Building an Evidence Base for Rapid Acting Interventions for Severe Suicide Risk
Jane Pearson, Ph.D.
Chair, Suicide Research Consortium
The goal is to expand the evidence base for fast-acting treatments for youth and adults with severe suicide risk, testing existing and novel interventions. Given the limited research on this topic, efforts could include early efficacy testing of novel treatments, as well as approaches that anticipate pragmatic clinical trials to evaluate effectiveness of interventions under routine practice conditions. Treatments could be tested for their benefit to: provide rapid and durable relief; ‘jumpstart’ suicide risk reduction when used sequentially with slower-acting and more durable interventions; and augment treatments for suicide risk and comorbid conditions. Pilot studies would be sought, with designs based on the stage of the science regarding efficacy, safety, and feasibility in acute care settings. Principal outcomes of interest are the reduction of suicide events, including ideation, attempts, death, and utilization of suicide crisis intervention services.
This initiative would encourage research efforts on rapid interventions to reduce suicide risk, including a range of approaches depending on the stage of science and existing evidence for the intervention(s) being tested. Studies of novel treatment approaches, including trials examining the utility of existing interventions not previously evaluated for reducing suicide risk as well as novel treatments in early in human trials, might employ efficacy-type designs with predefined intervention targets and tests of target engagement. Studies of existing interventions--those that have shown promise for providing fast acting relief of severe suicide risk--could involve effectiveness trials in acute care settings (emergency departments; inpatient care). Testing the sequence/combination of additional effective interventions to maintain gains from fast acting treatments would also be of interest. Mechanism(s) of intervention to be tested in pragmatic trials could include patient-reported and rater-assessed changes in mood, problem solving and coping skills, cognitive constriction and other distortions, and the wish to live.
There is an urgent need for fast-acting interventions for individuals with severe suicide risk (i.e., individuals who cannot be safely discharged to outpatient care) in acute health care settings such as emergency departments and inpatient psychiatric units. Pilot work is needed to evaluate the feasibility, tolerability, acceptability and safety of intervention modalities appropriate for these settings. Interventions could include extant or novel medications, devices, and/or psychotherapeutic-neurocognitive therapies. While the goal is to find interventions that rapidly reduce suicide ideation, attempts, death, and utilization of suicide crisis intervention services, studies would also need to demonstrate the ability to engage targets and/or mechanisms.
Examples of studies could include, but are not limited to:
- Tests of ketamine (and its metabolites and modalities [intravenous infusion, intramuscular injection, nasal spray, oral or sublingual forms]), followed by suicide-specific psychotherapy to maintain gains and provide relapse protective skills
- Device-based treatments, such as electroconvulsive therapy, magnetic seizure therapy, and accelerated transcranial magnetic stimulation, in combination with medications that target comorbid symptoms, such as depression and anxiety
- Tests of neurocognitive interventions to enhance executive functioning (reducing cognitive constriction; emotion dysregulation)
- Just-in-time app-based cognitive skills interventions to change the distress trajectory
- Tests of brexanolone infusion for women with severe post-partum depression with suicide risk