o educe suicide a es. In ol emen o he amily in a e ca e ollowing a suicide a emp is c i ical since hey may cons i u e he main suppo sys em. The amily may also se e as a e ca e moni o s o ea men adhe ence and de ec ion o any signs o suicidali y [121]. Conclusions Suicide p e en ion equi es s a egies ha encompass wo k a he indi idual, sys ems and communi y le el. Policy di ec ed a means es ic ion and public awa eness campaigns can be used in combina ion wi h s a egies di ec ed a he indi idual, including iden i ica ion, p ope diagnosis and e ec i e ea men s. Gi en he complexi y o iden i ying and managing suicide isk, a combina ion o in e en ions a se e al le els will be equi ed in o de o implemen an e icacious, comp ehensi e p e en ion p og am. Acknowledgmen s Resea ch on his pape was suppo ed by MH 48514 and he Con e Cen e o he Neu obiology o Suicidal Beha io MH 62185. Disclosu e M. Schwa z-Li shi z: none; G. Zalsman: none; L. Gine has ecei ed compensa ion o de elopmen o educa ional p esen a ions om Se ie , B is ol-Mye s Squibb, Janssen, and GlaxoSmi hKline; has ecei ed compensa ion o a el, accommoda ions, and mee ing expenses om Se ie , B is ol-Mye s Squibb, Janssen, and GlaxoS- mi hKline; and has ecei ed compensa ion o de elopmen o a p esen- a ion om GlaxoSmi hKline; M.A. Oquendo ecei es oyal ies o he use o he Columbia Suicide Se e i y Ra ing Scale; has ecei ed inancial compensa ion om P ize o he sa e y e alua ion o a clinical acili y, un ela ed o he cu en manusc ip ; was he ecipien o a g an om Eli Lilly o suppo a yea ’s sala y o he Lilly Suicide Schola , En ique Baca-Ga cia, MD, PhD; and has ecei ed un es ic ed educa ional g an s and/o lec u e ees om As aZeneca, B is ol-Mye s Squibb, Eli Lilly, Janssen, O suko, P ize , Sano i-A en is, and Shi e. He amily owns s ock in B is ol-Mye s Squibb. 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