There are two conditions in which patients who attempt suicide come to the health service. The first condition is a patient who has recently attempted suicide. The second condition is a patient with another medical complaint that triggers a tendency to commit suicide. This second condition is often found in people with chronic diseases, depression, or other psychiatric disorders. In both conditions, the doctor must be able to treat the patient holistically.

How to Treat Patients with Suicidal Behaviors
Image source: https://www.thejakartapost.com


Risk Stratification

Treatment of the patient begins with determining the risk of the patient committing suicide attempts. This risk assessment is carried out using anamnesis, physical examination, and supporting examinations, including screening, such as Ask Suicide-Screening Questions (ASQ).

The doctor must also assess the patient's protective factors, both internal and external, to avoid committing suicide. Internal factors are specific to each individual, such as coping mechanisms, spiritual life, and tolerance to despair. External factors such as responsibility for children/family, good relationships, and social support. Another thing that is taken into account is the doctor's exploration of suicidal ideation in patients, including ideas, plans, behavior, intentions, and ambivalence.

After considering these matters, categorize patients into three levels of risk.
1. High risk
characterized by patients with psychiatric disorders with severe symptoms or acute triggers. These patients feared that they could carry out lethal suicide attempts characterized by persistent ideas with strong intentions and a history of previous suicide attempts.
2. Moderate risk
patients with several risk factors and few protective factors. This patient had suicidal ideation, with plans, but without the intention or history of previous suicide attempts.
3. Low risk
characterized by patients with modifiable risk factors and strengthen protective factors. This third group of patients thought about death but was not accompanied by a planned or prior history.



Treatment

The treatment of patients at risk of committing suicide is to adjust to the risk grouping. High-risk group patients are indicated to be hospitalized. Moderate risk group patients can be hospitalized if necessary. Meanwhile, patients with low risk can be discharged with a control plan.

Empathy
Physicians should treat suicide attempts with empathy like any other patient. The explanation that is good and provides comfort to patients can improve the relationship between doctor and patient. This will affect the success of therapy.

Place of Examination
Patients at risk of attempting suicide should not leave the examination area until the examination has been completed. Patients should be examined in a closed room without any dangerous objects such as belts, shoes, or sharp medical devices. Mechanical detention of the patient can be done in patients who experience severe agitation and endanger the staff. The use of restraints can cause trauma to the patient to calm the patient verbally.

Treatment in the Emergency Room
Treatment of suicide attempts patients can be done while the patient is still in the emergency room while awaiting a psychiatrist's evaluation. Treatment focuses on helping patients to have the ability to recognize and deal with suicidal thoughts, including recognizing and creating a safe environment for patients and providing support for patients.


1. Non-pharmacological therapy

Psychotherapy is primarily targeted at patients with repeated suicide attempts. Psychotherapy consists of an exploratory process to understand behavior, interventions to increase positive behavior, prevent negative behavior, and focus on the patient's suicidal behavior.

Doctors must help patients adopt problem-solving behaviors, recognize emotional triggers that trigger suicidal thoughts, improve patients' cognitive abilities, and make plans to overcome suicidal thoughts. Psychotherapy has especially shown good results when applied to depressive disorders and personality thresholds associated with an increased risk of suicide. The types of psychotherapy widely used are cognitive behavioral therapy (CBT), psychodynamic therapy, and interpersonal therapy.

One of the psychotherapy modalities is dialectic. Dialectical behavioral therapy is primarily given to patients with personality disorders at chronic risk of suicide. This therapy focuses on improving self-skills in patients such as emotional regulation, impulse control, anger management, and interpersonal assertiveness to reduce suicide attempts effectively. However, several studies do not support the results of this study.


2. Pharmacological Therapy

A meta-analysis study found that antidepressants can reduce suicidal ideation in depressed patients aged 25 years and over. The use of antidepressants in depressed patients aged 24 years and under can reduce symptoms of depression.
However, the effect of reducing suicidal ideation was inconsistent in this study.

The use of antidepressants at this age is associated with changes in the risk of suicide, namely the emergence of new-onset, worsening of ideas, and suicide attempts. In 2004, the FDA issued a warning about the possible increased risk of suicide-related to the use of antidepressants at the age of fewer than 24 years. The most widely used antidepressants are selective serotonin reuptake inhibitors such as fluoxetine.

Other psychopharmaceutical therapies that are widely used are mood stabilizers such as lithium. Several studies have shown that lithium use reduces the incidence of suicide; even a meta-analysis study supports these studies' results. In an RCT study of patients with unipolar depression and bipolar depression, it was found that lithium use reduced the risk of suicide compared to placebo. The exact mechanism by which lithium reduces the risk of suicide is not yet known. It has been hypothesized that this is related to reducing episodes of mood swings or by reducing impulsivity and aggressive behavior.

In emergency cases, the drug that is often used is ketamine. Ketamine is a glutaminergic group, which is commonly used as a sedative. In one study, the use of low doses of ketamine demonstrated an antidepressant effect in patients with major depression and bipolar disorder. Single or repeated use of ketamine can reduce suicidal ideation. The undesirable effects of ketamine use are potential for abuse, transient therapeutic response, and side effects on the cardiovascular and psychotomimetic systems. Meanwhile, Clozapine, an atypical antipsychosis, reduces the risk of suicide in schizophrenic or schizoaffective patients.

Hospitalized
Patients at high risk of suicide should be hospitalized until suicidal thoughts are resolved. Doctors must ensure the rooms' safety where patients are treated to prevent patients from committing suicide attempts in the hospital.


Suicide Prevention Contract

A suicide prevention contract is a contract that aims to facilitate the management of a patient at risk of suicide. This contract is also known as a no-harm contract. This contract's contents are the patient's commitment not to attempt suicide, call for help if he has suicidal intent, and continue talking on the phone to as many people as needed until the suicidal thoughts subside.

Along with the development, more and more patients are using this contract. However, the patient's willingness to contract suicide prevention cannot indicate a discharge from hospitalized because suicide prevention contraception is used more as a subjective belief. The suicide prevention contract is not a legal document and cannot be used as medical evidence. Suicide prevention contraception does not replace the clinician's clinical judgment of the patient's suicide risk.

Effectiveness of Suicide Prevention Contracts
The effectiveness of a suicide prevention contract is unclear. One study found that many hospitalized patients had attempted suicide and died had a suicide prevention contract. This suggests that both verbal and written promises cannot be relied on as a therapeutic method. Reliance on contracted suicide prevention may decrease clinician awareness of patients.

Suicide Prevention Contract Benefits
Suicide prevention contracts can be used as a measuring tool for assessing patient desirability. Patients who refuse to make a suicide prevention contract indicate that patients feel inadequacy based on the doctor and their sub-optimal therapeutic relationship. This should serve as a marker for physicians to evaluate the therapeutic relationship it establishes with the patient. If needed, doctors can perform a re-suicidal risk analysis. Suicide prevention contracts are not recommended for patients in the emergency department, and patients recently admitted to hospitalization.

This suicide prevention contract approach is to ask the patient verbally or in writing not to continue the urge to commit suicide but to take steps mutually agreed upon, for example, contacting a doctor or immediate family. The patient is asked to make an appointment with himself. This effort shows the doctor's concern for the patient, as well as the concrete efforts the patient can make at a time when suicidal thoughts arise.


Monitoring

Patients with attempted suicide are prone to physical and psychological disorders. These patients also have a greater risk of future suicide attempts and hence warrant attention and monitoring.

Patients receiving antidepressant therapy should receive close monitoring for at least six months after remission of the last relapsing episode. At the end of the 6th month, the doctor must determine whether to continue antidepressant therapy. Doctors need to consider the severity of the patient's depressive episode, recurrence, sequelae, and accompanying medical and psychiatric disorders. Patients with a high risk of recurrence can be considered to continue therapy, change therapy, and add non-pharmacological therapy.

In high-risk patients, the use of antidepressants can be the long term of indefinite duration. Therefore, patients need regular follow-up to determine their need for antidepressants.  Doctors can maintain antidepressant doses if the patient has two or more depressive episodes; the patient has functional dysfunction; the patient has a history of severe and prolonged episodes and an inadequate response to therapy. In these patients, evaluation is carried out periodically to determine risk factors for recurrence, frequency of depression, and response to therapy. Psychotherapy is continued for 3-4 months (16-20 sessions); if possible, it can be given in groups of 8-15 people.

Treatment Adherence
Treatment adherence is also an important part of monitoring therapy. Discontinuation of therapy without a doctor's supervision and suddenly can harm the patient and induce a relapse. Discontinuation of treatment should be carried out with a gradual decrease in dose. Dose reduction can be made in 4 weeks. If symptoms are worsened during interruption of treatment, therapy should be given again.

What needs to be of concern during the follow-up post suicide attempts is whether or not the patient is predisposed to attempt suicide. The doctor must think about this, given the severity of the symptoms, the high severity of the risk of suicide, and the patient's risk factors. Cooperation between doctors and families is important to overcome if a patient makes an attempted suicide.


Managing Patients with Suicidal Desire which is Digested in the History of Other Complaints

Patients can see health professionals with other complaints, but it is explored that there is a desire to commit suicide. This can be explored by determining whether the patient has symptoms of depression or not. Determining the diagnosis of depression can be guided by a questionnaire that is asked of high-risk patients. The high-risk patients are patients with chronic disease or chronic pain, patients who experience significant life changes, little desire to recover, and other symptoms associated with depressive symptoms.

Approach these patients with empathy. Patients' unfavorable view of their depressive condition is often a barrier to therapy. For patients with suicidal ideation, history should be more detailed about whether the patient has plans to commit suicide. Doctors also need to assess the patient's ease of access to lethal objects, such as knives, ropes, or firearms. The doctor must also be able to determine whether the patient can make a non-suicide commitment or not. If there is one of the problems above, consider consulting a psychiatrist. If possible, patients can be hospitalized.



Conclusion
The management of suicide patients is determined based on the results of the patient's suicide risk assessment. The principles of early treatment are empathy and a safe environment for the patient. Empathy is used for physicians to discuss a patient's suicidal thoughts and assess a patient's risk of suicide, such as whether the patient has specific plans for suicide and has access to lethal methods such as a sharp weapon or a firearm.

Therapy for suicidal ideation includes contracting suicide prevention, psychotherapy, and long-term monitoring. Pharmacological therapy can be given if necessary, in selective serotonin reuptake inhibitors, lithium, or ketamine.