Brazilian Psychiatric Association guidelines for the management of suicidal behavior. Part 2. Screening, intervention, and prevention

Abstract

This article continues our presentation of the Brazilian Psychiatric Association guidelines for the management of patients with suicidal behavior, with a focus on screening, intervention, postvention, prevention, and promotion. For the development of these guidelines, we conducted a systematic review of the MEDLINE (via PubMed), Cochrane Database of Systematic Reviews, Web of Science, and SciELO databases for research published from 1997 to 2020. Systematic reviews, clinical trials, and cohort/observational studies on screening, intervention, and prevention in suicidal behavior were included. This project involved 14 Brazilian psychiatry professionals and 1 psychologist selected by the Psychiatric Emergencies Committee of the Brazilian Psychiatric Association for their experience and knowledge in psychiatry and psychiatric emergencies. Publications were evaluated according to the 2011 Oxford Center for Evidence-Based Medicine (OCEBM) Levels of Evidence Classification. Eightyfive articles were reviewed (of 5,362 initially collected and 755 abstracts on the drug approach). Forms of screening, intervention, and prevention are presented. The intervention section presents evidence for psychotherapeutic and drug interventions. For the latter, it is important to remember that each medication is effective only for specific groups and should not replace treatment protocols. We maintain our recommendation for the use of universal screening plus intervention. Although the various studies differ in terms of the populations evaluated and several proposals are presented, there is already significant evidence for certain interventions. Suicidal behavior can be analyzed by evidence-based medicine protocols. Currently, the best strategy is to combine several techniques through the Safety Plan. Nevertheless, further research on the topic is needed to elucidate some approaches with particular potential for intervention and prevention.

The Management of Psychiatric Emergencies in Situations of Public Calamity

“…When patients and family members go to the emergency department due to any psychiatric emergency, one must quickly and effectively attempt to analyze the situation to implement the best treatment as soon as possible. The protocol to care for patients in psychomotor agitation can be extrapolated to other emergencies, since the main goals are screening and severity assessment (13,21,24,30,38,39) In some cases, it may be difficult to perform all these steps as soon as patients are seen by health workers. Because time is important in an emergency, we suggest the following four basic questions (13, 29):…”

“…The secondary consequences of social distancing may increase the risk of suicide. It is important to consider changes in a variety of economic, psychosocial, and health-associated risk factors (19,21,38,39).…”

“…The therapeutic approach to suicidal behavior, both ideation or attempts, must include the assessment of risk and protective factors associated with intervention measures (called the safety plan) (38,39,51,52). For cases involving a high risk of suicide, strict observation of the individual is required, so they must stay in the emergency department or undergo hospitalization or home care.…”

“…According to Weber et al (54), the patient assessment should include the identification of the present level of risk and the modifiable and fixed risk factors related to the intention. The risk (e.g., previous suicide attempt, psychiatric illness, substance dependence) and protective factors (e.g., interpersonal support, positive coping skills) should also be identified (38,39).…”

“…In emergency service centers, patients at risk of suicide must first receive any general health care. Many suicide attempts are associated with severe trauma or intoxication, and such emergencies should not be neglected to assess psychiatric emergencies (they must be carried out together) (38,39).…”