CLINICAL HANDBOOK OF SCHIZOPHRENIA

502 VI. SPECIAL POPULATIONS AND PROBLEMSdence. Clinicians should consider discussing hospitalization with their patients as a viabletreatment option early in the course of treatment, and agreeing upon voluntary hospitalizationduring times of elevated risk. In less ideal circumstances, involuntary hospitalizationmight be necessary. When permitted, it may be advisable for clinicians to discuss thepossible range of treatment options and elicit cooperation from at-risk clients, their families,and other social supports as early as possible. Following hospitalization, cliniciansshould promote outpatient aftercare, including day hospitalization and other step-downcare programs, recognizing that suicide risk is high for individuals with schizophrenia inthe immediate period following hospital discharge.When a patient is judged to be at imminent risk for suicide, he or she should not beleft alone. Clinical work with individuals at risk for suicide should never be a solitary endeavor;clinicians should work to build a collaborative network of care providers to ensurethe highest quality of care for individuals at risk for suicide, and to provide supportfor one another, because working with at-risk populations can be highly stressful, andloss of a patient to suicide devastating. Clinicians are further advised to develop a safetyplan with the patient, listing explicit resources and supports to be accessed when risk ishigh, including support groups, distress lines and crisis centers, emergency access phonenumbers (e.g., 911), and use of emergency services and hospital emergency departments.There is little, if any, evidentiary support for use of so-called “no suicide contracts”; however,developing a safety plan to be enacted when a patient is suicidal can be helpful. Cliniciansshould endeavor to restrict access to potentially lethal means. Detailed note keepingis essential, and consultation is strongly encouraged. It is crucial that clinicians beempathic and supportive of the patient’s needs, and attentive to the therapeutic alliance.Mindfulness to suicide risk factors and warning signs, and provision of sensitive clinicalcare, may help to reduce risk for suicide in individuals with schizophrenia.KEY POINTS• Assess for potentially modifiable suicide risk factors and provide enhanced care for thosewho have multiple risk factors and/or lack sufficient resiliency factors.• Be vigilant to increased risk for suicide during high-risk periods: following initial diagnosisand hospital discharge; and when starting, stopping, augmenting, or switching medications.• Attend to suicide warning signs on an ongoing basis (e.g., ISPATHWARM).• Clinicians employing standardized psychological measures to assess suicide risk shouldhave appropriate training and experience in selecting, administering, scoring, and interpretingthese measures in individuals with schizophrenia.• Consider prescribing antipsychotics, antidepressants, and anxiolytics to help reduce symptomsassociated with schizophrenia and comorbid mood and/or anxiety disorders, carefullyconsidering patient medical history, past response to medications, and potential interactioneffects, side effects, withdrawal effects, toxicity of overdose, potential for abuse, and likelihoodof medication nonadherence.• Attend to the client’s potential for treatment nonadherence by providing clear instructionsand education about medication use and anticipated side effects.• Consider using psychotherapeutic and psychosocial interventions to help reduce the clients’symptoms, increase treatment adherence, and enhance social functioning and psychologicalwell-being.• Discuss the range of treatment options, including hospitalization, and elicit cooperation fromat-risk individuals, and their personal and professional supports, at the earliest possiblepoint.• Develop a safety plan with clients, listing explicit resources and supports to be accessedwhen risk is high, including support groups, distress lines and crisis centers, emergency accessnumbers (e.g., 911), and emergency services (including hospital emergency rooms).