The finding:
Suicidal ideation and behavior, the most common psychiatric emergency, is rising in prevalence across various demographics. Short inpatient hospitalizations aim to stabilize these acute crises, but their efficacy in suicide prevention is questionable, as recent psychiatric hospitalization is considered a clinical risk factor for subsequent suicide attempts and death.  In a randomized controlled study involving 200 patients admitted after a suicide attempt, an intervention incorporating up to four sessions of brief cognitive behavioral therapy (BCBT-inpatient) significantly lowered the odds of suicide attempts by 60% and reduced psychiatric readmissions by 72% over a six-month period. However, for patients with substance use disorder (SUD), including those with Alcohol Use Disorder (AUD) and Opioid Use Disorder (OUD), the intervention did not yield significant improvements. The study highlights the efficacy of targeted cognitive therapy in inpatient settings in decreasing immediate suicide risk and follow-up psychiatric admissions, especially among patients primarily diagnosed with depressive, trauma/stressor-related, and anxiety disorders.

Strength and weaknesses:
This study is a recent and relatively large randomized controlled trial and demonstrates effectiveness of targeted therapy for measures of suicide prevention at least as measured in the short-term (6 months). The study is strengthened by including patients with SUD who are often excluded from suicide research. Limitations of this study include high rates of attrition (upward of 50%, equivalent rates in both arms) and not including in the analysis other associated destabilized (or otherwise) psychiatric symptoms on admission & clinical status upon discharge. This study also excluded patients who presented with suicidal ideation and not attempt, even though suicidal thoughts correlate with increased risk for suicidal behavior; consequently, the findings only apply to suicide attempt, and future research should include the full spectrum of suicidal presentations.

Relevance:  
This study underscores the importance of incorporating targeted inpatient treatments like brief cognitive behavioral therapy (BCBT-inpatient) to enhance suicide prevention and optimize emergency department triage for patients in acute suicidal crises. It shows the potential of such interventions to decrease relapse rates and iatrogenic harm among frequent users of psychiatric emergency services. However, it also indicates a need for further research to determine effective treatments for suicidal patients with substance use disorders.

The finding: 
This population data analysis study used 2015-2019 National Survey on Drug Use and Health data to explore specific risk factors for suicidal ideation and attempts beyond general aggregate data, accounting for sociodemographic, behavioral, and clinical characteristics. The study found a significant increase in past-year suicidal ideation from 2015 to 2019, while the prevalence of suicide attempts remained stable despite the rise in ideation. Key risk factors associated with increased suicide risk included being aged 18-25, having some college education, unemployment, identifying as lesbian, gay, or bisexual, and having a sedative/tranquilizer use disorder. The strongest risk factor was found to be age 18-25 for both ideation and attempts. Conversely, being female, Black, or having less than a high school education were linked to lower ideation but higher attempt rates. Specifically, suicide attempts among Black individuals rose by 48% over the study period, while those among White adults declined by 32.9%. Additionally, less than half of the adults with suicidal ideation received mental health care in the past year, with particularly low care utilization noted among young adults and racial-ethnic minority groups. Yet, over 40% did seek general health care in emergency department settings.

Strength and weaknesses:
This study uses a large population sample for statistical analysis and considers clinical factors within subgroups by demographic and clinical information when recorded. Limitations include that the data is obtained from a cross-sectional population survey tool which can risk underreporting and inaccurately capturing variables when using screens and not clinical diagnoses, as well as did not report suicide attempts in individuals who did not report/recall ideation.

Relevance:
People most at risk for suicide continue to have inadequate healthcare contact, but do have emergency healthcare contact, which calls for an urgent focus on and investigation of barriers to mental health care access to these specific populations to mitigate suicide risk, and address these for population level suicide prevention.

This perspective article offers a new algorithm for initial antipsychotic selection. Given that the emergency department (ED) is often where antipsychotics are first discussed and prescribed, any cogent argument regarding these prescriber practices should be carefully considered. Contending that early career practitioners benefit from specific recommendations, the authors suggest that aripiprazole, olanzapine, perphenazine, and risperidone should be considered first line antipsychotics. The authors’ rationale also carefully considered side effects, such as the relatively low risk of tardive dyskinesia for perphenazine. The authors also opine on the risks and benefits of olanzapine – a medication known both for its side effects and high efficacy. Here, olanzapine is the only first line option, while clozapine is catapulted to the only second line consideration.

This article offers guidance for both early career and seasoned clinicians; early career practitioners are armed with an evidenced-based approach for sequencing the first two-to-three medication trials. The veteran prescriber, alternatively, is encouraged by the synthesis of new data and the opportunity to update prescribing practices with more nuanced prescribing rationales. Importantly, as a caveat in the article summary, the authors do express support for early initiation of long-acting injectables in certain clinical circumstances, and not necessarily only for those who have proven to have poor adherence.  

These recommendations for initial antipsychotic choices are based on a body of literature focusing primarily on long term outcomes. The medication selection criteria for initial versus maintenance cohorts is not entirely disparate, but prescribers in an emergency setting should take this distinction into consideration.