James Sall, PhD, FNP-BC; Lisa Brenner, PhD, ABPP; Amy M. Millikan Bell, MD, MPH; Michael J. Colston, MD
Financial Support: The development of this guideline was funded by the VA. The DoD and VA paid expenses for their experts to travel to the Washington, DC, area to review the evidence on suicide and develop treatment recommendations.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-0687.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor, Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Corresponding Author: James Sall, PhD, FNP-BC, 926 Oak Bluff Trail, New Braunfels, TX 78132; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Sall: 926 Oak Bluff Trail, New Braunfels, TX 78132.
Dr. Brenner: University of Colorado, Anschutz Medical Campus, 1700 North Wheeling Street, Aurora, CO 80045.
Dr. Millikan Bell: Army Public Health Center, 8252 Blackhawk Road, Aberdeen Proving Ground, MD 21010.
Dr. Colston: Fort Belvoir Community Hospital, 9300 DeWitt Loop, Fort Belvoir, VA 22060.
Author Contributions: Conception and design: J. Sall, L. Brenner, M.J. Colston.
Analysis and interpretation of the data: J. Sall, L. Brenner, M.J. Colston.
Drafting of the article: J. Sall, L. Brenner, A.M. Millikan Bell, M.J. Colston.
Critical revision for important intellectual content: J. Sall, L. Brenner, A.M. Millikan Bell, M.J. Colston.
Final approval of the article: J. Sall, L. Brenner, A.M. Millikan Bell, M.J. Colston.
Provision of study materials or patients: L. Brenner.
Obtaining of funding: L. Brenner.
Administrative, technical, or logistic support: J. Sall, L. Brenner, A.M. Millikan Bell, M.J. Colston.
Collection and assembly of data: J. Sall, L. Brenner, M.J. Colston.
In May 2019, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved an update to the 2013 joint clinical practice guideline for assessing and managing patients who are at risk for suicide. This guideline provides health care providers with a framework by which to screen for, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients who may be at risk for suicide.
In January 2018, the VA/DoD Evidence-Based Practice Work Group convened to develop a joint VA/DoD guideline including clinical stakeholders and conforming to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel drafted key questions, systematically searched and evaluated the literature through April 2018, created algorithms, and advanced 22 recommendations in accordance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.
This synopsis, which includes 3 clinical practice algorithms, summarizes the key recommendations of the guideline related to screening and evaluation, risk management and treatment, and other management methods. Risk management and treatment recommendations address both pharmacologic and nonpharmacologic approaches for patients with suicidal ideation and behavior. Other management methods address lethal means safety (such as restricting access to firearms, poisons, and medications and installing barriers to prevent jumping from lethal heights) and population health strategies.
Algorithm A: Identification of risk for suicide.
* Continue to Step 7 if screening results are negative but additional evidence (e.g., collateral) suggests the need for continued screening or evaluation.
Algorithm B: Evaluation by provider.
* Necessary as part of a comprehensive assessment of suicide risk but not sufficient.
† Reference 12.
Algorithm C: Management of patients at acute risk for suicide.
CBT = cognitive behavioral therapy; DBT = dialectical behavior therapy; MDD = major depressive disorder; WtoH = Window to Hope.
* Reference 13.
† Reference 14.
‡ Other treatments may be indicated for underlying conditions (see U.S. Department of Veterans Affairs/Department of Defense clinical practice guidelines for MDD, posttraumatic stress disorder, substance use disorder, etc.).
Appendix Table. Table of Recommendations
Sall J, Brenner L, Millikan Bell AM, et al. Assessment and Management of Patients at Risk for Suicide: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines. Ann Intern Med. 2019;171:343–353. [Epub ahead of print 27 August 2019]. doi: https://doi.org/10.7326/M19-0687
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Published: Ann Intern Med. 2019;171(5):343-353.
Published at www.annals.org on 27 August 2019
Emergency Medicine, Guidelines, Hospital Medicine, Prevention/Screening.
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