Both talk therapy and medications show some efficacy for reducing suicide risk

Below please find summaries of new articles that will be published in the next issue of

Annals of Internal Medicine

. The summaries are not intended to substitute for the full articles as a source of information.

1. Both talk therapy and medications show some efficacy for reducing suicide risk


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M19-0869


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M19-2347


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Both cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) reduce suicide risk compared with usual treatment. Ketamine and lithium reduced the rate of suicide compared with placebo, but there was limited information on harms. Findings from a systematic review are published in

Annals of Internal Medicine

and were used to inform clinical guidelines from the U.S. Department of Veterans Affairs and U.S. Department of Defense (VA/DoD).

Suicide rates in the U.S. have increased by 30 percent from 2000 to 2016 and suicide ideation, planning, and attempts have grown the most among persons aged 18 to 25 years. Suicide rates are especially high among veterans. As such, finding effective treatments and management strategies is imperative.

Researchers from ECRI Institute reviewed and synthesized evidence from 8 systematic reviews and 15 randomized controlled trials of nonpharmacologic and pharmacologic interventions intended to prevent suicide in at-risk persons. Nonpharmacologic treatments included psychological interventions, such as CBT, or talk therapy, and DBT, which combines elements of CBT, skills training, and mindfulness techniques with the aim of helping persons with borderline personality disorder develop skills in emotion regulation, interpersonal effectiveness, and distress tolerance. Pharmacologic treatments studied included ketamine and lithium. The researchers found moderate-strength evidence supporting the use of face-to-face or Internet-delivered CBT in reducing suicide attempts, suicidal ideation, and hopelessness compared with usual care. Low-strength evidence suggests that DBT could help reduce suicidal ideation. With regard to pharmaceutical treatments, the researchers found moderate-strength evidence supporting use of short-term intravenous ketamine for reducing suicidal ideation and for the use of lithium for reducing suicide.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at

[email protected]

. To speak with the lead author, Kristen E. D’Anci, PhD, please contact Laurie Menyo at

[email protected]

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2. VA clinical practice guidelines aim to reduce suicide among at-risk populations


Each day, 20 veterans die by suicide, a rate about 20 percent higher than that of the general population

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M19-0687


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M19-1796


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Updated 2019 clinical practice guidelines from the U.S. Department of Veterans Affairs and the U.S. Department of Defense aim to reduce suicide among at-risk populations. The guidelines include recommendations on screening, evaluation, treatment, and management of patients with an elevated risk for suicide. A synopsis of the guidelines is published in

Annals of Internal Medicine

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Suicide is a worsening public health problem, with rates approximately doubling among service members between 1999 and 2016. Each day, 20 veterans die by suicide. Compared with age- and sex-matched civilian cohorts, veterans have a 21 percent higher suicide rate. Differences also exist between veterans who do and those who do not use Veterans Health Administration (VHA) services, with an 8 percent increase in suicides was observed among veterans who used VHA services versus 35.5 percent among those who did not. To help reduce the nation’s suicide rates, clinicians need a framework by which to screen for evaluate, treat, and mange patients at risk.

The VA and DoD Evidence-Based Practice Work Group convened to develop an updated joint VA/DoD guideline for the assessment and management of patients at risk for suicide. The previous guideline had been published in 2013. The current guidelines focus on screening and evaluation, risk management and treatment, and other management methods. The authors recommend screening for and evaluating suicide risk in the clinical setting, however since an effective method has not been identified, several means, such as self-report measures and clinical interviews, are recommended. Once risk has been identified, pharmacological treatments may be considered. Short-term ketamine infusions or lithium alone or in combination with another psychotropic agent are advised. Clozapine may be used for patients with a previous suicide attempt. Cognitive behavioral therapy and dialectal behavior therapy may also be used. The researchers also recommend reducing access to lethal means of suicide, such as firearms, poisons, and medications.

The author of an editorial from the University of Rochester Medical Center supports the guidelines as being the best available in the U.S., but says that we have a lot to learn from other countries, such as Denmark, Finland, and the United Kingdom, which have been able to reduce their suicide rates through early prevention. The author of and Case Western Reserve School of Medicine writes that suicide is not just a VA problem and that reducing veterans’ suicide rates will require reducing overall population suicide rates. More research should be conducted to assess community-level activities to reduce risk.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at

[email protected]

. To speak with lead author James Sall, PhD, FNP-BC, please contact him directly at

[email protected]

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3. Use of synthetic cannabinoid laced with rat poison leads to bleeding disorder in exposed patients


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L19-0321


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Use of synthetic cannabinoids laced with rodenticide led to an outbreak of coagulopathy in Illinois that spread to other states. Clinicians report a case of an otherwise healthy 26-year-old woman who developed a bleeding disorder after smoking the contaminated product. The case report is published in

Annals of Internal Medicine

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Researchers from Toxikon Consortium (a multi-disciplinary collaboration of all toxicology resources from The University of Illinois Hospital and Health Sciences System, Cook County Health, and The Illinois Poison Center) and Oregon State University reported a case of a young woman who came to the emergency department with 2 days of bleeding from her mucous membranes and heavy menstrual bleeding. She reported 4 years of smoking synthetic cannabinoids daily as a substitute for cannabis. Two days prior to visiting the emergency department, she had smoked a product called “Matrix,” which she brought with her to be examined.

Based on clinician observation, the patient was treated for rodenticide poisoning with 2 units of fresh frozen plasma followed by 50 mg of phytonadione (VK1) orally every 8 hours. The clinicians were aware, of the regional outbreak of coagulopathy that had recently occurred in the area and investigators found multiple second generation vitamin K antagonist rodenticides in patient’s blood samples. Additionally, the product she had smoked was analyzed and the same rodenticides identified in the patient’s blood were detected in the product. Second-generation vitamin K antagonist rodenticides, sometimes called “superwarfarins”, are far more potent and longer acting than warfarin, and can lead to very prolonged coagulopathy. While VK1 is an effective treatment for coagulopathy, the patient’s treatment was complicated by the high out of pocket cost of VK1 and because local pharmacies could not readily supply the high doses of oral VK1. According to the researchers, clinicians should plan ahead for similar inpatient and outpatient complications. It is not known to the researchers how the synthetic cannabinoids became contaminated with rodenticides.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at

[email protected]

. To speak with author Arkady Rasin, MD, please contact him directly at

[email protected]

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4. Combination of smaller and larger infarctions seen on brain imaging in middle age associated with substantial cognitive decline later in life


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M18-0295


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Having a combination of smaller and larger infarctions seen on brain imaging in middle age is associated with substantial cognitive decline over the next 20 years of life. Having only larger or only smaller infarction was not associated with this same risk. Findings from a longitudinal cohort study are published in

Annals of Internal Medicine

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Silent infarctions are a primary cause of strokes in the brain, but they are also common in people without a history of a stroke. Infarctions are generally only reported if they are larger (at least 3mm) and are ignored clinically if they are smaller than that. When mature adults have images of their brains for any reason, the images sometimes show these small infarctions, which are associated with future strokes and stroke mortality. However, little is known about the association between these infarctions and cognitive decline.

Researchers from the University of Mississippi Medical Center sought to determine the relationship between infarctions in middle age and later cognitive decline. They studied magnetic resonance imaging (MRI) data from 1993 to 1995 for 1,884 stroke-free middle-aged patients whose infarctions were characterized as none, smaller only, larger only (3 to 20 mm), or both larger and smaller. The patients were also assessed for cognitive decline up to 5 times over a 20-year period. The researchers found that the amounts of cognitive decline associated with only smaller infarctions and only larger infarctions were similar and were not statistically different from that associated with no infarctions. However, having a combination of both smaller and larger infarctions seemed to escalate risk for cognitive decline later in life in stroke-free persons. In fact, at the end of the 20-year follow up, those with both smaller and larger infarctions had cognitive scores that were akin to having aged 50 years, instead of just 20. According to the researchers, these findings suggest that people who have both kinds of infarctions may have more pervasive cerebrovascular disease processes. Ignoring the smaller infarctions, particularly when they occur along with larger ones, may lead to underestimating dementia risk.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at

[email protected]

. To speak with the lead author, B. Gwen Windham, MD, MHS, please contact Karen Bascom at

[email protected]

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5. Slower may be better when tapering patients to lower opioid doses


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M19-1488


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Many patients may benefit from slower tapering to lower, safer opioid doses. According to the authors of a commentary published in

Annals of Internal Medicine

, achieving effective, safe, and compassionate tapers requires implementing and incentivizing tapering protocols, recognizing prescription opioid dependence as a distinct clinical condition necessitating treatment, and expanding the indication for buprenorphine.

The extended use of opioids for chronic pain has created a population of patients prescribed long-term opioid therapy lasting years or decades, and many are on doses much higher than is recommended by current professional guidelines. These patients may benefit from tapering to lower, safer opioid doses, but how to effectively and safely do so has been the source of debate.

Authors from Oregon Health & Science University, Stanford University School of Medicine, and the University of Washington School of Medicine say that slower may be better when tapering patients to a lower opioid dose and physicians should be incentivized to taper responsibly. Currently, the Centers for Disease Control and Prevention (CDC) recommend tapering opioid doses by 10 percent each week to achieve discontinuation by 10 weeks. The authors suggest that taking a more individualized approach, with smaller dose reductions, especially for patients with chronic pain. Taper speed should be informed by patient response to dose reductions, and tapering should be provided in the context of psychological support and pain management with nonopioid treatments. They say that prescription opioid dependence is a condition distinct from opioid use disorder and should be recognized as such. For patients with difficulty tapering and suspected prescription opioid dependence, the authors argue that buprenorphine is effective and should be used. The authors recommend expanding the indication for high-dose buprenorphine formulations to include prescription opioid dependence because it could save lives, improve quality of life, and reduce incidence of nonlethal unintentional overdose.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at

[email protected]

. To speak with the lead author, Roger Chou, MD (Oregon Health & Science University), please contact Erik Robinson at

[email protected]

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