A lifetime history of suicide attempt predisposes the individual to future suicide attempts and, eventually, death by suicide. Consequently, there has been a growing interest in the development and implementation of various effective interventions in populations with a recent suicide attempt. Evidence-based interventions in attempted suicide can be grouped under pharmacological treatments, psychosocial interven-tions, brief interventions and outreach approaches, somatic treatments, and digital interventions (Menon & Vijayakumar, 2022). The key types and modes of interven-tions studied are tabulated in Table 5.2.
Pharmacological Management of Suicide
Various psychopharmacological options have been tried to attenuate suicidal ten-dencies in people who presented with suicide attempts or recurrent suicide ide-ations. Among adults, antipsychotics have demonstrated beneficial effects in reducing self-harm tendencies compared to placebo. Even the oft-quoted anti- suicidal properties of mood stabilizer agents such as lithium were not replicated in well-designed clinical trials. A couple of randomized, double-blind, placebo- controlled clinical trials supported short-term anti-suicidal effects of ketamine (last-ing a few days to a few weeks), especially in controlling new-onset suicidal ideations (Abbar et al., 2022; Domany et al., 2020).
Psychosocial Management of Suicide
A recent Cochrane review revealed that among adults, cognitive behavioral therapy (CBT) showed an effective reduction of repeat self-harm behaviors. The effects resulting from CBT lasted for more than 6–12 months during the follow-up period (Witt et al., 2021a). The same authors conclude that dialectical behavior therapy (DBT) also had beneficial effects in terms of reduction in the frequency of suicidal ideations. DBT has been shown to reduce the frequency of suicidal attempts and the number of visits to crisis intervention centers. Insufficient, inconclusive evidence exists for acceptance and commitment therapy (ACT), mentalization-based thera-pies, and group-based emotion regulation therapy in control of suicidal thoughts.
Brief Intervention, Contact, and Outreach Approaches
One clinical trial evaluated the effect of a brief Attempted Suicide Short Intervention Program (ASSIP), comprising 3-weekly therapy sessions conducted in person based on the person-centered model of suicide (Gysin-Maillart et al., 2016). The sessions were supplemented by sending personalized letters to the study participants for a period of 2 years. ASSIP was noted to diminish the risk of repeat suicide attempts by 83%, even after adjusting for a history of multiple past attempts.
Another trial has demonstrated that adjunctive periodic text messages with “car-ing” content (expressing unconditional care and concern) were effective in reducing prospective suicide attempts over a period of 12 months (Comtois et al., 2019). However, the messages were not effective in controlling the frequency of suicidal ideations. Collaborative “safety planning interventions,” comprising a personalized list of warning signs for suicidal behavior along with a list of coping strategies, combined with regular telephonic follow-up, were shown to be effective in the reduction of recurrent suicidal tendencies (Stanley et al., 2018).
Digital Interventions
Online CBT modules that covered areas such as problem identification, emotion recognition, and problem-solving approaches, coupled with suicide risk assess-ment, and providing evidence-based recommendations for suicide mitigation have been found to be beneficial in the reduction of suicide risk (Simon et al., 2022). The LifeApp’tite trial incorporated a multicomponent intervention packed with psycho-educational materials, self-rating scales for suicidal ideations and depression, safety planning, along with a “digital hope kit” comprising positive memories to be recol-lected and places to be visited during crisis times. When this package was integrated with routine in-person therapy sessions, there was a significant reduction in repeat suicide attempt rates (O’Toole et al., 2019).
Management of Suicidal Ideation and Behavior in Special Populations
Children andAdolescents(CAP)
After the suicide attempt, medical stabilization of the child or adolescent is the most important step in the management of suicidal behavior in the CAP population. After medical stabilization, the following steps are important:
• Involvement of the family member to monitor patient safety until stabilization •\ Restricting access to lethal means of suicide
• Identifying and managing the warning signs and triggers for repeat suicidal ideation
• Educating patients and caregivers about the disinhibiting effects of drugs and addictive substances
• Providing coping strategies to manage suicidal ideations
• Instructing family members to avail emergency care in case of any decompensation
A recent Cochrane review revealed no robust anti-suicidal effects for the various psychopharmacological agents tested (Witt et al., 2021b). In contrast to adults, ado-lescents with suicidal ideations responded better to DBT (commonly referred to as DBT-A) (Witt et al., 2021a). Standard therapies such as CBT, mentalization-based therapy, and family therapy had minimal to significant effects in reducing suicidal ideations among adolescents presenting with suicidal tendencies. Positive effects have been noted for family-focused interventions on the frequency of suicide ide-ations in adolescents with suicidal behavior. These interventions primarily focused upon educating parents and family about self-injurious behavior, adolescent devel-opment, ways to promote adolescent self-esteem, strategies to manage psychologi-cal stress, addressing family conflicts, and ensuring family harmony. The Saving and Empowering Young Lives in Europe (SEYLE) study, a multi-center, cluster-randomized controlled trial that compared the effects of gatekeeper training of teachers and students found that such approaches effectively reduced the frequency of suicide attempts and severe suicidal ideation among school-going ado-lescents (Wasserman et al., 2015).