Inpatient Treatment of Suicidality: A Systematic Review of Clinical Trials

Ali Abdolizadeh, MSc; Brett D. M. Jones, MD, MSc; Maryam Hosseini Kupaei, HBSc; Amal Shah, HBSc; Terri Rodak, MA, MISt; Salman Farooqui, HBSc; Mohammed Omair Husain, MBBS, MRCPsych; Cory R. Weissman, MD; Juveria Zaheer, MD, MSc; David Gratzer, MD; Daniel M. Blumberger, MD, MSc; Muhammad Ishrat Husain, MBBS, MD (Res.), MRCPsych

J Clin Psychiatry 2025;86(1):24r15382

Abstract

Objective: Psychiatric inpatients represent an acutely vulnerable population with high rates of suicidality (ie, suicidal ideation, attempts, and completed suicide). This systematic review aimed to evaluate treatments for suicidality delivered within inpatient settings.

Data Sources: MEDLINE, Embase, APA PsycInfo, CINAHL, and The Cochrane Library were systematically searched using 3 concepts: suicidality, inpatient population/setting, and treatment/ interventions. Searches were limited to years 2001–2024, with no language restrictions.

Study Selection: Of 19,921 articles identified, 11,519 were screened, and 179 underwent full-text review. We included clinical trials on pharmacologic and nonpharmacologic interventions for suicidality in psychiatric inpatients aged 18–65 with moderate to high levels of suicidality that measured changes in suicidality.

Data Extraction and Synthesis: Studies were organized into tables by study design, treatments, participants, suicide measure, outcomes, and key findings. Due to heterogeneity, a meta-analysis was not conducted; instead, a narrative synthesis was used for qualitative analysis.

Results: Forty-nine studies were included. Of 14 pharmacologic trials, intravenous ketamine showed most consistent rapid reduction in suicidality. Thirty-five nonpharmacologic trials, covering a broad spectrum of treatments including chronotherapy, neurostimulations, and psychotherapies, were reviewed. The results were mixed, with some interventions showing potential in reducing suicidality, particularly in the mood, personality, and trauma-related disorders. Many studies had methodological concerns including nonrandomized designs, lack of control arms, and retrospective assessments.

Conclusion: A range of interventions for treating suicidality in inpatient settings have been evaluated, with mixed results. The current review underscores the need for larger, well-designed trials to assess the effectiveness of these treatments in inpatient settings.

J Clin Psychiatry 2025;86(1):24r15382

Author affiliations are listed at the end of this article.

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References (87)

Silverman MM, Berman AL, Sanddal ND, et al. Rebuilding the Tower of Babel: a revised nomenclature for the study of suicide and suicidal behaviors. Part 1: background, rationale, and methodology. Suicide Life Threat Behav. 2007;37(3):248–263.
Silverman MM, Berman AL, Sanddal ND, et al. Rebuilding the Tower of Babel: a revised nomenclature for the study of suicide and suicidal behaviors. Part 2: suicide-related ideations, communications, and behaviors. Suicide Life Threat Behav. 2007;37(3):264–277.
Lebenbaum M, Cheng J, de Oliveira C, et al. Evaluating the cost effectiveness of a suicide prevention campaign implemented in Ontario, Canada. Appl Health Econ Health Pol. 2020;18(2):189–201.
Haagsma JA, Graetz N, Bolliger I, et al. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Inj Prev. 2016;22(1):3–18.
Ilic M, Ilic I. Worldwide suicide mortality trends (2000-2019): a joinpoint regression analysis. World J Psychiatry. 2022;12(8):1044–1060.
Nock MK, Borges G, Bromet EJ, et al. Suicide and suicidal behavior. Epidemiol Rev. 2008;30(1):133–154.
Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006;3(11):e442. PubMed
Mathers CD, Stein C, Fat DM, et al. Global Burden of Disease 2000: Version 2 methods and results, Global Programme on Evidence for Health Policy Discussion Paper No. 50. World Health Organization; 2006.
Skinner R, McFaull S, Draca J, et al. Suicide and self-inflicted injury hospitalizations in Canada (1979 to 2014/15). Health Promot Chronic Dis Prev Can. 2016;36(11):243–251.
Zaheer J, Jacob B, de Oliveira C, et al. Service utilization and suicide among people with schizophrenia spectrum disorders. Schizophr Res. 2018;202:347–353. PubMed
Schaffer A, Sinyor M, Kurdyak P, et al. Population-based analysis of health care contacts among suicide decedents: identifying opportunities for more targeted suicide prevention strategies. World Psychiatry. 2016;15(2):135–145.
Meerwijk EL, Parekh A, Oquendo MA, et al. Direct versus indirect psychosocial and behavioural interventions to prevent suicide and suicide attempts: a systematic review and meta-analysis. Lancet Psychiatry. 2016;3(6):544–554.
Chung DT, Ryan CJ, Hadzi-Pavlovic D, et al. Suicide rates after discharge from psychiatric facilities: a systematic review and meta-analysis. JAMA Psychiatry. 2017;74(7):694–702.
Chammas F, Januel D, Bouaziz N. Inpatient suicide in psychiatric settings: evaluation of current prevention measures. Front Psychiatry. 2022;13:997974. PubMed
Navin K, Kuppili PP, Menon V, et al. Suicide prevention strategies for general hospital and psychiatric inpatients: a narrative review. Indian J Psychol Med. 2019;41(5):403–412.
Fakhari A, Azizi H, Farahbakhsh M, et al. Effective programs on suicide prevention: combination of review of systematic reviews with expert opinions. Int J Prev Med. 2022;13:39.
Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. PubMed
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. American Psychiatric Publishing; 1980.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd rev ed. American Psychiatric Publishing; 1987.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. American Psychiatric Publishing; 1994.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, Text Rev. American Psychiatric Publishing; 2000.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Publishing; 2013.
Slee VN. The International Classification of Diseases: Ninth Revision (ICD-9). Ann Intern Med. 1978;88(3):424–426. PubMed
World Health Organization. International Statistical Classification of Diseases and Related Health Problems. 10th ed. 2016.
Beck AT, Kovacs M, Weissman A. Assessment of suicidal intention: the Scale for Suicide Ideation. J Consult Clin Psychol. 1979;47(2):343–352.
Posner K, Brown GK, Stanley B, et al. The Columbia–Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011;168(12):1266–1277. PubMed
Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23(1):56–62.
Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry. 1979;134(4):382–389. PubMed
Rush AJ, Trivedi MH, Ibrahim HM, et al. The 16-Item Quick Inventory of Depressive Symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Biol Psychiatry. 2003;54(5):573–583.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613.
Covidence systematic review software. Veritas Health Innovation; 2020. https://www.covidence.org.
Higgins JPT, Altman DG, Gøtzsche PC, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928. PubMed
Burger J, Capobianco M, Lovern R, et al. A double-blinded, randomized, placebo controlled sub-dissociative dose ketamine pilot study in the treatment of acute depression and suicidality in a military emergency department setting. Mil Med. 2016;181(10):1195–1199. PubMed
Domany Y, Shelton RC, McCullumsmith CB. Ketamine for acute suicidal ideation. An emergency department intervention: a randomized, double-blind, placebo controlled, proof-of-concept trial. Depress Anxiety. 2020;37(3):224–233.
Shivanekar S, Gopalan P, Pizon A, et al. A pilot study of ketamine infusion after suicide attempt: new frontiers in treating acute suicidality in a real-world medical setting. Int J Environ Res Public Health. 2022;19(21):13792. PubMed CrossRef
Gaither R, Ranney M, Peachey A, et al. A feasibility study of low-dose ketamine for acute management of suicidal ideation. J Am Coll Emerg Physicians Open. 2022;3(4):e12790. PubMed
Vande Voort JL, Morgan RJ, Kung S, et al. Continuation phase intravenous ketamine in adults with treatment-resistant depression. J Affect Disord. 2016;206:300–304. PubMed
Abbar M, Demattei C, El-Hage W, et al. Ketamine for the acute treatment of severe suicidal ideation: double blind, randomised placebo controlled trial. BMJ. 2022;376:e067194. PubMed
Domany Y, McCullumsmith CB. Single, fixed-dose intranasal ketamine for alleviation of acute suicidal ideation. An emergency department, trans-diagnostic approach: a randomized, double-blind, placebo-controlled, proof-of-concept trial. Arch Suicide Res. 2022;26(3):1250–1265.
Kaur S, Parmar C, Gaur V, et al. The efficacy of oral ketamine in severely depressed patients at high risk of suicide. Asian J Psychiatr. 2023;86:103678. PubMed
Canuso CM, Singh JB, Fedgchin M, et al. Efficacy and safety of intranasal esketamine for the rapid reduction of symptoms of depression and suicidality in patients at imminent risk for suicide: results of a double-blind, randomized, placebo-controlled study. Am J Psychiatry. 2018;175(7):620–630. PubMed
Fu DJ, Ionescu DF, Li X, et al. Esketamine nasal spray for rapid reduction of major depressive disorder symptoms in patients who have active suicidal ideation with intent: double-blind, randomized study (ASPIRE I). J Clin Psychiatry. 2020;81(3):19m13191. PubMed
Ionescu DF, Fu DJ, Qiu X, et al. Esketamine nasal spray for rapid reduction of depressive symptoms in patients with major depressive disorder who have active suicide ideation with intent: results of a phase 3, double-blind, randomized study (ASPIRE II). Int J Neuropsychopharmacol. 2021;24(1):22–31.
Ahmadi J, Jahromi MS, Ehsaei Z. The effectiveness of different singly administered high doses of buprenorphine in reducing suicidal ideation in acutely depressed people with co-morbid opiate dependence: a randomized, double blind, clinical trial. Trials. 2018;19(1):462.
Ahmadi J, Sarani EM, Jahromi MS. Rapid effect of a single-dose buprenorphine on reduction of opioid craving and suicidal ideation: a randomized, double blind, placebo-controlled study. Tzu Chi Med J. 2020;32(1):58–64.
Brecht S, Desaiah D, Marechal ES, et al. Efficacy and safety of duloxetine 60 mg and 120 mg daily in patients hospitalized for severe depression: a double-blind randomized trial. J Clin Psychiatry. 2011;72(8):1086–1094. PubMed
Demyttenaere K, Desaiah D, Raskin J, et al. Suicidal thoughts and reasons for living in hospitalized patients with severe depression: post-hoc analyses of a double-blind randomized trial of duloxetine. Prim Care Companion CNS Disord. 2014;16(3):PCC.13m01591. PubMed
Benedetti F, Riccaboni R, Locatelli C, et al. Rapid treatment response of suicidal symptoms to lithium, sleep deprivation, and light therapy (chronotherapeutics) in drug-resistant bipolar depression. J Clin Psychiatry. 2014;75(2):133–140.
Sahlem GL, Kalivas B, Fox JB, et al. Adjunctive triple chronotherapy (combined total sleep deprivation, sleep phase advance, and bright light therapy) rapidly improves mood and suicidality in suicidal depressed inpatients: an open label pilot study. J Psychiatr Res. 2014;59:101–107.
Lin CH, Chen CC, Huang CJ. Electroconvulsive therapy versus fluoxetine in suicidal resolution for patients with major depressive disorder. J ECT. 2020;36(4):234–241.
Patel M, Patel S, Hardy DW, et al. Should electroconvulsive therapy be an early consideration for suicidal patients? J ECT. 2006;22(2):113–115.
George MS, Raman R, Benedek DM, et al. A two-site pilot randomized 3 day trial of high dose left prefrontal repetitive transcranial magnetic stimulation (rTMS) for suicidal inpatients. Brain Stimul. 2014;7(3):421–431.
Zhang T, Zhu J, Wang J, et al. An open-label trial of adjuvant high-frequency left prefrontal repetitive transcranial magnetic stimulation for treating suicidal ideation in adolescents and adults with depression. J ECT. 2021;37(2):140–146.
Jelinek L, Peth J, Runde A, et al. Metacognitive Training for Depression: feasibility, safety and acceptability of two new treatment modules to reduce suicidality. Clin Psychol Psychother. 2021;28(3):669–681.
Probst T, Decker V, Kießling E, et al. Suicidal ideation and skill use during in patient dialectical behavior therapy for borderline personality disorder. A diary card study. Front Psychiatry. 2018;9:152.
Davidson KM, Brown TM, James V, et al. Manual-assisted cognitive therapy for self-harm in personality disorder and substance misuse: a feasibility trial. Psychiatr Bull (2014). 2014;38(3):108–111.
Diefenbach GJ, Rudd MD, Merling LF, et al. Brief cognitive-behavioral therapy for suicidal inpatients. Cognitive Behav Pract. 2021;28(2):224–240.
Tarrier N, Haddock G, Lewis S, et al. Suicide behaviour over 18 months in recent onset schizophrenic patients: the effects of CBT. Schizophr Res. 2006;83(1):15–27.
Haddock G, Pratt D, Gooding PA, et al. Feasibility and acceptability of suicide prevention therapy on acute psychiatric wards: randomised controlled trial. BJPsych Open. 2019;5(1):e14.
LaCroix JM, Perera KU, Neely LL, et al. Pilot trial of post-admission cognitive therapy: inpatient program for suicide prevention. Psychol Serv. 2018;15(3):279–288.
Ghahramanlou-Holloway M, LaCroix JM, Perera KU, et al. Inpatient psychiatric care following a suicide-related hospitalization: a pilot trial of Post-Admission Cognitive Therapy in a military medical center. Gen Hosp Psychiatry. 2020;63:46–53.
Cha CB, Najmi S, Amir N, et al. Testing the efficacy of attention bias modification for suicidal thoughts: findings from two experiments. Arch Suicide Res. 2017;21(1):33–51.
Bentley KH, Sauer-Zavala S, Cassiello-Robbins CF, et al. Treating suicidal thoughts and behaviors within an emotional disorders framework: acceptability and feasibility of the unified Protocol in an inpatient setting. Behav Modif. 2017;41(4):529–557.
Bentley KH, Sauer-Zavala S, Stevens KT, et al. Implementing an evidence-based psychological intervention for suicidal thoughts and behaviors on an inpatient unit: process, challenges, and initial findings. Gen Hosp Psychiatry. 2020;63:76–82.
Herrmann TS, Nazarenko E, Marchand W, et al. Randomized controlled trial of a brief mindfulness-based intervention for suicidal ideation among veterans. Mil Med. 2024;189(3–4):732–741. PubMed
Vaslamatzis G, Theodoropoulos P, Vondikaki S, et al. Is the residential combined (psychotherapy plus medication) treatment of patients with severe personality disorder effective in terms of suicidality and impulsivity? J Nerv Ment Dis. 2014;202(2):138–143.
Fowler JC, Clapp JD, Madan A, et al. A naturalistic longitudinal study of extended inpatient treatment for adults with borderline personality disorder: an examination of treatment response, remission and deterioration. J Affect Disord. 2018;235:323–331. PubMed
Ross CA, Haley C. Acute stabilization and three-month follow-up in a trauma program. J Trauma Dissociation. 2004;5(1):103–112.
Menefee DS, Leopoulos WS, Tran JK, et al. Inpatient trauma-focused treatment for veterans: implementation and evaluation of patient perceptions and outcomes of an integrated evidence-based treatment approach. Mil Med. 2016;181(11):e1590–e1599. PubMed
Britton PC, Conner KR, Maisto SA. An open trial of motivational interviewing to address suicidal ideation with hospitalized veterans. J Clin Psychol. 2012;68(9):961–971.
Britton PC, Conner KR, Chapman BP, et al. Motivational interviewing to address suicidal ideation: a randomized controlled trial in veterans. Suicide Life Threat Behav. 2020;50(1):233–248.
Ducasse D, Dassa D, Courtet P, et al. Gratitude diary for the management of suicidal inpatients: a randomized controlled trial. Depress Anxiety. 2019;36(5):400–411.
O’Connor RC, Ferguson E, Scott F, et al. A brief psychological intervention to reduce repetition of self-harm in patients admitted to hospital following a suicide attempt: a randomised controlled trial. Lancet Psychiatry. 2017;4(6):451–460.
Pfeiffer PN, King C, Ilgen M, et al. Development and pilot study of a suicide prevention intervention delivered by peer support specialists. Psychol Serv. 2019;16(3):360–371.
Zatzick D, Jurkovich G, Heagerty P, et al. Stepped collaborative care targeting posttraumatic stress disorder symptoms and comorbidity for us trauma care systems: a randomized clinical trial. JAMA Surg. 2021;156(5):430–474.
Engstrom A, Moloney K, Nguyen J, et al. A pragmatic clinical trial approach to assessing and monitoring suicidal ideation: results from a national US trauma care system study. Psychiatry. 2022;85(1):13–29.
Jun WH, Lee EJ, Park JS. Effects of a suicide prevention programme for hospitalised patients with mental illness in South Korea. J Clin Nurs. 2014;23(13–14):1845–1856.
Ellis TE, Green KL, Allen JG, et al. Collaborative assessment and management of suicidality in an inpatient setting: results of a pilot study. Psychotherapy. 2012;49(1):72–80.
Ellis TE, Rufino KA, Allen JG, et al. Impact of a suicide-specific intervention within inpatient psychiatric care: the collaborative assessment and management of suicidality. Suicide Life Threat Behav. 2015;45(5):556–566.
Ellis TE, Rufino KA, Allen JG. A controlled comparison trial of the Collaborative Assessment and Management of Suicidality (CAMS) in an inpatient setting: outcomes at discharge and six-month follow-up. Psychiatry Res. 2017;249:252–260. PubMed
O’Connor SS, Comtois KA, Wang J, et al. The development and implementation of a brief intervention for medically admitted suicide attempt survivors. Gen Hosp Psychiatry. 2015;37(5):427–433.
O’Connor SS, Mcclay MM, Choudhry S, et al. Pilot randomized clinical trial of the Teachable Moment Brief Intervention for hospitalized suicide attempt survivors. Gen Hosp Psychiatry. 2020;63:111–118.
Bahlmann L, Lübbert MBJS, Sobanski T, et al. Relapse Prevention Intervention after Suicidal Event (RISE): feasibility study of a psychotherapeutic short-term program for inpatients after a recent suicide attempt. Front Psychiatry. 2022;13:937527. PubMed
Dadiomov D, Lee K. The effects of ketamine on suicidality across various formulations and study settings. Ment Health Clin. 2019;9(1):48–60.
Cameron CM, Nieto S, Bosler L, et al. Mechanisms underlying the anti-suicidal treatment potential of buprenorphine. Adv Drug Alcohol Res. 2021;1:10009. PubMed
Weissman CR, Hadas I, Yu D, et al. Predictors of change in suicidal ideation across treatment phases of major depressive disorder: analysis of the STAR*D data. Neuropsychopharmacol. 2021;46(7):1293–1299.
Kaster TS, Vigod SN, Gomes T, et al. Risk of serious medical events in patients with depression treated with electroconvulsive therapy: a propensity score matched, retrospective cohort study. Lancet Psychiatry. 2021;8(8):686–695.