Videos

Drs Stephen Faraone, Theresa Cerulli, Craig Chepke, and Andrew J. Cutler discuss how to co-manage a patient with ADHD with other specialties.

Patient Case #1: Co-Managing ADHD

In Case You Missed It: Psychiatric Times Psychedelics Supplement

Slideshows

Vol. 39, Issue 9 covers the latest in psychedelics research and development in psychiatry.

 (OABD) is not an uncommon condition among the aging population. Available evidence indicates that individuals with OABD have less family psychiatric history but more medical comorbidities than individuals with early onset bipolar disorder (EOBD). Additionally, individuals with OABD have worse clinical outcomes and higher rates of health care service utilization than age-matched controls. When assessing individuals with OABD, underlying medical conditions, adverse effects prescribed medications, and/or drugs of abuse need to be ruled out as possible etiologies for OABD. In this article, we describe the evidence-based treatments among individuals with OABD.

Current evidence regarding the efficacy of specific 

 However, available data indicates that medication adherence skills training (MAST-BD) improves adherence to medications, ability to manage medications, symptoms of depression, and certain aspects of health‐related quality of life (including energy and social functioning) among older individuals with bipolar disorders (BD).

 A manual-based medical care model (BCM) including self-management sessions that focus on control of BD symptoms, healthy habits, provider engagement, telephone-based care coordination, reinforcement of self-management goals, and guideline education that is focused on medical issues in BD has been shown to improve patient satisfaction, follow-through rates, and good tolerability to treatment among individuals with OABD.

Although there is limited data on the treatment of individuals with OABD from controlled studies, available evidence indicates efficacy for 

, anticonvulsants, antipsychotics, antidepressants, and electroconvulsive therapy (ECT) among these individuals.

 It has been noted that there is no separate section on the treatment of OABD in the majority of treatment guidelines.

 The general principles for the pharmacotherapeutic treatment of individuals with OABD are similar to those for individuals with EOBD, but with closer monitoring for adverse effects, as these individuals have more medical comorbidities and are often on multiple medications. We describe some of the common medications and medication classes that have been used among individuals with OABD in the following section.

Lithium remains the classic drug that has been used for the treatment of individuals with OABD, and it is noted to provide the most benefit among individuals who present with manic symptoms and among individuals who have limited comorbid neurological disorders.

 Among individuals with OABD, lithium remains the favored monotherapy drug for maintenance treatment.

 Evidence suggests that the risk for suicide and cognitive decline among individuals with OABD may also be reduced with the use of lithium.

 As individuals with OABD are more prone to experiencing adverse effects from lithium, it is imperative to assess renal, thyroid, and cardiac functions prior to starting treatment with 

 Additionally, when prescribing lithium to individuals with OABD, it is important assess the risks for developing lithium toxicity, as these individuals often have reduced renal clearance and multiple medical comorbidities.

Caution must also be exercised when lithium is coprescribed with thiazide and loop diuretics, angiotensin converting enzyme inhibitors, andNSAIDs, as the risk for lithium toxicity is high in these situations.

 The common adverse effects associated with the use of lithium are sedation, edema, weight gain, hypothyroidism, renal dysfunction, gait impairment, and cognitive impairment.

 In individuals with OABD, it is recommended that the daily lithium dosage range be approximately one-fourth to one-half of the adult daily dosage, and that the targeted lithium levels be between 0.4 mEq/L and 0.7 mEq/L.

 Anticonvulsants are often used in the treatment of individuals with OABD, although the data on their efficacy from controlled studies is limited.

 (VPA) is increasingly being used among individuals with OABD, despite there being no clear evidence for its greater efficacy or tolerability when compared to lithium.

 There should be caution with the prescription of VPA to individuals with OABD, as it may cause serious adverse effects by interacting with other commonly prescribed drugs like warfarin, phenytoin, phenobarbital, and acetylsalicylic acid.

 Among individuals with OABD, therapeutic levels of VPA can be achieved on lower daily dosages when compared to younger adults.

 Individuals with OABD who have had partial response to lithium monotherapy or have a rapid-cycling illness may respond better to a combination of lithium and VPA.

In 1 randomized controlled trial (RCT), investigators compared lithium carbonate to divalproex among individuals ≥ 60 years of age with bipolar I disorder who presented with manic, hypomanic, or mixed episodes.

 In this 9-week trial, the targeted lithium serum concentration was 0.80-0.99 mEq/L, and the targeted serum concentration was 80-99 μg/mL. The investigators noted that the cumulative rates of response in the lithium and divalproex groups at week 3 were 62.5% and 57.1%, respectively (P=0.37). The cumulative rates of response in the lithium and divalproex groups at week 9 were 78.6% and 73.2% (P=0.31) respectively. The cumulative rates of remission in the lithium and divalproex groups at week 3 were 45.5% and 43.8% (P=0.74), respectively; at week 9, they were 69.6% and 63.4% (P=0.29), respectively. The attrition rates for the lithium group were 14% at week 3 and 51% at week 9. For the divalproex group, the attrition rates were 18% at week 3 and 44% at week 9. The rates of sedation as an adverse effect were similar between the 2 groups, but rates of tremors were greater in the group receiving lithium.

Among individuals ≥ 55 years of age with bipolar I disorder, the use of lamotrigine was found to delay the time to intervention for any mood episode and for a depressive episode when compared to placebo.

 In the same study, lithium was also found to delay the time to intervention for any manic, hypomanic, or mixed episodes when compared to placebo. Back pain and headaches were the common adverse effects in the lamotrigine group, but there were no rashes noted in this group. The most common adverse events in the lithium group were dyspraxia, tremor, xerostomia, 

, infection, amnesia, dizziness, diarrhea, nausea, and fatigue. When compared to other anticonvulsant mood stabilizers, an advantage to using lamotrigine among individuals with OABD is its better cognitive profile.

The use of carbamazepine among individuals with OABD has not been studied in controlled clinical trials.

 The trial data from mixed aged populations indicates that for the treatment of acute mania and for the maintenance treatment for BD, carbamazepine appears to be inferior to both lithium and VPA.

 Individuals with BD who present with nonclassical or atypical features of BD appear to respond better to carbamazepine.

 Among individuals with OABD, carbamazepine appears to be less well tolerated than other anticonvulsant mood stabilizers, possibly due to its significant drug-drug interactions.

The efficacy and tolerability of gabapentin, oxcarbazepine, topiramate, and zonisamide among individuals with OABD have not been evaluated in controlled studies, and their routine cannot be recommended among these individuals.

, quetiapine extended release (XR), risperidone, and ziprasidone have been approved by the US Food and Drug Administration (FDA) for the treatment of BD.

 The FDA has approved olanzapine-fluoxetine combination (OFC), quetiapine, and lurasidone for the acute treatment of bipolar depression.

 Lurasidone is approved as monotherapy and as an adjunct to lithium or divalproex treatment, whereas OFC and quetiapine are approved as a monotherapy for acute treatment of bipolar depression.

A post-hoc analysis of pooled data from 2 quetiapine monotherapy trials found that among individuals ≥ 55 years of age with BD and mania, quetiapine 400 mg to 800 mg a day when compared to placebo resulted in significant improvements in symptoms from baseline to day 21.

 It was also noted that there was sustained reductions in mania scores noted from day 4 of treatment. The most common adverse effects in the quetiapine group were dry mouth, somnolence, postural hypotension, 

In a post-hoc analysis of 2 placebo-controlled, 6-week, randomized, double-blind studies of lurasidone, investigators evaluated data from a monotherapy trial and as an adjunctive agent among individuals ≥ 55 years of age who met the DSM-IV-TR criteria for 

 In the monotherapy study, investigators compared fixed flexible doses of lurasidone 20 to 60 mg a day or 80 to 120 mg a day to placebo. In the second study, investigators compared flexible doses of lurasidone dosed at 20 to 120 mg a day as an adjunct to either lithium or valproate to placebo. The primary endpoint was a mean change at week 6 on the Montgomery-Åsberg Depression Rating Scale (MADRS) total score. In the first study, the mean change in the MADRS total score at week 6 was significantly greater in the lurasidone group when compared to the placebo group (effect size=0.83, P=0.003). In the second study, mean change in the MADRS at week 6 was not significantly different in lurasidone group when compared to the placebo group (effect size=0.26, P=0.398). There were no differences noted in the monotherapy study (6.8% versus 6.9%) or the adjunctive therapy study (3.8% versus 7.1%) on the rates of discontinuation due to adverse events between the lurasidone and placebo groups.

Asenapine 10 mg twice daily orally was trialed as monotherapy for 4 weeks in an open-label study that included 11 individuals with acute bipolar mania and a mean age of 67.7 years who were consecutively admitted to a psychogeriatric unit.

 The investigators found that there was an improvement in manic symptoms at week 4 in all the participants in the study. Remission of symptoms was noted in 7 of the 11 individuals. As for adverse effects, 3 individuals had mild sedation. One individual developed a rash on day 6 of treatment. One individual developed peripheral edema on day 14 of treatment. The adverse effects resolved quickly following the discontinuation of the drug.

In a 12-week prospective, open-label trial of asenapine among individuals ≥ 60 years of age who had an inadequate response to other BD treatments, the investigators found that there were significant improvements on the Brief Psychiatric Rating Scale (P<0.05), the Clinical Global Impression, bipolar version (CGI-BP, P<0.01), and the CGI-BP mania (P<0.05) and depression (P<0.01) subscales from baseline with the use of asepanine.

 The mean dose of asenapine in this study was 11.2 mg a day. The most commonly reported adverse effects in the study were gastrointestinal discomfort (33%), restlessness (13%), tremors (13%), cognitive difficulties (13%), and sluggishness (13%).

Among 3 institutionalized older men with BD who did not respond to treatment with lithium, valproate, 

, or traditional antipsychotics either as monotherapy or in combination treatment, clozapine was found to be effective in treating symptoms of mania and psychosis.

 There was sustained improvement in symptoms noted among these individuals over 11 months. Additionally, there were no significant reductions in the granulocyte count noted among these individuals during the trial period.

A retrospective cohort study that included individuals aged 65 to 89 years with a diagnosis of bipolar I or II disorder who had received a prescription for either lithium or an atypical antipsychotic medication between January 1, 2005, and September 30, 2017, found that the most commonly prescribed antipsychotics in this group were aripiprazole and quetiapine (33% respectively).

 This was followed by risperidone (17%), olanzapine (13%), and lurasidone (4%). At the end of the data collection period, it was noted that all the individuals on lithium had discontinued treatment when compared to 83.33% of individuals on atypical antipsychotics (P=0.03). The days to discontinuation did not differ between the 2 groups: 1128.67 days for the lithium group versus 1127.83 days for the atypical antipsychotics group, respectively (P=0.998). The discontinuation of treatment due to adverse effects occurred in 41.67% of individuals on lithium and 30% of individuals on atypical antipsychotics (P=0.523). Tremor was the most commonly reported adverse effect with lithium (40%), followed by renal failure (30%), toxicity (20%), and bloating/swelling (10%). Extrapyramidal symptoms (50%) and sedation (33%) were most common in those on an atypical antipsychotic medications. This was followed by restlessness and hallucinations (17%). In the lithium group, a total of 7 patients had either significant changes in TSH levels or eGFR. In the atypical antipsychotic medication group, 8 individuals had significant changes in A1C or triglycerides. No significant changes in QTc interval were noted in either group. Other common reasons for discontinuation were perceived lack of efficacy (16.67% for the lithium group versus 20% for the SGA group, P=0.80) and loss to follow-up (29.17% for the lithium group and 20% for the SGA group, P=0.448). Hospitalizations due to BD occurred in 14% of the lithium group and 11% of the SGA group.

An analysis of the Global Aging & Geriatric Experiments in Bipolar Disorder Database that used cross-sectional data from 16 studies among individuals ≥ 50 years of age with BD found that 46.6% of these individuals were using antipsychotics.

 Individuals who were using antipsychotics were found to be younger (P=0.01), less likely to be employed (P<0.001), had more psychiatric hospitalizations (P=0.009), and were less likely to be prescribed lithium (P<0.001). Among these individuals, more than 93% of individuals were receiving atypical antipsychotics.

As antipsychotics can increase the risk for cerebrovascular adverse events and death among older adults, especially those individuals with 

, there should be a clear risk/benefit analysis conducted before prescribing these medications. There should also be close monitoring for these serious adverse effects.

In their population-based retrospective cohort study, Schaffer et al found that the prescription of antidepressants significantly reduced the likelihood of admissions for manic/mixed episodes (adjusted rate ratio [aRR]=0.5), but not depressive episodes (aRR=0.7) among individuals ≥ 66 years of age with BD when compared to the control group, who did not receive a prescription for an antidepressant during the same time.

Current evidence indicates that there are no controlled studies of ECT among individuals with OABD.

 Available evidence indicates that ECT is often used among older adults with BD when rapid treatment response is needed and/or in situations where symptoms are refractory to 

. ECT has also been found to be a safe and effective treatment among older individuals with severe or refractory mania.

 ECT is also useful in situations where the individual with BD is at imminent suicide or homicide risk or in cases where the clinical presentation includes severe agitation, catatonia, or psychosis and/or in cases where the individual’s medical condition is not stable.

 Both right unilateral and bilateral ECT have been found to have equal efficacy in the treatment of individuals with depressive episodes.

 However, longer time for postictal recovery and greater memory impairments are noted among individuals who receive bilateral ECT.

Tampi et al have proposed a treatment algorithm for individuals with OABD.

 The authors suggest that the among individuals with OABD, there should a minimum of 3 to 4 weeks in trials for the initial medication that is chosen.

 If monotherapy is not beneficial, then a judicious medication combination can be used. Medications should be continued for at least the next 6 to 12 months among those individuals who respond adequately to treatment. After a 12-month period, a gradual taper and discontinuation of adjunctive medications could be attempted among individuals whose symptoms are in remission.

 Inadequate compliance to medication treatment and comorbid substance use disorder and/or cooccurring neurological disorders are known to reduce response to treatment.

 enumerates the possible treatments for individuals with OABD.

Possible Treatments for Individuals With OABD

OABD is serious condition that is not uncommon among older adults. Psychosocial treatments are noted to be beneficial as adjunctive treatment among individuals with OABD. Available evidence indicates that individuals with OABD respond well to medication classes that are commonly used to treat BD among younger individuals. ECT is often beneficial among individuals who present with severe or refractory symptoms and those individuals who present with catatonia, psychosis, or severe suicidality or homicidality. The prompt assessment of symptoms and appropriate treatment will assist in reducing morbidity and mortality due to OABD.

is professor and chairman of the Department of Psychiatry at Creighton University School of Medicine and Catholic Health Initiatives (CHI) Health Behavioral Health Services in Omaha, Nebraska. He is also an adjunct professor of psychiatry at Yale School of Medicine.

is cofounder and managing principal of Behavioral Health Advisory Group in Princeton, New Jersey.

2. Depp CA, Lebowitz BD, Patterson TL, et al. 

Medication adherence skills training for middle-aged and elderly adults with bipolar disorder: development and pilot study.

3. Kilbourne AM, Post EP, Nossek A, et al. 

Service delivery in older patients with bipolar disorder: a review and development of a medical care model.

Treatment for late-life bipolar disorder.

5. Dols A, Kessing LV, Strejilevich SA, et al. 

Do current national and international guidelines have specific recommendations for older adults with bipolar disorder? A brief report.

Using lithium in older age bipolar disorder: special considerations.

Treatment of bipolar disorder in older adults.

8. Sajatovic M, Madhusoodanan S, Coconcea N. 

Managing bipolar disorder in the elderly: defining the role of the newer agents.

9. Shulman KI, Almeida OP, Herrmann N, et al. 

Delphi survey of maintenance lithium treatment in older adults with bipolar disorder: an ISBD task force report.

10. Kessing LV, Søndergård L, Kvist K, et al. 

Suicide risk in patients treated with lithium.

Practice guideline for the treatment of patients with bipolar disorder (revision).

13. Shulman KI, Rochon P, Sykora K, et al. 

Changing prescription patterns for lithium and valproic acid in old age: shifting practice without evidence.

14. Chen ST, Altshuler LL, Melnyk KA, et al. 

Efficacy of lithium vs. valproate in the treatment of mania in the elderly: a retrospective study.

Divalproate augmentation in lithium-resistant rapid cycling mania in four geriatric patients.

Low-dose lithium augmentation of divalproex in geriatric mania.

17. Young RC, Mulsant BH, Sajatovic M, et al. 

GERI-BD: a randomized double-blind controlled trial of lithium and divalproex in the treatment of mania in older patients with bipolar disorder.

18. Sajatovic M, Gyulai L, Calabrese JR, et al. 

Maintenance treatment outcomes in older patients with bipolar I disorder.

20. Greil W, Kleindienst N, Erazo N, et al. 

Differential response to lithium and carbamazepine in the prophylaxis of bipolar disorder.

Carbamazepine and valproate monotherapy: feasibility, relative safety and efficacy, and therapeutic drug monitoring in manic disorder.

22. Atypical antipsychotic medications: use in adults. Centers for Medicare & Medicaid Services. October 2015. Accessed September 27, 2022. 

https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Pharmacy-Education-Materials/Downloads/atyp-antipsych-adult-factsheet11-14.pdf

23. McIntyre RS, Cha DS, Kim RD, Mansur RB. 

A review of FDA-approved treatment options in bipolar depression.

24. Sajatovic M, Calabrese JR, Mullen J. 

Quetiapine for the treatment of bipolar mania in older adults.

25. Sajatovic M, Forester BP, Tsai J, et al. 

Efficacy of lurasidone in adults aged 55 years and older with bipolar depression: post hoc analysis of 2 double-blind, placebo-controlled studies.

26. Baruch Y, Tadger S, Plopski I, Barak Y. 

Asenapine for elderly bipolar manic patients.

27. Sajatovic M, Dines P, Fuentes-Casiano E, et al. 

Asenapine in the treatment of older adults with bipolar disorder.

Treatment of elderly institutionalized bipolar patients with clozapine.

Comparison of lithium to second generation antipsychotics for the treatment of bipolar disorder in older veterans.

30. Chen P, Eyler LT, Gildengers A, et al. 

Demographic and clinical characteristics of antipsychotic drug-treated older adults with bipolar disorder from the Global Aging & Geriatric Experiments in Bipolar Disorder Database (GAGE-BD).

31. Mittal V, Kurup L, Williamson D, et al. 

Risk of cerebrovascular adverse events and death in elderly patients with dementia when treated with antipsychotic medications: a literature review of evidence.

32. Schaffer A, Mamdani M, Levitt A, et al. E

ffect of antidepressant use on admissions to hospital among elderly bipolar patients.

Neuromodulation treatments for geriatric mood and cognitive disorders.

Efficacy of electroconvulsive therapy in the treatment of nondepressed psychiatric illness in elderly patients: a review of the literature.

Unilateral and bilateral ECT in elderly patients. A comparative study.

36. Tampi RR, Joshi P, Bhattacharya G, Gupta S. 

Evaluation and treatment of older-age bipolar disorder: a narrative review.

37. Young RC, Gyulai L, Mulsant BH, et al. 

Pharmacotherapy of bipolar disorder in old age: review and recommendations.

38. Sajatovic M, Strejilevich SA, Gildengers AG, et al. 

A report on older-age bipolar disorder from the International Society for Bipolar Disorders Task Force.

Articles

What treatments are available for those with older age bipolar disorder? 

Management of Patients With Older Age Bipolar Disorder

Richard Berlin, MD, shares his poem "Contemplating Retirement," which will appear in the October 2022 issue of 

embrace. I let my mind wander to new meds

the effort of starting with someone new—

and rapport, history-taking’s excavation,

responsibility’s weight, all the risks,

Last week I changed my voicemail greeting

to declare I’m not accepting new patients,

"Patients get better, treatments end, openings appear in my schedule and I leave them open..."


"Contemplating Retirement"

 is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. To create a better world, he is an advocate for treating mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism. He serves on the Editorial Board of

In Memoriam: The Healing Force of Pharoah Sanders’ Music

,” I celebrated the psychological healing of his music in my eulogy of the jazz saxophonist Pharoah Sanders. I do not know if he ever played in Russia, but the history of jazz there goes back and forth between such freedom of expression and suppression.

More on King Charles III, Psychiatry, Religion, and Spirituality

Considering National and Personal Character in Russia’s Invasion of Ukraine

Tomorrow, October 1st, as written about in the September 27th issue of the 

 article “When Russia Said ‘Da’ to Jazz,” is the 100th anniversary of the coming of jazz to Russia.

 It is being celebrated there under the auspices of Russia’s own native saxophonist, Igor Butman. They are reconstructing the original concert, which set off a period of jazz popularity in Russia. This period lasted until World War II, after which Stalin cracked down on all jazz as the Cold War with the United States heated up. Some intermittent thawing occurred, especially via the shortwave radio programs of Voice of America.

In the meanwhile, a courageous jazz underground of more avant grade music, like that of Pharoah Sangers, grew in the 1970s and 80s, culminating in open governmental acceptance after the Soviet Union dissolved in 1991. Now, under Putin. It will be interesting to see what happens to jazz after this anniversary. Perhaps jazz is a good measuring stick for the degree of authoritarian leadership in a country.

Why is this relevant to psychiatry? Freedom of thought and expression is certainly at risk in the ever-growing cultish groups and conspiracy theories online and offline in the United States and elsewhere. Thankfully, there are formalized methods, such as the BITE (Behavior, Information, Thought, Emotion) Model, to address this problem, as discussed in the May 22, 2022, 

™ interview with Steven Hassan, PhD, titled “

As its essence, isn’t psychiatry an improvisatory quest for more freedom of mind and relationships, so ably represented in jazz music?

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

1. Hasse JE. When Russia said ‘da’ to jazz. 

. September 27, 2022. Accessed Spetember 30, 2022. 

https://www.wsj.com/articles/cultural-commentary-russia-jazz-100-anniversary-joseph-stalin-valentin-parnakh-sam-wooding-frank-withers-duke-ellington-garvin-bushell-sidney-bechet-eddit-rosner-oleg-ludstrem-cyril-moshkow-leonid-utyosov-benny-goodman-earl-hines-thad-jones-mel-lewis-igor-butman-11664316734

Is jazz a good litmus test for Russia’s leadership? 

The Freedom and Suppression of Jazz in Russia

A safety plan is a critical evidence-based intervention that can reduce suicidal behavior, either as a standalone intervention or as part of a comprehensive treatment plan.

 The purpose of the safety plan is to provide patients who are at heightened risk for suicide with concrete, actionable coping strategies they can use during a suicidal crisis to decrease their risk of attempting suicide. In addition to its practical and intended use, a safety plan also conveys hope by demonstrating to an individual with suicidal ideation that there are more effective ways of managing their problems.

A safety plan is different from a no-suicide contract. Research has shown that no-suicide contracts are ineffective and can lead patients to withhold information about suicidal thoughts and behaviors from their providers.

At the beginning of treatment, or if a previously non-suicidal patient begins reporting suicidal risk factors, it is important to determine risk for suicide by conducting a comprehensive suicide risk assessment. This may include patients who have experienced previous episodes of suicidal ideation or behavior because, when the previous suicide risk is greater than the current risk, it is a better predictor of suicidal behavior.

 Safety planning should then be conducted immediately upon determining that a patient is at heightened risk for suicide.

As with all interventions, clinicians should provide patients with a rationale for safety planning. If possible, clinicians can emphasize the collaborative nature of the intervention by sitting next to the patient when completing the plan. Clinicians should start by eliciting warning signs that risk for suicide is increasing. This helps patients gain awareness of when they need to access and use their safety plan. It is typically easier for patients to implement safety plan coping strategies at the early stages of a suicidal crisis than it is after the episode escalates in intensity. Noticing warning signs can help patients begin using coping strategies so that a more severe crisis and related suicidal behavior are prevented.

Once the clinician and patient have a good understanding of the patient’s warning signs, the first section of the safety plan can be completed. Warning signs may include feelings of hopelessness or irritability; thoughts like, “I’ll always be alone”; behaviors like arguing with a parent; and/or physiological sensations such as intense pain from a chronic medical condition. They can also include events, such as the anniversary of the death of a loved one.

The next part of the safety plan involves identifying different categories of coping strategies patients will use once they have recognized that they are at heightened risk for suicide. The safety plan begins with internal coping strategies the patient can use without assistance from others and progresses through incrementally more intensive strategies the patient can use if the initial strategies are ineffective.

Internal coping strategies typically involve experiences that distract the patient from their suicidal thoughts, emotional distress, or urges by diverting their attention onto other activities, stimuli, or sensations. Clinicians can identify internal coping strategies by asking patients, “What have you done in the past that has been at least a little helpful when you have experienced any of these warning signs?” If the patient has trouble identifying coping strategies, you can make suggestions.

Some patients may benefit from focusing on sensory experiences like listening to music or taking a hot shower. Patients may also engage in a distracting activity, such as going for a walk, watching an entertaining TV show, or playing video games. When completing this section of the safety plan, clinicians should be as specific and detailed as possible. For example, if a patient identifies listening to music as a coping strategy, the clinician should find out exactly which songs or artists the patient finds helpful and how the patient will listen to them (eg, on their phone).

After completing each coping strategy section, clinicians elicit feedback from patients. Clinicians should assess how likely it is that the patient will use the strategies in a suicidal crisis and problem solve for any obstacles that may get in the way. A simple way to assess the utility of each part of the plan is to ask, “Thinking about how you feel when in a suicidal crisis, how likely are you to use these strategies on a scale of 0 to 100, where 0 indicates that you will definitely not use these strategies and 100 indicates that you have no doubt that you will use them?” If the patient provides a rating of less than 90, the clinician will need to do some additional work to assess practical problems or beliefs that may be interfering with the patient’s likelihood of using the strategies. This might involve eliminating some strategies and replacing them with other, more helpful ones.

For the next section of the safety plan, patients are asked to identify individuals and social settings that can serve as a distraction during a suicidal crisis. It should be emphasized that these are not individuals the patient is contacting to directly ask for help, but rather individuals who can provide social experiences that can divert the patient’s attention from suicidal thoughts or urges. The identified individuals should be known to be responsive and accessible, and the patient should be explicit about the medium for communication (ie, via phone, via text, or in person).

Patients may also wish to identify social locations they can visit, such as a local park, a coffee shop, or an AA meeting. Many patients find it helpful to be around other people during a suicidal crisis, even if the people are strangers. As with the section on internal coping strategies, clinicians should assess the likelihood that patients will use the strategies in this section before moving on.

Next, the patient will identify individuals that they can contact to directly ask for support. The identified individuals should have a history of being responsive or helpful when the patient has asked them for support in the past. The patient will need to determine whether they feel comfortable explicitly stating that they are having a suicidal crisis, or whether they would prefer to be vague (ie, telling the person they feel “down” or “anxious” instead). If the patient is not sure whether an identified person will be willing and able to help, they can have a conversation with the person in the coming week about their desire to reach out for support if needed. They may even tell the person what they would like them to do if they call on them for support. If the patient is not comfortable having this type of conversation, it may be helpful for the clinician to provide some brief coaching on communication skills and to offer to roleplay the conversation.

Once support people have been identified, clinicians should be explicit about the order in which the patient will contact them and the medium for contact. Finally, the names and phone numbers of the individuals should be added to the safety plan.

If the patient has moved through all the previous coping strategies and is still in suicidal crisis, the final strategy is to contact mental health providers or facilities that can intervene with professional help. Typically, the clinician’s name will be at the top of this section, followed by additional mental health clinicians and trusted medical professionals. Clinicians should be explicit with clients about how emergencies are handled both during and after business hours, whether they have an answering service, or if there is another provider in the practice who may be on call if the patient experiences a crisis after hours.

This section can also include hotline services, like the new mental health crisis number, 988, which is now available in the United States. Finally, patients should designate a local urgent care service or psychiatric emergency room if hospitalization is required. Patients should also determine how they will get to their designated facility (ie, will they call an ambulance or ask a friend or family member to drive them?).

The next step in safety planning is making the patient’s environment safer. Clinicians should focus on reducing the patient’s access to their identified means for suicide. It is important to restrict access to firearms, regardless of whether the patient expresses a desire to use a firearm for suicide. In the United States, approximately half of individuals who commit suicide do so using firearms.

 Having a firearm in the household is also associated with a 5-fold increase in death by suicide.

When asking the patient about their chosen means for suicide, collaboration is key. Often, patients view having access to a means for suicide as a coping strategy in and of itself. A patient may consider a stockpile of pills hidden in a drawer an “escape hatch” they can use if their problems become overwhelming. That patient may then have a negative reaction to the clinician’s suggestion that they turn their medication over to a friend for safekeeping.

Clinicians can be collaborative by asking patients for suggestions to make their environment safer before offering their own suggestions. For instance, a patient may prefer keeping a pill box with 1 week’s worth of medication while a family member has possession of the remaining bottle. A patient who is unwilling to give up their firearm may be willing to store it in a locked safe and give the key to a trusted friend. Clinicians can emphasize that the measures are temporary and will last only until the suicidal crisis is over.

The last component of the safety plan is identifying reasons for living. Clinicians should work with patients to identify at least 1 thing that makes the patient’s life worth living. The simplest way to help patients identify reasons for living is simply to ask, “What is 1 thing that is most important and worth living for?” If patients have difficulty identifying 1 reason for living, clinicians can prompt them by asking about different areas where individuals often find meaning, including relationships, important goals, or religion and spirituality. If the patient is still having trouble identifying a compelling reason for living, the clinician might suggest that even the potential of having a future reason for living, or the possibility that life might seem worthwhile, can also be reasons for living. For example, a young female patient of mine did not have children, but she identified wanting to be a mother sometime in the future as a potential reason for living.

Once the safety plan is complete, the clinician’s work is to increase the likelihood that the patient will actually use it in a suicidal crisis. The clinician will start by asking for general feedback about the safety planning process and whether the patient believes the plan will be helpful. The clinician will then try to uncover obstacles that might get in the way of the patient using the plan when needed.

Sometimes practical problems may get in the way. For example, the patient may not remember to use their plan, particularly when they are in the midst of a suicidal crisis. It is usually a good idea to ask patients to review their safety plan every day, regardless of whether they are feeling suicidal. Clinicians should be explicit with patients about when they will review their plan. Most patients can benefit from reviewing their plan each morning, as this helps keep the plan at the forefront of their minds throughout the remainder of the day. Another obstacle might be the accessibility of the plan. The clinician will want to be sure the patient has access to their plan wherever they are. Patients may wish to take a picture of it with their phone, or to make multiple copies and store them in different locations (ie, in their car, in their desk at work, on a nightstand).

Some patients may express doubt that the plan will be helpful. The clinician can communicate that the safety plan is not meant to solve all their problems—the safety plan is just meant to keep the patient alive so that they can continue to work on more longstanding problems in therapy. The clinician can also stress that the safety plan can evolve and change over time, as the patient determines that some of the strategies are not helpful and learns new strategies in therapy that may be more helpful. The patient just needs to agree to use the plan, regardless of whether they are confident it will be helpful.

Each subsequent session with the patient should begin with a review of the plan and a discussion of any strategies the patient has tried to determine their utility. If a patient outright refuses to use their safety plan, clinicians should consider whether the patient should be referred to a higher level of care.

is a licensed clinical psychologist at the 

Beck Institute for Cognitive Behavior Therapy

is the communications manager at the Beck Institute for Cognitive Behavior Therapy.

1. Nuij C, van Ballegooijen W, de Beurs D, et al. 

Safety planning-type interventions for suicide prevention: meta-analysis

The case against no-suicide contracts: the commitment to treatment statement as a practice alternative

Suicide ideation at its worst point: a predictor of eventual suicide in psychiatric outpatients

Suicide case-fatality rates in the United States, 2007 to 2014: a nationwide population-based study

Gun safety management with patients at risk for suicide. 

What is a safety plan, and how can clinicians use it to help patients with suicidal behavior? 

Safety Planning: An Essential Feature of Cognitive Behavior Therapy for Suicide Prevention

I caught a brief interchange of the September 27th “Late Show” when Stephen Colbert was interviewing the well-known foreign war correspondent Clarissa Ward. She seemed to be concluding that Russia has an unusual propensity to tolerate suffering, so that a long war would not be all that psychologically difficult for the country as a whole.

Her comment reminded me of how long Russia was able to hold out, starvation common by the end, to the siege of Leningrad by the German Nazis in World War II. They ultimately shifted the whole tide of the war.

There are many jokes about Russian tolerance for suffering, and the role of vodka in coping with it. Take Woody Allen in his 1975 film “Love and Death,” when the antihero Boris Grushenko said this about human suffering, in a sort of word play like that of the psychiatrist and writer, R.D. Laing:

It could be a long and cold winter for Russia…