The mainstay of acute mania treatment for schizoaffective disorder, bipolar type (SAD-BT) patients includes the use of antipsychotic therapy combined with one of the two first-line mood stabilizers lithium or a form of valproic acid (VPA) (e.g. divalproex) [1, 2]. In controled acute mania studies with bipolar I patients, response rates to monotherapy with antipsychotics, lithium or VPA are comparable and roughly 50% [2]. While carbamazepine can be used for maintenance treatment, and has been studied in acute mania, rapid titration is poorly tolerated due to central nervous system (CNS) adverse effects such as sedation, dizziness, ataxia, and nausea, and thus should be avoided unless treatment with lithium or VPA is contraindicated [3]. As an inducer of cytochrome P450 (CYP) enzymes and the drug transporter P-glycoprotein (PGP), carbamazepine may reduce antipsychotic levels by 30–80% and thus presents a source of kinetic interaction than can be problematic during acute and maintenance treatment [4]. Carbamazepine is also associated with hyponatremia [1]. Other anticonvulsants have been studied for acute mania and have been found to be ineffective, including gabapentin, lamotrigine, licarbazepine, oxcarbazepine, and topiramate [2].

Typical or first-generation antipsychotic (FGA)

The current scientifically informed view of suicide is that, while complex, suicide is a health-related outcome. Driven by a convergence of health factors along with other psychosocial and environmental factors, suicide risk is multifactorial. Like most health outcomes, a set of genetic, environmental, and psychological/behavioral factors are relevant. It is critically important that health professionals develop a current understanding of suicide as older views have permeated and clouded societal understanding leading to assumptions and judgment that have silenced generations of people suffering suicidal struggles or loss of a loved one to suicide.

For which patients does this guidance apply? These principles should be applied in clinical decision making for a broader group of patients than just those with expressed suicidal ideation. Suicide risk includes any patients with elevated risk, many of whom do not present with a chief complaint of suicidal ideation. Their risk may be identified by a recent suicide attempt, or by a family history of suicide along with current psychosocial stressors, or the patient facing a life transition or loss along with deterioration in clinical status. (See Suicide Risk Assessment in Chapter 6). At the broadest level, current clinical standards (including those of The Joint Commission which is based in the USA but accredits health systems in the USA and internationally) consider all patients being treated in behavioral healthcare settings (psychiatric inpatient and outpatient care, psychological therapy, substances use disorder treatment, etc.) as having potentially elevated suicide risk.

The science of suicide risk and prevention is growing, making one thing very clear. While suicide risk involves a complex set of risk factors, the end common pathway is a life-threatening health crisis. As is the case with all health-related causes of death, a robust public health strategy can reduce mortality. This chapter provides a framework for understanding the public health approach to preventing suicide. Examples of effective public health suicide prevention strategies at national and regional levels are provided.

When engaging with persons at risk for suicide, healthcare professionals have an opportunity to make a real difference in the life of the patient. However, the situation can place a great deal of pressure on those trying to help. When dealing with a person struggling with suicidal thoughts, a variety of concerns might arise

The proportion of time a person spends in direct contact with a health professional is minute. We can make the most of our direct encounters by following best practices for connection, assessment and respond described in Chapters 5, 6, and 7. But ultimately, we must also consider how to extend the impact of our interventions beyond our healthcare environment into the lives and networks of the people we serve.

Cultural factors including conscious and unconscious beliefs and attitudes have an influence on suicide risk for individuals, families, and populations. Science shows clearly that suicide risk draws on multiple risk and protective factors at the individual and environmental levels. By understanding how particular beliefs and stigma may impact suicide risk, healthcare professionals can communicate more effectively with patients from different cultural backgrounds for the purpose of both risk assessment and patient care. For example, eliciting the patient’s perspectives about particular life challenges, about mental healthcare, and even about suicide itself, can be useful in engaging the patient in both self-care and treatment planning.