Management of Suicidal Thoughts and Behaviors in Youth. Systematic Review

Sim L, Wang Z, et al (2025).

Prepared by the Mayo Clinic Evidence-based 

Practice Center under

The information is here.

Abstract

Background: Suicide is a leading cause of death in young people and an escalating public health crisis. We aimed to assess the effectiveness and harms of available treatments for suicidal thoughts and behaviors in youths at heightened risk for suicide. We also aimed to examine how social determinants of health, racism, disparities, care delivery methods, and patient demographics affect outcomes.

Methods: We conducted a systematic review and searched several databases including MEDLINE®, Embase®, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and others from January 2000 to September 2024. We included randomized clinical trials (RCTs), comparative observational studies, and before-after studies of psychosocial interventions, pharmacological interventions, neurotherapeutics, emerging therapies, and combinations therapies. Eligible patients were youths (aged 5 to 24 years) who had a heightened risk for suicide, including youths who have experienced suicidal ideation, prior attempts, hospital discharge for mental health treatment, or command hallucinations; were identified as high risk on validated questionnaires; or were from other at-risk groups. Pairs of independent reviewers selected and appraised studies. Findings were synthesized narratively.

Results: We included 65 studies reporting on 14,534 patients (33 RCTs, 13 comparative observational studies, and 19 before-after studies). Psychosocial interventions identified from the studies comprised psychotherapy interventions (33 studies, Cognitive Behavior Therapy, Dialectical Behavior Therapy, Collaborative Assessment and Management of Suicidality, Dynamic Deconstructive Psychotherapy, Attachment-Based Family Therapy, and Family-Focused Therapy), acute (i.e., 1 to 4 sessions/contacts) psychosocial interventions (19 studies, acute safety planning, family-based crisis management, motivational interviewing crisis interventions, continuity of care following crisis, and brief adjunctive treatments), and school/community-based psychosocial interventions (13 studies, social network interventions, school-based skills interventions, suicide awareness/gatekeeper programs, and community-based, culturally tailored adjunct programs). For most categories of psychotherapies (except DBT), acute interventions, or school/community-based interventions, there was insufficient strength of evidence and uncertainty about suicidal thoughts or attempts. None of the studies evaluated adverse events associated with the interventions. The evidence base on pharmacological treatment for suicidal youths was largely nonexistent at the present time. No eligible study evaluated neurotherapeutics or emerging therapies.

Conclusion: The current evidence on available interventions intended for youths at heightened risk of suicide is uncertain. Medication, neurotherapeutics, and emerging therapies remain unstudied in this population. Given that most treatments were adapted from adult protocols that may not fit the developmental and contextual experience of adolescents or younger children, this limited evidence base calls for the development of novel, developmentally and trauma-informed treatments, as well as multilevel interventions to address the rising suicide risk in youths.

Zero Suicide Model Implementation and Suicide Attempt Rates in Outpatient Mental Health Care

Ahmedani, B. K., et al. (2025).

JAMA Network Open, 8(4), e253721.

https://doi.org/10.1001/jamanetworkopen.2025.3721

Key Points

Question  Is implementation of the Zero Suicide model in outpatient mental health care associated with reductions in suicide attempts?

Findings  This quality improvement study of 55 354 to 451 837 individuals per month aged 13 years or older found that implementation of the Zero Suicide model was associated with a reduction in suicide attempt rates in 3 of 4 health systems, while the fourth system experienced a lower sustained rate. Two systems that implemented the model before the observation period maintained low or declining rates.

Meaning  Findings from this study support implementation of the Zero Suicide model in outpatient mental health care.

Abstract (partial) 

Importance  Suicide is a major public health concern, and as most individuals have contact with health care practitioners before suicide, health systems are essential for suicide prevention. The Zero Suicide (ZS) model is the recommended approach for suicide prevention in health systems, but more evidence is needed to support its widespread adoption.

Objective  To examine suicide attempt rates associated with implementation of the ZS model in outpatient mental health care within 6 US health systems.

Conclusions and Relevance  In this quality improvement study, ZS model implementation was associated with a reduction in suicide attempt rates among patients accessing outpatient mental health care at most study sites, which supports widespread efforts to implement the ZS model in these settings within US health systems.

The study is linked above.

Here are some thoughts:

This study examined the impact of the Zero Suicide (ZS) model on suicide attempt rates within outpatient mental health care settings across six U.S. health systems.  The ZS model, a recommended approach for suicide prevention in health systems, was implemented in four of the health systems during the study period, while the other two had already adopted the model prior to the study.    

The study found that the implementation of the ZS model was associated with a reduction in suicide attempt rates in three of the four health systems that implemented the model during the study period.  The fourth system showed a sustained lower rate of suicide attempts following implementation.  The two health systems that had implemented the ZS model before the study period maintained low or declining rates of suicide attempts.    

This research is important for psychologists because it provides evidence supporting the effectiveness of the ZS model in reducing suicide attempts in outpatient mental health care settings.  Given that suicide is a major public health concern and that a large proportion of individuals who attempt suicide have had contact with the health system prior to their attempt, the study's findings highlight the critical role of health systems in suicide prevention.  The results of this study support the implementation of the ZS model in outpatient mental health care.

Suicide-related emergencies underdetected among minority, male youth, and preteens, study finds

Will Houston

UCLA Health

Originally poste 29 OCT 24

A new study by UCLA Health reveals that hospital emergency departments may be missing signs of suicidal thoughts and behaviors in children, boys and Black and Hispanic youth. 

The research(Link is external) (Link opens in new window), published in the journal JAMA Open Network, analyzed electronic health records of nearly 3,000 children and teenagers presenting to two emergency departments in southern California for mental health reasons. Using machine learning algorithms, the researchers determined standard medical record surveillance methods miss youth with suicide-related emergencies. These methods disproportionately missed suicide-related visits among Black, Hispanic, male, and preteen youths, compared with other races and ethnicities, female youths, and adolescents. 

“Existing methods are missing kids, and not missing them at random,” said Dr. Juliet Edgcomb(Link opens in new window), study corresponding author, associate director of the UCLA Health Semel Institute for Mental Health Informatics and Data Science Hub(Link is external) (Link opens in new window) and assistant professor-in-residence in the UCLA Health Department of Psychiatry. “Without accurate and equitable detection of suicide-related emergencies, it is difficult for suicide prevention strategies to help the populations they aim to serve.” 

Here is the article.

Here is the research article.

Here are some thoughts:

A recent study by UCLA Health researchers found that emergency departments are not effectively identifying children and teenagers who are experiencing suicidal thoughts and behaviors. The study, which analyzed electronic health records of nearly 3,000 young patients, revealed that current methods for detecting suicidality are inadequate and disproportionately miss suicidal emergencies among minority youth, preteen youth, and boys. The study highlights the need for improved detection methods, particularly those incorporating artificial intelligence, to better address this growing mental health crisis and ensure that all youth at risk receive appropriate care.

Psychotherapy With Suicidal Patients Part 2: An Alliance Based Intervention for Suicide

E. M. Plakun

Psychiatric Practice

January 2019 - Volume 25: Issue 1, 41-45

Abstract

This column, which is the second in a 2-part series on the challenge of treating patients struggling with suicide, reviews one psychodynamic approach to working with suicidal patients that is consistent with the elements shared across evidence-based approaches to treating suicidal patients that were the focus of the first column in this series. Alliance Based Intervention for Suicide is an approach to treating suicidal patients developed at the Austen Riggs Center that is not manualized or a stand-alone treatment, but rather it is a way of establishing and maintaining an alliance with suicidal patients that engages the issue of suicide and allows the rest of psychodynamic therapy to unfold.

(cut)

From the Conclusion

There is no magic in ABIS (Alliance Based Intervention for Suicide), and it will not work in all cases, but these principles are effective in making suicide an interpersonal issue with meaning in the relationship. This allows direct engagement of the issue of suicide in the therapeutic relationship and direct discussion of the central question of whether the patient can and will commit to the work. ABIS supports the therapist in efforts to assess whether the therapist has the will and the wherewithal to meet the patient’s anger and hate, as manifested by suicide, as fully as the therapist is prepared to meet the patient’s love and attachment. Neither side of the transference alone is adequate in work with suicidal patients.

There are no randomized trials of ABIS, but it is a way of working that has evolved at Austen Riggs over the course of a hundred years. In a study of previously suicidal patients at Riggs, at an average of 7 years after admission, 75% were free of suicidal behavior as an issue in their lives.6 These patients were considered “recovered” rather than “in remission,” using the same slope-intercept mathematical modeling as in cancer research. These findings offer encouraging support for the value of ABIS as an intervention to add to psychodynamic psychotherapy as a way to establish and maintain a viable therapeutic alliance with suicidal patients.

The article is here.

Assessment of Patient Nondisclosures to Clinicians of Experiencing Imminent Threats

Levy AG, Scherer AM, Zikmund-Fisher BJ, Larkin K, Barnes GD, Fagerlin A.
JAMA Netw Open. Published online August 14, 20192(8):e199277.
doi:10.1001/jamanetworkopen.2019.9277

Question 

How common is it for patients to withhold information from clinicians about imminent threats that they face (depression, suicidality, abuse, or sexual assault), and what are common reasons for nondisclosure?

Findings 

This survey study, incorporating 2 national, nonprobability, online surveys of a total of 4,510 US adults, found that at least one-quarter of participants who experienced each imminent threat reported withholding this information from their clinician. The most commonly endorsed reasons for nondisclosure included potential embarrassment, being judged, or difficult follow-up behavior.

Meaning

These findings suggest that concerns about potential negative repercussions may lead many patients who experience imminent threats to avoid disclosing this information to their clinician.

Conclusion

This study reveals an important concern about clinician-patient communication: if patients commonly withhold information from clinicians about significant threats that they face, then clinicians are unable to identify and attempt to mitigate these threats. Thus, these results highlight the continued need to develop effective interventions that improve the trust and communication between patients and their clinicians, particularly for sensitive, potentially life-threatening topics.

Artificial Intelligence & Mental Health

Smriti Joshi
Chatbot News Daily
Originally posted

Here is an excerpt:

There are many barriers to getting quality mental healthcare, from searching for a provider who practices in a user's geographical location to screening multiple potential therapists in order to find someone you feel comfortable speaking with. The stigma associated with seeking mental health treatment often leaves people silently suffering from a psychological issue. These barriers stop many people from finding help and AI is being looked at a potential tool to bridge this gap between service providers and service users.

Imagine how many people would be benefitted if artificial intelligence could bring quality and affordable mental health support to anyone with an internet connection. A psychiatrist or psychologist examines a person’s tone, word choice, and the length of a phrase etc and these are all crucial cues to understanding what’s going on in someone’s mind. Machine learning is now being applied by researchers to diagnose people with mental disorders. Harvard University and University of Vermont researchers are working on integrating machine learning tools and Instagram to improve depression screening. Using color analysis, metadata, and algorithmic face detection, they were able to reach 70 percent accuracy in detecting signs of depression. The research wing at IBM is using transcripts and audio from psychiatric interviews, coupled with machine learning techniques, to find patterns in speech to help clinicians accurately predict and monitor psychosis, schizophrenia, mania, and depression. A research, led by John Pestian, a professor at Cincinnati Children’s Hospital Medical Centre showed that machine learning is up to 93 percent accurate in identifying a suicidal person.

The post is here.

The bold new fight to eradicate suicide

Simon Usborne
The Guardian
Originally published August 1, 2017

Here is an excerpt:

They call it “Zero Suicide”, a bold ambition and slogan that emerged from a Detroit hospital more than a decade ago, and which is now being incorporated into several NHS trusts. Since our first meeting, Steve has himself embraced the idea, and in May of this year held talks with Mersey Care, one of the specialist mental health trusts already applying a zero strategy. His plans are at an early stage, but he is setting out to create a Zero Suicide foundation. He wants it to identify good practices across the 55 mental health trusts in England and create a new strategy to be applied everywhere.

The zero approach is a proactive strategy that aims to identify and care for all those who may be at risk of suicide, rather than reacting once patients have reached crisis point. It emphasises strong leadership, improved training, better patient-screening and the use of the latest data and research to make changes without fear or delay. It is a joined-up strategy that challenges old ideas about the inevitability of suicide, the stigma that surrounds it, and the idea that if a reduction target is achieved, the deaths on the way to it are somehow acceptable. “Even if you believe we are never going to eradicate suicide, we must strive towards that,” Steve said to me. “If zero isn’t the right target, then what is?”

Zero Suicide is not radical, incorporating as it does several existing prevention strategies. But that it should be seen as new and daringly ambitious reveals much about how slowly attitudes have changed. In the 1957 book The Uses of Literacy: Aspects of Working-Class Life, a semi-autobiographical examination of the cultural upheavals of the 1950s, Richard Hoggart recalled his upbringing in Leeds. “Every so often one heard that so-and-so had ‘done ’erself in’ … or ‘put ’er ’ead in the gas-oven’,” he wrote. “It did not happen monthly or even every season, and not all attempts succeeded; but it happened sufficiently often to be part of the pattern of life.” He wondered how “suicide could be accepted – pitifully but with little suggestion of blame – as part of the order of existence”.

The article is here.

Moral Injury, Posttraumatic Stress Disorder, and Suicidal Behavior Among National Guard Personnel.

Craig Bryan, Anna Belle Bryan, Erika Roberge, Feea Leifker, & David Rozek
Psychological Trauma: Theory, Research, Practice, and Policy 

Abstract

To empirically examine similarities and differences in the signs and symptoms of posttraumatic stress disorder (PTSD) and moral injury and to determine if the combination of these 2 constructs is associated with increased risk for suicidal thoughts and behaviors in a sample of U.S. National Guard personnel. Method: 930 National Guard personnel from the states of Utah and Idaho completed an anonymous online survey. Exploratory structural equation modeling (ESEM) was used to test a measurement model of PTSD and moral injury. A structural model was next constructed to test the interactive effects of PTSD and moral injury on history of suicide ideation and attempts. Results: Results of the ESEM confirmed that PTSD and moral injury were distinct constructs characterized by unique symptoms, although depressed mood loaded onto both PTSD and moral injury. The interaction of PTSD and moral injury was associated with significantly increased risk for suicide ideation and attempts. A sensitivity analysis indicated the interaction remained a statistically significant predictor of suicide attempt even among the subgroup of participants with a history of suicide ideation. Conclusion: PTSD and moral injury represent separate constructs with unique signs and symptoms. The combination of PTSD and moral injury confers increased risk for suicidal thoughts and behaviors, and differentiates between military personnel who have attempted suicide and those who have only thought about suicide.

The article is here.

AI May Hold the Key to Stopping Suicide

Bahar Gholipour
NBC News
Originally posted May 23, 2017

Here is an excerpt:

So far the results are promising. Using AI, Ribeiro and her colleagues were able to predict whether someone would attempt suicide within the next two years at about 80 percent accuracy, and within the next week at 92 percent accuracy. Their findings were recently reported in the journal Clinical Psychological Science.

This high level of accuracy was possible because of machine learning, as researchers trained an algorithm by feeding it anonymous health records from 3,200 people who had attempted suicide. The algorithm learns patterns through examining combinations of factors that lead to suicide, from medication use to the number of ER visits over many years. Bizarre factors may pop up as related to suicide, such as acetaminophen use a year prior to an attempt, but that doesn't mean taking acetaminophen can be isolated as a risk factor for suicide.

"As humans, we want to understand what to look for," Ribeiro says. "But this is like asking what's the most important brush stroke in a painting."

With funding from the Department of Defense, Ribeiro aims to create a tool that can be used in clinics and emergency rooms to better find and help high-risk individuals.

The article is here.

Individuals at High Risk for Suicide Are Categorically Distinct From Those at Low Risk.

Tracy K. Witte, Jill M. Holm-Denoma, Kelly L. Zuromski, Jami M. Gauthier, & John Ruscio
Psychological Assessment, Vol 29(4), Apr 2017, 382-393

Abstract

Although suicide risk is often thought of as existing on a graded continuum, its latent structure (i.e., whether it is categorical or dimensional) has not been empirically determined. Knowledge about the latent structure of suicide risk holds implications for suicide risk assessments, targeted suicide interventions, and suicide research. Our objectives were to determine whether suicide risk can best be understood as a categorical (i.e., taxonic) or dimensional entity, and to validate the nature of any obtained taxon. We conducted taxometric analyses of cross-sectional, baseline data from 16 independent studies funded by the Military Suicide Research Consortium. Participants (N = 1,773) primarily consisted of military personnel, and most had a history of suicidal behavior. The Comparison Curve Fit Index values for MAMBAC (.85), MAXEIG (.77), and L-Mode (.62) all strongly supported categorical (i.e., taxonic) structure for suicide risk. Follow-up analyses comparing the taxon and complement groups revealed substantially larger effect sizes for the variables most conceptually similar to suicide risk compared with variables indicating general distress. Pending replication and establishment of the predictive validity of the taxon, our results suggest the need for a fundamental shift in suicide risk assessment, treatment, and research. Specifically, suicide risk assessments could be shortened without sacrificing validity, the most potent suicide interventions could be allocated to individuals in the high-risk group, and research should generally be conducted on individuals in the high-risk group.

The article is here.

Zero Suicide in Health Care

Published on Dec 15, 2014

If you ask people what you should do to help a person who may be suicidal, most—if not all—would say that person should be referred to a health care professional or organization. So it may come as a shock to learn that many health care professionals and organizations do not know what to do…or even consider it their responsibility to do anything. In this provocative talk, Dr. Michael Hogan describes how the Zero Suicide approach aims to improve care and outcomes for individuals at risk of suicide in health care systems.

Michael Hogan, PhD, is an independent advisor and consultant with Hogan Health Solutions. He serves on the Executive Committee of the National Action Alliance for Suicide Prevention, a public-private partnership advancing the National Strategy for Suicide Prevention (2012). Dr. Hogan was the Public Sector Co-Lead of the Clinical Care and Intervention Task Force that developed the idea of Zero Suicide; he now co-leads the Zero Suicide Advisory Group which strives to promote suicide prevention as a core component of health care services.

www.zerosuicide.com

Episode 25: The Assessment, Management, and Treatment of Suicidal Patients

Suicide is the 10th leading cause of death in the United States and the most frequent crisis encountered by mental health professionals. This video/podcast reviews basic information about the assessment, management, and treatment of patients at risk to die from suicide. It fulfills Act 74 requirements for Pennsylvania licensed psychologists, social workers, marriage and family therapists, and professional counselors.

Program Learning Objectives:

At the end of this program the participants will learn basic information that will help them to

1. Assess patients who are at risk to die from a suicide attempt;
2. Manage the risks of suicide; and
3. Treat patients who are at risk to die from a suicide attempt.

Podcast

Video

Resources

Bongar, B., & Sullivan, G. (2013). The suicidal patient: Clinical and legal standards of care. (3rd ed.). Washington, DC: American Psychological Association.

Bryan, C. J. (2015). Cognitive behavior strategies for preventing suicidal attempts. NY: Routledge.

Jamison, K. R. (2000). Night Falls Fast: Understanding suicide. New York: Random House.

Jobes, D. (2016). Managing suicide risk (2nd Ed.). NY: Guilford.

Joiner, T. (2005). The myths of suicide. Cambridge, MA: Harvard University Press.

McKeon, R. (2009). Suicidal behavior. Cambridge, MA: Hogrefe & Huber.

Disclaimer

As an educational program, this podcast/video does not purport to provide clinical or legal advice on any particular patient. Listeners or viewers with concerns about the assessment, management, or treatment of any patient are urged to seek clinical or legal advice. Also, individual psychotherapists need to use their clinical judgment with their patients and incorporate procedures or techniques not covered in this podcast/video, or modify or omit certain recommendations herein because of the unique needs of their patients.

This one-hour video/podcast provides a basic introduction to the assessment, management, and treatment of patients at risk to die from a suicide attempt. This podcast/video may be a useful refresher course for experienced clinicians. However, listeners/viewers should not assume that the completion of this course will, in and of itself, make them qualified to assess or treat individuals who are at risk to die from suicide. For those who do not have formal training in suicide, this podcast/video should be seen as providing an introduction or exposure to the professional literature on this topic.

Proficiency in dealing with suicidal patients, like proficiency in other areas of professional practice, is best achieved through an organized sequence of study including mastery of a basic foundation of knowledge and attitudes, and supervision. It is impossible to give a fixed number of hours of continuing education and supervision that professionals need to have before they can be considered proficient in assessing, managing, and treating suicidal patients. Much depends on their existing knowledge base and overall level of clinical skill. It would be indicated to look at competency standards from noted authorities, such as those developed by the American Association of Suicidology ( http://www.sprc.org/training-events/amsr), by David Rudd and his associates (Rudd et al., 2008), or Cramer et al. (2014).

After you review the material, click here to link to CE credit.

Click here for slides related to the podcast.

Predicting Suicide is not Reliable, according to recent study

Matthew Large , M. Kaneson, N. Myles, H. Myles, P. Gunaratne, C. Ryan
PLOS One
Published: June 10, 2016
http://dx.doi.org/10.1371/journal.pone.0156322

Discussion

The pooled estimate from a large and representative body of research conducted over 40 years suggests a statistically strong association between high-risk strata and completed suicide. However the meta-analysis of the sensitivity of suicide risk categorization found that about half of all suicides are likely to occur in lower-risk groups and the meta-analysis of PPV suggests that 95% of high-risk patients will not suicide. Importantly, the pooled odds ratio (and the estimates of the sensitivity and PPV) and any assessment of the overall strength of risk assessment should be interpreted very cautiously in the context of several limitations documented below.

With respect to our first hypothesis, the statistical estimates of between study heterogeneity and the distribution of the outlying, quartile and median effect sizes values suggests that the statistical strength of suicide risk assessment cannot be considered to be consistent between studies, potentially limiting the generalizability of the pooled estimate.

With respect to our second hypothesis we found no evidence that the statistical strength of suicide risk assessment has improved over time.

The research is here.

The Internet, Suicide, & How Sites Like PostSecret Can Help

Studies show the Internet fails suicidal users. PostSecret shows how to help.
by Jennifer Golbeck, Ph.D.
Psychology Today Blog
Originally published October 4, 2014

People suffering from depression can feel isolated, lonely, and in need of help. As with so many other areas, the Internet is a natural place to turn for support. But, as with so many other things, the Internet is not always safe.

William Melchert-Dinkel, a former nurse who lives in Minnesota, was convicted last month for assisting the suicide of a British man online. Melchert-Dinkel spent his time visiting suicide-related internet forums where he posed as a suicidal female nurse. He would offer people step-by-step instructions on how to kill themselves (usually by hanging), and in ten cases, he entered into suicide pacts with other forum members. He believes five of those people went through with the suicides. In some cases, he may have watched people commit suicide over a webcam.

The entire blog post is here.