Now that I’ve explained to you who is at risk for suicide and how suicidal behavior could have its roots come from a neurobiological origin, let’s continue with how we can prevent suicide.
In terms of novel approaches of suicide prevention, Mann & Rizk suggest some of these approaches. One of them is training primary care providers target internal stressors in the management of major depressive episodes which have been shown to prevent suicide, however, it has not been shown to prospectively influence risk of suicidal behavior when taking into the account external stressors.
Mann & Rizk also suggest two types of therapies: Pharmacotherapy and Psychotherapy. With Pharmacotherapy, they reference lithium and clozapine which have effects on the internal stressors of depression and acute psychosis. Intravenous ketamine being a rapidly acting treatment that robustly reduces depressive symptoms and suicidal ideation in hours instead of weeks. They also mention Intranasal ketamine (or esketamine) which shows promise as an anti–suicidal ideation treatment and is less invasive, but its absorption is more erratic, and, like intravenous ketamine, must be administered in medical settings. and Psychotherapy. Most studied the cognitive-behavioral therapy (CBT) and dialectical behavior therapy, which both can prevent suicide attempts. CBT works by improving the capacities for cognitive regulation of emotion, it’s been associated with decreased activity in the amygdala-associated negative emotional reactivity and enhanced activity of the emotion regulation network. Dialectical behavior therapy prevents suicidal behavior via problem-solving and stress management or elements of the diathesis such as dampening amygdala reactivity to negative emotions.
Previously, I mentioned two pharmacotherapies: Ketamine & Esketamine, which I also found additional articles in order to better explain how these medications work. In a study by Parikh & Walkup (2021), they reference Dwyer et al.’s study of a randomized cross-over trial of single-dose ketamine compared with midazolam for the treatment of refractory depression in adolescents. The study’s results when measured with the Montgomery-Åsberg Depression Rating Scale (or MADRS) 24 hours after infusion, showed that ketamine had a significant greater effect than midazolam in reducing depressive symptoms. In another study, Canuso et al. (2018) conducted a proof-of-concept study on the efficacy and safety of intranasal esketamine for rapid reduction of depression in suicidality in high-risk patients, the preliminary results of this study indicate that intranasal esketamine compared with placebo, given in addition to comprehensive standard-of-care treatment, may result in significantly rapid improvement in depressive symptoms, including some measures of suicidal ideation, among depressed patients at imminent risk for suicide.
Another approach mentioned by Mann & Risk, are Brief Interventions and Active Postdischarge Outreach in the Emergency Department or From Inpatient Units. This is because after seeking help for suicidal thoughts or low-lethality suicide attempts in the emergency department, discharged patients have an elevated suicide attempt rate. Suicide prediction models based on computational analyses of electronic health records could help identify individuals with a higher-risk for suicide at time of discharge, these individuals would be the most likely to potentially benefit most from intensive treatment and follow-up. There already exists, some brief, inexpensive psychological and educational interventions for use for individuals that are presenting to the emergency department with acute suicidal crisis. These interventions are also easy to implement, and don’t require much staff resources. They seek to project a helpful option for a patient in crisis to help them overcome the social cognitive distortion that the social network is more hostile than helpful.
Continuing by another study by Kalin (2020), in which references The Treatment for Adolescents with Depression study and The Child/Adolescent Anxiety Multimodal Study whose results highlight the efficacy of relatively short-term interventions and point to the need for treatments that can fundamentally affect childhood developmental trajectories that will enable initial interventions to have long-lasting positive effects.
One final novel approach by Mann & Rizk is the restriction of Lethal Means, this works because it seeks to make access to the most popular high-lethality methods more difficult. It takes advantage of two key observations. One, the acute risk of acting on suicidal thoughts is brief, and second, the flexibility of the suicidal person in changing from one method to another is surprisingly limited. Studies of survivors of suicide attempts have indicated that most attempts are the result of a rash decision to act that was made minutes earlier, even if the method of suicide was planned months or years head ahead.
Now, one last addition from the Mann & Rizk article of “A brain-centric model of suicidal behavior”, let’s move our attention to what they refer as the Future of Research and Suicide Prevention. They first refer suicide in a possibility as a distinct mental disorder. This is due to the prevailing evidence that suggests that suicide could be considered a moderately heritable independently of the heritability of major psychiatric disorders, and as I have shown you through various articles, there those exist a number of neurobiological abnormalities that could prove that monitoring genes associated to the risk of suicide is a possibility. Now speaking of monitoring, another suggestion made by Mann & Rizk on the future of research is Real-Time Monitoring of Acute Suicidal Crisis. In the article, suicidal ideation, which is usually preceded and may even represent a risk of an imminent suicide attempt, can go unrecognized by even the most systematic periodic evaluation of outpatients. A reference to a 2020 article revealed that around 60% of individuals denying suicidal ideation on a weekly basis through self-report measures reported that they were having suicidal thoughts while using an ecological momentary assessment (or EMA) technology that delivered questions on their smartphones six times a day over the same 1-week period. Combining this EMA-collected real-time data on suicidal thoughts and behavior with what is known as “passive sensing,” which collects data from individuals’ smartphones, allows examination of the very short-term risk factors of suicide in multiple domains. And this is helpful because the wide availability of smartphones can allow accumulation of massive amounts of personal level data that may lead to identification of a, what the article references to a “phonotype” or “screenotype”. Another technique that the Mann & Rizk article references is the Implicit Cognitions and Neuroimaging for Suicide Risk Detection. Neural decoding is an approach where machine-learning methods have been used to identify the neural activity pattern involved in the mental representation of a deceased loved one and to track unconscious deceased-related thinking. fMRI-measured neural representation of mental concept representations differentiates suicidal ideators from suicide attempters and healthy control subjects. The possible identification of a neural signature of suicidal ideation could be a biomarker for suicide risk even when suicidal ideation is denied or unrecognized.