Cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) are effective psychological treatments that may be used to reduce suicidal risk among adults, according to a study published in the Annals of Internal Medicine. Ketamine and lithium are also effective to mitigate risk, but more evidence on the safety of these compounds is needed.

The investigators of this study sought to evaluate the benefits and harms of both nonpharmacologic and pharmacologic interventions in reducing suicidal behaviors and preventing suicide in at-risk adults.

The investigators searched databases, such as MEDLINE, EMBASE, and PsycINFO, for relevant systematic reviews and randomized controlled trials published between November 2011 and May 2018. The investigators identified 8 systematic reviews and 15 randomized controlled trials that assessed the impact of psychological and pharmacologic interventions for managing suicide risk. Data were abstracted and assessed for quality and accuracy.

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Compared with treatment as usual, findings suggest that CBT is effective at reducing suicide attempts, suicidal ideation, and hopelessness. A limited amount of evidence also showed that DBT could reduce suicidal ideation when compared with controls or crisis response planning. Regarding pharmacologic treatments, the investigators found that ketamine reduced suicidal ideation with minimal adverse events compared with treatment with midazolam or placebo. Among patients with unipolar or bipolar mood disorders, treatment with lithium was more effective at reducing suicide rates compared with placebo; however, there was no observable difference between lithium and other medications in their ability to reduce suicide rates.

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Limitations of the study included the qualitative (not quantitative) nature of synthesizing new evidence with previously reported meta-analyses and potential methodological shortcomings of the existing systematic reviews, which may result in bias or overrepresentation of some study findings included in more than 1 review. Finally, the investigators acknowledge the heterogeneity of nonpharmacologic therapies and limited information regarding whether or not these treatments are harmful.

The investigators concluded that both CBT and DBT demonstrated modest benefit in terms of the reduction in rate of suicidal behaviors, including suicidal ideation and attempts. Similarly, ketamine and lithium were shown to help reduce the rates of suicide among at-risk adults. However, the studies did not report on potential harms; future studies should provide evidence supporting the efficacy and safety of other nonpharmacologic or pharmacologic treatments.


D’Anci KE, Uhl S, Giradi G, Martin C. Treatments for the prevention and management of suicide: a systemic review [published online August 27th, 2019]. Ann Intern Med. doi: 10.7326/M19-0869