The development of accurate measures for assessing acute suicide risk would likely enhance prevention efforts. Given the accuracy of certain measures in predicting lifetime risk for suicide, identified individuals should be referred for support and/or treatment.
Large epidemiological studies demonstrate reductions in suicide rates with increased antidepressant use. Randomized, controlled trials of the effects of these anti-depressants on suicide have largely failed to reveal significant differences versus placebo, perhaps due to methodological limitations.
Compelling evidence suggests that lithium maintenance treatment reduces suicide in certain populations. Evidence is mounting that clozapine treatment reduces suicide in specific populations, as well.
Important questions regarding lithium still remain. Controlled studies are needed to confirm the effectiveness of lithium and to define the factors (e.g., timing, dose, diagnosis) that influence it.
Despite manifest anxiety and agitation often marking acute suicide risk, the effects of anti-anxiety drugs on suicidality remains largely unknown. Likewise, the literature contains virtually no new and only non-randomized, uncontrolled studies regarding the potentially effective treatment modality of electroconvulsive therapy.
Carefully designed trials are necessary to understand the potential of pharmacotherapies to reduce suicidal behavior. Studies should include the antidepressants, lithium, clozapine, anti-anxiety drugs, as well as electroconvulsive therapy. The lack of long-term assessment of therapeutic strategies and the exclusion of high-risk patients from clinical trials represent critical gaps in the field.
Medicine alone is not sufficient for treatment of suicidality, nor are treatments equally effective across individuals and diagnoses. Psychotherapy provides a necessary therapeutic relationship that reduces the risk of suicide. Cognitive-behavioral approaches that include problem-solving training seem to reduce suicidal ideation and attempts more effectively than treatment as usual or supportive therapy. As with drug therapy, research on the long-term effectiveness of these interventions is lacking.
Controlled clinical trials are necessary to determine the types and aspects of psychotherapy that are effective in reducing suicide for diverse individuals. Current evidence suggests that continued contact with a psychotherapist is critical. This needs to be rigorously evaluated.