Clinical Notes

• One of the most important aspects about dealing with suicidal thoughts is to understand what they mean. Suicide is best understood not so much as a movement toward death as it is most often a movement away from intolerable emotion or anguish as a result of the person being ill.
   
• Most suicidal persons express their suicidal intentions to others beforehand. These expressions may be direct: e.g. "I can't stand it and I'm going to kill myself" or indirect, e.g. "Sometimes I think it's not worth going on”. The experience of suicidal thoughts or feelings is often associated with fear and ambivalence.
   
• It is important to learn to detect early warning signs for suicidal thoughts (e.g. intense sadness or hopelessness, shame, guilt, difficulty sleeping, feeling very anxious or angry). This may vary from person to person, but suicidal thoughts are rarely experienced in the absence of other difficulties.
   
• Suicidal thoughts and acts in people with bipolar disorder are most strongly intertwined with periods of depression or mixed states (symptoms of mania and depression during the same period of time), therefore early recognition and targeted treatment of these high-risk illness states is of key importance.

The importance of getting treatment:

• Reducing the intensity of suffering is a key hallmark of suicide prevention. That means that the best initial response to suicidal thoughts is to communicate with a health care provider in order to find ways to alleviate suffering, obtain an accurate diagnosis, and access the right treatment.
   
• When experiencing symptoms of bipolar disorder (e.g. changes in mood or sleep), it is important to regularly check-in about suicidal thoughts and behaviors with treatment providers.
   
• Suicidal thoughts and feeling may cause great despair and lead to isolation and withdrawal from family and close friends. It is so important during these times to communicate with significant others, and seek immediate help in a local emergency department if needed.
   
• Treatment for bipolar disorder, in particular for depression or mixed states, typically results in a decrease or disappearance of suicidal feelings and thoughts.

Specific treatment strategies for prevention of suicide:

• Having a written safety plan is an important part of staying safe. Safety plans should include warning signs, distraction techniques (e.g. listening to music), distress tolerance skills (e.g. breathing exercises), a list of close supports and care providers to contact, assigning a person to take charge in getting help when needed, specifics of how to make the environment safe, and a list of things that give meaning and hope.
• Periods of intense suicidal thoughts pass, and wishes to be dead can come and go. Preventing easy access to things that can harm (e.g. firearms, leftover medications) is a very important way to prevent acting on the thoughts if they return or worsen.
• There is some evidence that treatment with lithium in particular may help prevent suicidal thoughts. Having a discussion with a doctor about whether lithium is an appropriate treatment is advisable.
• Research is underway to develop better treatments for bipolar disorder including ones that specifically target suicidal thoughts.

Treatment discontinuation/relapse:

• Treatment discontinuation may lead to a "rebound effect" on mood symptoms, including thoughts of suicide. Staying consistent with treatment over time can therefore be protective against suicidal thoughts and behaviors.
• Always discuss treatment changes with the doctor before acting.
• Bipolar disorder is a lifelong illness which can change abruptly and in unexpected ways. Continuity of care is therefore very important, including keeping up with regular visits with health care providers to prevent or identify relapse and suicidal thoughts.
• Avoiding excessive use of alcohol and keeping stable daily routines can help prevent relapse.

Family and community supports:

• Suicidal persons may be indirect in their communication with family or friends because they are afraid of how the person will react. Asking someone who is suffering about suicidal feelings, listening attentively and offering to help can open up more discussion and create opportunities to assist a loved one in seeking help. Most people feel quite relieved when they are able to talk openly.
• Learn about access to local, free help resources such as crisis telephone lines. These places are staffed by trained, non-judgmental individuals who are comfortable talking with individuals or families about suicide thoughts.
• National organizations around the world (e.g. American Foundation for Suicide Prevention) are committed to providing hope and help, and have resources available online.
• Families and friends can be an important part of a safety plan. Be involved in helping a loved one create a written plan to keep safe. 

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A New Paradigm in Suicide Prevention: A summary of a talk given by Dr. Ayal Schaffer
at the ISBD 2023 Annual Meeting in Chicago.