Suicide is the second leading cause of death among people ages ten to 34 in the United States. And it’s a growing problem: Between 2000 and 2016, the national suicide rate increased by 30% among all Americans and 50% among girls and women, according to the American Psychological Association (APA). There’s no one reason for this increase. Still, the APA has theories, from growing economic struggles for working-class citizens to suicide victims’ lack of access to potentially life-saving treatments.

While the cost of care, for the most part, is out of clinicians’ hands, a new study offers evidence-based insight into how practitioners can direct patients to the most effective mental health treatments. The research is part of a larger set of suicide prevention recommendations published by the Department of Veterans Affairs and the Department of Defense.‍

What Did the Study Find?

“The entire guideline has more information about screening for risk of suicide and also provides guidance on reducing access to things, such as guns, and providing information on safety planning,” Kristen D’Anci, Ph.D., author of the study and a researcher with the ECRI Institute, says. She adds that the full recommendations also summarize suicide risk factors, which can help clinicians determine whether a patient might require referral to a specialized care provider.

For this study, the authors looked at eight systematic reviews and 15 randomized controlled trials that assessed therapies for adults at risk of suicide. The research included non-medicinal and medicinal strategies — that is, therapy, crisis-response planning, and community-support programs versus antidepressants, anxiety medication, lithium, antipsychotics, ketamine, and naloxone. They assessed each option’s effect on suicides, suicide attempts, suicidal ideation, self-harm, and hopelessness.

Here are their conclusions about the efficacy of various treatments for patients at risk of suicide:

‍Cognitive Behavioral Therapy (CBT) Is Best

The study found CBT was the most effective method to reduce suicide attempts, ideation, and hopelessness in patients. In addition, it worked better than “treatment as usual,” which researchers defined as offering crisis resources, assessment by the primary care provider, and referral to services as needed.

When CBT works, it empowers patients to change their thinking patterns and behaviors by reevaluating their beliefs and learning new problem-solving skills. It’s usually a multi-week process done online or in person with a therapist; patients receive “homework” to complete between sessions.

“Of relevance for patients with suicidal ideation, this homework typically involves working on exercises that help a person build hope, increase awareness for living, and build skills to cope with feelings of distress or manage crises,” notes D’Anci. ‍

Dialectical Behavior Therapy (DBT) Can Be a Successful Alternative

Compared with the control group or those receiving crisis planning, patients going through DBT saw reduced suicidal ideation. But D’Anci clarifies that this conclusion is based on research conducted in populations with Borderline Personality Disorder. (DBT was developed for suicidal women and people with Borderline Personality Disorder.)

“The findings for DBT were weaker than those for CBT,” explains D’Anci. “But DBT is similar to CBT in that it helps patients learn new skills and to recognize thoughts that may be detrimental and change the thought process to be more constructive. In addition, it tends to focus on developing skills in emotional regulation and distress tolerance, which may be beneficial for individuals with suicidal ideation.”‍

Ketamine and Lithium Might Be Effective Options for Some Patients

The study looked at research where ketamine—once used as an anesthetic but now a popular antidepressant—was primarily administered via IV to patients with major depressive disorder. It reduced suicidal ideation with minimal adverse events compared to a placebo or midazolam.

While ketamine can reduce anxiety symptoms and improve mood, the research is limited, D’Anci cautions. There are also concerns about the safety of ketamine, including risks of abuse and dissociative effects. As a result, patients with substance use and psychotic disorders were excluded from the studies.

“The benefit of ketamine is its relatively quick impact on suicidal ideation, although there is no information on suicide attempts or deaths,” says D’Anci. “We don’t know the long-term efficacy of ketamine. Taking these factors into consideration, the workgroup determined that ketamine would be a useful tool for a select group of patients.”

The researchers also found lithium, a mood stabilizer approved for bipolar disorder, reduced rates of suicide among patients with unipolar or bipolar mood disorders (compared to placebo).

“Lithium alone is potentially of benefit specifically in patients with bipolar disorder,” says D’Anci. “There is some evidence to support the use of lithium plus other medications in patients with unipolar depression or bipolar disorder.”

But, D’Anci adds, providers should also learn about the downsides of lithium. For example, people at risk of suicide may deliberately overdose, so clinicians must properly store and monitor the drug due to its toxicity. 

While there isn’t a single, correct way to treat patients at risk of suicide, clinicians need to look for risk factors and intervene with the proper care.