One Size Does Not Fit All: A Comprehensive Clinical Approach to Reducing Suicidal Ideation, Attempts, and Deaths

David A Jobes, Samantha A Chalker, David A Jobes, Samantha A Chalker

Abstract

While the existence of mental illness has been documented for centuries, the understanding and treatment of such illnesses has evolved considerably over time. Ritual exorcisms and locking mentally ill patients in asylums have been fundamentally replaced by the use of psychotropic medications and evidence-based psychological practices. Yet the historic roots of mental health management and care has left a certain legacy. With regard to suicidal risk, the authors argue that suicidal patients are by definition seen as mentally ill and out of control, which demands hospitalization and the treatment of the mental disorder (often using a medication-only approach). Notably, however, the evidence for inpatient care and a medication-only approach for suicidal risk is either limited or totally lacking. Thus, the "one-size-fits-all" approach to treating suicidal risk needs to be re-considered in lieu of the evolving evidence base. To this end, the authors highlight a series of evidence-based considerations for suicide-focused clinical care, culminating in a stepped care public health model for optimal clinical of suicidal risk that is cost-effective, least-restrictive, and evidence-based.

Keywords: stepped care; suicidal risk; suicide-focused clinical care.

Conflict of interest statement

David Jobes has conflicts to disclose related to grant funding from the National Institute of Mental Health and the American Foundation for Suicide Prevention; he receives book royalties from the American Psychological Association Press and Guilford Press; and he is the founder of CAMS-care, LLC (a professional training and consultation company). Samantha Chalker has no conflicts to disclose.

Figures

Figure 1
Figure 1
Different suicidal states include suicidal ideators (SI), suicide attempters (SAs), and multiple SAs. For those that seek mental health care: (SI) may be best matched to the Collaborative Assessment and Management of Suicidality (CAMS), SAs may be best matched to Cognitive Therapy for Suicide Prevention (CT-SP) or Brief Cognitive Behavior Therapy (BCBT), and dysregulated individuals with borderline personality disorder (BPD) with a multiple SA history may be best matched to Dialectical Behavior Therapy (DBT). Those that are suicidal but do not seek mental health treatment may be best matched to those with live-experienced and peer-based supports. Lifeline = the United States national suicide prevention lifeline phone number: 1-800-273-TALK (8255).
Figure 2
Figure 2
The y-axis is mental health care costs; the steps of the pyramid correspond from the bottom to the top with the least restrictive intervention the most restrictive intervention. ASSIP = Attempted Suicide Short Intervention Program; BCBT = Brief Cognitive Behavior Therapy; CAMS = Collaborative Assessment and Management of Suicidality; CT-SP = Cognitive Therapy for Suicide Prevention; DBT = Dialectical Behavior Therapy; MI = Motivational Interviewing; PACT = Post Admission Cognitive Therapy; TMBI = Teachable Moment Brief Intervention.

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