Integration of Suicide Prevention Into Outpatient Management of Bipolar Disorder

Suicide prevention is a critical objective in the treatment of bipolar disorder. This article describespractical mechanisms by which monitoring and management of suicide risk can be integrated into theroutine care of patients with bipolar disorder. Suicide risk is assessed in terms of inclination (the driveto commit a self-destructive act) and opportunity (access to lethal means). Intervention strategies areadapted to the needs of bipolar patients across 3 phases of treatment: the acute episode; the continuationphase, when symptom reduction has occurred but adaptive recovery has not; and the maintenancephase, in which optimization of adaptive function and vigilance against impending relapse are paramount.Integration of suicide prevention into the outpatient management plan begins with a routinediscussion of suicide risk at the initiation of a treatment relationship, even in the absence of otherknown risk factors. This discussion paves the way for ongoing assessment of suicidality. Just as therecommended routine monitoring of every euthymic bipolar patient includes at least some minimalassessment for prodromal symptoms of acute mania or depression, every clinical visit can includesufficient probes to determine the need for new interventions specific to suicide prevention. Ongoingassessment of risk and protective factors can be linked to a range of individualized interventionsdesigned to meet the varying needs of patients over time. The intensity of monitoring and interventionsreflects the clinician’s knowledge of risk factors and may be life saving, but it is also importantthat patients and others involved in their care understand that monitoring cannot guarantee safety.