Article

Brief Cognitive-Behavioral Therapy Effects on Post-Treatment Suicide Attempts in a Military Sample: Results of a Randomized Clinical Trial With 2-Year Follow-Up

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Abstract

Objective: The authors evaluated the effectiveness of brief cognitive-behavioral therapy (CBT) for the prevention of suicide attempts in military personnel. Method: In a randomized controlled trial, active-duty Army soldiers at Fort Carson, Colo., who either attempted suicide or experienced suicidal ideation with intent, were randomly assigned to treatment as usual (N=76) or treatment as usual plus brief CBT (N=76). Assessment of incidence of suicide attempts during the follow-up period was conducted with the Suicide Attempt Self-Injury Interview. Inclusion criteria were the presence of suicidal ideation with intent to die during the past week and/or a suicide attempt within the past month. Soldiers were excluded if they had a medical or psychiatric condition that would prevent informed consent or participation in outpatient treatment, such as active psychosis or mania. To determine treatment efficacy with regard to incidence and time to suicide attempt, survival curve analyses were conducted. Differences in psychiatric symptoms were evaluated using longitudinal random-effects models. Results: From baseline to the 24-month follow-up assessment, eight participants in brief CBT (13.8%) and 18 participants in treatment as usual (40.2%) made at least one suicide attempt (hazard ratio=0.38, 95% CI=0.16-0.87, number needed to treat=3.88), suggesting that soldiers in brief CBT were approximately 60% less likely to make a suicide attempt during follow-up than soldiers in treatment as usual. There were no between-group differences in severity of psychiatric symptoms. Conclusions: Brief CBT was effective in preventing follow-up suicide attempts among active-duty military service members with current suicidal ideation and/or a recent suicide attempt.

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... Dieser Effekt wird dabei von 4 der 10 in die Analyse eingeschlossenen Behandlungsansätze getragen: Einer kurzen psychodynamischen Therapie, die 4 Sitzungen umfasst und auf die Klärung interpersoneller Schwierigkeiten fokussiert [9]; dem Attempted Suicide Short Intervention Programm (ASSIP; [10,11]), einer 3-4 Sitzungen umfassenden Kurzintervention zur Aufarbeitung eines zurückliegenden Suizidversuchs und der kognitiven Therapie für suizidale Patienten (KT-SP; [12]) bzw. der kurzen kognitiven Verhaltenstherapie zur Suizidprävention (KVT-SP; [13]). Die beiden zu letzt genannten Verfahren weisen hinsichtlich Behandlungsstruktur und Methodenauswahl so erhebliche Übereinstimmungen auf, dass man die Therapiestudie von Rudd et al. [13] als Replikationsstudie zur Untersuchung von Brown et al. [12] verstehen kann. ...
... der kurzen kognitiven Verhaltenstherapie zur Suizidprävention (KVT-SP; [13]). Die beiden zu letzt genannten Verfahren weisen hinsichtlich Behandlungsstruktur und Methodenauswahl so erhebliche Übereinstimmungen auf, dass man die Therapiestudie von Rudd et al. [13] als Replikationsstudie zur Untersuchung von Brown et al. [12] verstehen kann. Folgt man dieser Interpretation, so handelt es sich bei dem beschriebenen Therapieprogramm um eines der wenigen Psychotherapieverfahren für suizidale Patienten, dessen Effektivität sich in einer Replikationsstudie bestätigen ließ und zu dem Therapiemanuale vorliegen [14,15]. ...
... Im 18 Monate währenden Untersuchungszeitraum fand sich eine um nahezu 50 % geringere Rate an Suizidversuchen in der Behandlungsgruppe im Vergleich zur Standardbehandlung (24 % KT vs. 42 % TAU). In der Untersuchung von Rudd et al. [13] erhielten 152 Soldaten entweder eine KVT-SP oder Standardbehandlung. Im 24 Monate währenden Untersuchungszeitraum fand sich eine um nahezu 60 % geringere Rate an Suizidversuchen in der Behandlungsgruppe im Vergleich zur TAU-Bedingung (14 % KVT vs. 40 % TAU). ...
Article
ZUSAMMENFASSUNG Suizidversuche gelten als einer der wichtigsten Risikofaktoren für Suizide. Vor diesem Hintergrund wurden in den vergangenen Jahren verschiedene Psychotherapieangebote für Personen nach einem Suizidversuch entwickelt und evaluiert. Im Rahmen des Artikels wird der Stand der Effektivitätsforschung skizziert, ein Beispiel für ein wirksames suizidfokussiertes Psychotherapieprogramm wird vorgestellt und der gegenwärtige Forschungs- und Wissenstand wird kritisch reflektiert. Grundsätzlich kommt der suizidspezifischen Psychotherapie in der individuumzentrierten Suizidprävention besondere Bedeutung zu; die empirische Fundierung und Dissemination entsprechender Programme ist jedoch noch unzureichend. ABSTRACT Suicide attempts are considered one of the most important risk factors for suicide. Against this background, various psychotherapeutic treatments for people after a suicide attempt have been developed and evaluated in recent years. In this article, the current evidence from efficacy research is summarized, an example of an effective suicide-focused psychotherapy program is presented, and the current state of research and knowledge is critically reflected. In principle, suicide-specific psychotherapy is of particular importance in individual-centered suicide prevention; however, the empirical foundation and dissemination of specific treatments is still insufficient.
... 2. Brief Cognitive Behavioural Therapy (CBT) for Suicide Prevention -is a manualised approach involving brief CBT for suicide in six 60-minute sessions. The intervention incorporates skills development and emphasises internal self-management (24,25). ...
... A systematic review of the evidence on CBT concluded that it was effective in reducing self-harm behaviour and repeated suicide attempts in fewer than 10 individual sessions in patients who had made a previous suicide attempt (39). Brief CBT for Suicide Prevention compared to conventional CBT has the advantage of being more cost effective and time e cient (24). ...
... Elements of both these manuals were taken to create the brief CBT for Suicide Prevention manual used for this study. The brief CBT for Suicide Prevention incorporates skills development and emphasises internal self-management (24). The therapy focuses on the identi cation of internal, external and/or thematic triggers for suicidal thinking and behaviours, as well as factors that maintain the desire to suicide, using thought records and/or chain analyses. ...
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Background Despite being preventable, suicide is a leading cause of death and a major global public health problem. For every death by suicide, many more suicide attempts are undertaken, and this presents as a critical risk factor for suicide. Currently there are limited treatment options with limited underpinning research for those who present to Emergency Departments with suicidal behaviour. The aim of this study is to assess if adding one of two structured suicide specific psychological interventions (Attempted Suicide Short Intervention Program [ASSIP] or Brief Cognitive Behavioural Therapy [CBT] for Suicide Prevention) to a standardised clinical care approach (Suicide Prevention Pathway [SPP]) improves outcomes for consumers presenting to a Mental Health Service with a suicide attempt. Methods This is a randomised controlled trial with blinding of those assessing the outcomes. People who attempt suicide or experience suicidality after a suicide attempt, present to the Gold Coast Mental Health and Specialist Services, are placed on the Suicide Prevention Pathway (SPP) and meet the eligibility criteria, are offered the opportunity to participate. A total of 411 participants will be recruited for the study, with 137 allocated to each cohort (participants are randomised to SPP, ASSIP + SPP, or CBT + SPP). The primary outcomes of this study are re-presentation to hospital with suicide attempt and/or suicidal ideations. Death by suicide rates will also be examined. Self-reported level of suicidality, depression, anxiety, stress, resilience, problem-solving skills, self- and therapist-reported level of therapeutic engagement are also being examined. Psychometric data are collected at baseline, end of interventions, 6,12, and 24 months. Discussion This project will move both ASSIP and Brief CBT from efficacy to effectiveness research, with clear aims of assessing the addition of two structured psychological interventions to treatment as usual, providing a cost-benefit analysis of the interventions, thus delivering outcomes providing a clear pathway for rapid translation of successful interventions. Trials registration : NCT04072666 - Registered on 28th August 2019 on Clinical Trials US Gov (https://www.clinicaltrials.gov/ct2/show/NCT04072666?term=NCT04072666&draw=2&rank=1) and ANZCTR (https://www.anzctr.org.au/TrialSearch.aspx)
... Dentro dessa abordagem há a possibilidade de, ao longo de 12 sessões, terapeuta e paciente analisarem os fatores que podem desencadear a crise, e com isso elaborar um plano de tratamento no qual se pode agir em resposta à crise praticando habilidades de regulação emocional e reduzindo as cognições associadas ao comportamento suicida. Rudd et al. (2015) demonstram em sua pesquisa a efetividade da TCC breve na prevenção de tentativas de suicídio junto a membros do serviço militar ativos com ideação suicida atual e/ou tentativa de suicídio recente. ...
... Além da psicoeducação, foi utilizado também: termômetro emocional; monitoramento de humor; tarefa de casa; ativação comportamental; resolução de problemas; regulação emocional; plano de prevenção de recaídas e processamento de emoções/reações ao tratamento e término (Asarnow et al. 2015). Além das técnicas mencionadas Rudd et al. (2015), relatam a importância de se elaborar uma conceituação cognitiva colaborativamente ao paciente, e o uso de técnicas de relaxamento e mindfulness. ...
... O uso da TCC Breve se mostrou mais efetiva em comparação com o tratamento usual para soldados suicidas no Exército dos EUA, o qual ao longo de 12 sessões, o terapeuta e o paciente buscaram analisar os fatores precipitantes da crise, que são eles os pensamentos suicidas e tentativas anteriores. Todavia, o marcador mais expressivo ao tratamento é a redução na incidência de tentativas após o início do acompanhamento terapêutico, vale salientar a importância de criar e praticar um plano de resposta à crise, além de praticar habilidades de regulação emocional e reduzir as cognições associadas aos comportamentos suicidas (Bernecker et al. 2020;Rudd et al., 2015). Rudd et al. (2015), encontraram resultados significativos no que se refere ao uso da TCC breve em que os participantes eram significativamente menos propensos a realizarem uma tentativa de suicídio durante o acompanhamento do que os participantes que apenas receberam o tratamento habitual. ...
Article
Full-text available
O suicídio é um fenômeno complexo, um problema de saúde pública mundial. De acordo com a Organização Mundial da Saúde (OMS), 800 mil pessoas morrem por ano em todo o mundo. Torna-se imprescindível salientar que não somente a ideação suicida e a intenção suicida são unicamente características centrais de uma atual crise suicida como também podem estar relacionadas à uma maior probabilidade de o indivíduo vir à morte por suicídio. A Terapia Cognitivo Comportamental (TCC) é um modelo de tratamento terapêutico estruturado, de curta duração e parte da perspectiva que o pensamento influencia o sentimento, que por sua vez, influencia o comportamento. Assim ao identificarem crenças relacionadas ao suicídio, maior a probabilidade de uma intervenção clínica eficaz. Trata-se de uma revisão sistemática integrativa da literatura na Biblioteca Virtual em Saúde (BVS) e PubMed, usando os descritores “Cognitive Behavioral Therapy”, “Suicide, Attempted”, “Psychology, Clinical” no período temporal de 2011 a 2021. Foram selecionados 04 artigos científicos que abordaram acerca do suicídio e incluíram a TCC como uma variável em suas pesquisas, sendo composto por três ensaios clínicos randomizados e um estudo de modelo analítico de decisão. Foram encontrados enquanto resultados que a TCC voltada para pacientes com ideação e/ou tentativa de suicídio teve uma média geral de 12 sessões. Compreendendo o papel protetor que pode ser desempenhado pela família/comunidade, verificou-se que é uma abordagem que tem apresentado resultados eficazes em uma curta duração.
... Suicide Prevention is a manualised approach involving brief CBT for suicide in six 60-min sessions. The intervention incorporates skills development and emphasises internal self-management [24,25]. ...
... A systematic review of the evidence on CBT concluded that it was effective in reducing self-harm behaviour and repeated suicide attempts in fewer than 10 individual sessions in patients who had made a previous suicide attempt [40]. Brief CBT for suicide prevention compared to conventional CBT has the advantage of being more cost-effective and time-efficient [24]. ...
... The elements of both these manuals were taken to create the Brief CBT for Suicide Prevention manual used for this study. The Brief CBT for Suicide Prevention incorporates skills development and emphasises internal self-management [24]. The therapy focuses on the identification of internal, external, and/or thematic triggers for suicidal thinking and behaviours, as well as factors that maintain the desire to suicide, using thought records and/or chain analyses. ...
Article
Full-text available
Background Despite being preventable, suicide is a leading cause of death and a major global public health problem. For every death by suicide, many more suicide attempts are undertaken, and this presents as a critical risk factor for suicide. Currently, there are limited treatment options with limited underpinning research for those who present to emergency departments with suicidal behaviour. The aim of this study is to assess if adding one of two structured suicide-specific psychological interventions (Attempted Suicide Short Intervention Program [ASSIP] or Brief Cognitive Behavioural Therapy [CBT] for Suicide Prevention) to a standardised clinical care approach (Suicide Prevention Pathway [SPP]) improves the outcomes for consumers presenting to a Mental Health Service with a suicide attempt. Methods This is a randomised controlled trial with blinding of those assessing the outcomes. People who attempt suicide or experience suicidality after a suicide attempt, present to the Gold Coast Mental Health and Specialist Services, are placed on the Suicide Prevention Pathway (SPP), and meet the eligibility criteria, are offered the opportunity to participate. A total of 411 participants will be recruited for the study, with 137 allocated to each cohort (participants are randomised to SPP, ASSIP + SPP, or CBT + SPP). The primary outcomes of this study are re-presentation to hospitals with suicide attempts. Presentations with suicidal ideation will also be examined (in a descriptive analysis) to ascertain whether a rise in suicidal ideation is commensurate with a fall in suicide attempts (which might indicate an increase in help-seeking behaviours). Death by suicide rates will also be examined to ensure that representations with a suicide attempt are not due to participants dying, but due to a potential improvement in mental health. For participants without a subsequent suicide attempt, the total number of days from enrolment to the last assessment (24 months) will be calculated. Self-reported levels of suicidality, depression, anxiety, stress, resilience, problem-solving skills, and self- and therapist-reported level of therapeutic engagement are also being examined. Psychometric data are collected at baseline, end of interventions, and 6,12, and 24 months. Discussion This project will move both ASSIP and Brief CBT from efficacy to effectiveness research, with clear aims of assessing the addition of two structured psychological interventions to treatment as usual, providing a cost-benefit analysis of the interventions, thus delivering outcomes providing a clear pathway for rapid translation of successful interventions. Trials registration ClinicalTrials.gov NCT04072666 . Registered on 28 August 2019
... As noted in a separate recommendation below, this is coupled with a commitment to be proactive in identifying and overcoming barriers to care, rather than simply waiting for problems to emerge that ultimately increase the probability of withdrawal from treatment. There are a range of therapeutic approaches and perspectives in the treatment literature on how best to accomplish informed consent and organize this initial dialogue and intervention, among the most frequently cited are dialectical behavior therapy (DBT) (11), cognitive therapy for suicide prevention (CT-SP) (12), brief cognitive behavioral therapy for suicide prevention (BCBT-SP) (13,14), attempted suicide short intervention program (ASSIP) (15), and the collaborative assessment and management of suicidality (CAMS) (16). ...
... It is important to note that any discussion targeting treatment hesitancy also creates an opportunity for development of a brief crisis management plan, including means safety steps, even if a decision is made to opt out of care. Specifically, discussion of the limited duration of treatment can be highly motivating [e.g., (4,(9)(10)(11)(12)(13)(14) sessions of suicide-focused care] (16). ...
... Although the majority of RCT's that have been effective in reducing suicidal thinking and/or suicide attempts employ models often described or labeled as cognitivebehavioral in orientation, the underlying principles and clinical strategies used in these treatments are not unique to this single theoretical perspective. As noted above, examples of frequently cited treatment approaches utilized in RCT's are Linehan's (11) dialectical behavior therapy, Jobes' CAMS (16,20), CBT-SP (12), brief cognitive behavioral therapy (13,14,21), and Attempted Suicide Short Intervention Program (ASSIP) (15). Most (arguably all) of these treatment approaches employ interventions and strategies that target self-regulatory processes, especially strategies designed to improve the patient's ability to recognize and change aversive and dysregulated emotional states. ...
Article
Full-text available
The last several decades have witnessed growing and converging evidence from randomized controlled trials (RCT’s) that an identifiable set of simple clinical management strategies are effective for those at risk for suicidal thinking and/or suicide attempts. The current article offers a brief review of clinical strategies supported by RCT’s targeting suicidality as “commonalities of treatments that work” and related recommendations for use in the delivery of care for suicidal individuals in generic fashion, regardless of any particular treatment, theoretical orientation, or intervention perspective. The article includes eight recommendations that can be easily adapted across the full range of clinical contexts, institutional settings, and delivery systems, recommendations that help frame a broader clinical narrative for suicide prevention. Recommendations cut across five identifiable domains or clinical strategies for the delivery of care: (1) informed consent discussion that identifies risks of opting out of care and emphasizes the importance of shared responsibility and a collaborative process, (2) an explanatory model that emphasizes the importance of individual self-management skills and targeting the causes of suicide rather than describing suicidality as a function of mental illness, (3) the importance of proactively identifying barriers to care and engaging in targeted problem-solving to facilitate treatment adherence, (4) a proactive and specific plan for management of future suicidal episodes, and (5) reinforcing the importance of taking steps to safeguard lethal means and facilitate safe storage of firearms.
... Cognitive behavioral therapy (CBT) is an effective treatment for a wide range of emotional disorders and concerns, such as depression, anxiety, and suicidal thoughts and behaviors (Butler, Chapman, Forman, & Beck, 2006;Karlin & Cross, 2014;National Institute for Health and Clinical Excellence, 2011;Rudd et al., 2015;Williams & Martinez, 2008). It is also arguably the most extensively researched, in-demand, and efficacious psychological treatment. ...
... Given the well-established association between suicidal thoughts and behaviors and emotion dysregulation (e.g., Turton et al., 2021), and that the vast majority of individuals who experience suicidal thoughts and behaviors meet criteria for at least one emotional disorder (e.g., depression, posttraumatic stress disorder, anxiety) (e.g., Bentley et al., 2016;Nock, Hwang et al., 2009;Nock et al., 2010;Nordentoft et al., 2011), participants were strong candidates for transdiagnostic, emotion-focused CBT strategies aimed to improve adaptive emotion management., Moreover, CBT-based approaches have been shown to be effective interventions for suicidal and nonsuicidal self-injurious thoughts and behaviors (Tarrier, Taylor, & Gooding, 2008;D'Anci, Uhl, Giradi, & Martin, 2019) and are gaining increasing evidential support as brief interventions for inpatient units (e.g., Diefenbach et al., 2021;Rudd et al., 2015;Nawaz, Reen, Bloodworth, Maughan, & Vincent, 2021). The three transdiagnostic CBT skills included in this intervention-mindful emotional awareness, cognitive restructuring, and opposite action-also appear as key components of other evidence-based treatments for suicidal thoughts and behaviors (e.g., mindfulness and opposite action in Dialectical Behavior Therapy, cognitive restructuring in Cognitive Therapy for Suicide Prevention). ...
Article
The practice of therapeutic skills outside of sessions in which they are learned is one presumed key component of cognitive behavioral therapy (CBT). Yet, our understanding of how skills practice relates to clinical outcomes remains limited. Here, we explored patients’ emotional responses to CBT skills practices in a pilot study pairing smartphone app-delivered skills reminders and guided practice (ecological momentary intervention [EMI]) using ecological momentary assessment (EMA). Participants (n = 25) were adults recently hospitalized for a suicide attempt or severe suicidal thinking. They received brief inpatient CBT (1 to 3 sessions covering core CBT skills from the Unified Protocol), followed by one month of EMI and EMA after discharge. On average, participants reported modest reductions in negative affect after skills use (i.e., immediate responses; median time elapsed = 4.30 minutes). Additionally, participants tended to report less negative affect when the timepoint preceding the current assessment included EMI skills practice, rather than EMA alone (i.e., delayed responses; median time elapsed between prompts = 2.17 hours). Immediate effects were unrelated to longer-term clinical outcomes, whereas greater delayed effects were associated with lower symptom severity at follow-up. Future studies should further examine how CBT skills use in daily life may alleviate symptoms.
... If alternative treatments for individuals with PTSD or trauma-related symptoms who are at increased risk for suicide are used, it is plausible that suicide specific clinical guidelines would be followed. The VA/DOD clinical practice guidelines for the assessment and management of patients at risk for suicide (2019) cite strong evidence for the recommendation of managing and treating suicidality with cognitive behavioral interventions focused on suicide prevention, such as Cognitive Therapy for Suicide Prevention (CT-SP; Brown et al., 2005) and Brief Cognitive Behavior Therapy for Suicide (BCBT; Rudd et al., 2015). Although other treatments such as Dialectical Behavior Therapy (DBT; Linehan, 2014), Crisis Response Planning or Safety Planning Intervention (CRP/SPI; Bryan et al., 2017, Stanley & Brown, 2012, and problemsolving based psychotherapies (Salkovskis et al., 1990) are recommended in these guidelines, the evidence is not as strong for these therapies as it is for CT-SP and BCBT. ...
... One study examined BCBT only (Rudd et al., 2015), which showed reductions in both PTSD-and suicide-related symptoms for active duty military personnel. Specifically, participants in the BCBT group compared to treatment as usual were 60% less likely to have a suicide attempt during the two year follow-up period, and there was a significant difference between groups in suicide attempts at 6 months follow-up. ...
Article
Full-text available
Posttraumatic stress disorder (PTSD) is a well-established risk factor for suicidal thoughts and behaviors. Historically, guidelines for treating PTSD have recommended against the use of trauma-focused therapies with patients who are high-risk for suicide likely due to concerns about potential suicide-related iatrogenesis, specifically the “triggering” of suicidal behaviors. This systematic review examines evidence for the impact of treatments specifically designed to treat PTSD or suicide on both PTSD- and suicide-related outcomes. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed and a total of 33 articles met full inclusion criteria, of which 23 examined PTSD treatments, 4 examined suicide-focused treatments, and 6 examined combined treatments. PTSD and combined treatments reduced both PTSD- and suicide-related outcomes, with most studies examining Cognitive Processing Therapy or Prolonged Exposure. Suicide-focused treatments (e.g., cognitive therapies for suicide prevention) also reduced suicide-related outcomes, but findings were mixed for their impact on PTSD-related outcomes. Overall, PTSD treatments had the most support, primarily due to a larger number of studies examining their outcomes. This supports current clinical guidelines, which suggest utilizing PTSD treatments for individuals at risk for suicide and who have PTSD. Suicide-focused and combined treatments also appeared to be promising formats although additional research is needed. Future research should seek to compare the effectiveness of the approaches to the treatment of PTSD and suicidal thoughts and behaviors concurrently, as well as to inform guidelines aimed at supporting decisions about the selection of an appropriate treatment approach.
... Specifically, because hopelessness is significantly associated with affective forecasting errors such as overestimating future negative events (e.g., likelihood of frequency, likelihood of value) and underestimating future positive events (Macleod et al., 2005;Marroquín et al., 2013;Marroquín & Nolen-Hoeksema, 2015), we sought to understand if hopelessness might act as a proxy for affective forecasting and display similar errors in predicting future outcomes. We investigated this question by using data from two randomized clinical trials (Bryan et al., 2017;Rudd et al., 2015). Both samples consisted of military personnel presenting for emergency behavioral health appointments. ...
... The following secondary analyses were conducted on 152 active-duty military personnel participating in a randomized controlled trial (see Rudd et al., 2015). 2 Inclusion criteria included military personnel at elevated suicide risk, specifically having suicidal ideation with intent to die within the past week or a recent suicide attempt (i.e., in the past month). ...
Article
Full-text available
Background Forecasts about the future can dictate actions and behaviors performed in the present moment. Given that periods of elevated acute suicide risk often consist of elevated negative affect and hopelessness, individuals during these periods may more bias-prone and make decisions (e.g., suicide attempts) based on inaccurate affective forecasts about their futures (e.g., overestimating future pain/psychiatric symptom severity). The aim of this study was to examine the accuracy of hopelessness in predicting future feelings—an important step for understanding possible decision-making biases that may occur near elevated periods of acute suicide risk. Methods Secondary longitudinal data analyses were performed on two randomized clinical trial samples of active-duty military personnel (Ns = 97 and 172) with past-week suicide ideation and/or a lifetime suicide attempt history. Results Results were consistent with the affective forecasting literature; in both samples, individuals overestimated future pain. Conclusions Results from two studies offer preliminary evidence for the existence of affective forecasting errors near the time of a suicide attempt/during periods of elevated suicide risk.
... PHP treatment includes a combination of psychotherapy, pharmacotherapy, vocational counseling, peer support, and aftercare planning. Psychotherapy includes evidence-based care drawing primarily from cognitive behavior therapy, dialectical behavior therapy, and acceptance and commitment therapy, each of which is associated with reductions in suicide risk (Barnes et al., 2017;Linehan et al., 2015;Rudd et al., 2015). Treatment occurs Monday through Friday; patients attend, on average, five 50-min psychotherapy groups per day. ...
Article
The Depressive Symptom Index-Suicidality Subscale (DSI-SS) is a four-item self-report measure of suicidal ideation severity widely used across research and clinical contexts. However, the psychometric properties of the English-language version of the DSI-SS have not been extensively examined within a psychiatric sample, and important properties of this scale (e.g., sensitivity to change) have yet to be examined. Within a sample of 448 adult psychiatric patients enrolled in a partial hospital program (PHP), we examined several measurement properties of the DSI-SS, including its factor structure, internal consistency, validity, and sensitivity to change, as well as the presence of differential item functioning (DIF). Confirmatory factor analysis that specified a one-factor model indicated that the DSI-SS had good model fit. DSI-SS scores demonstrated good internal consistency, ω = .90 [95% CI = .89-.91], convergent validity (rs = .52-.74), discriminant validity (rs = .12-.27), and sensitivity to change. None of the four DSI-SS items evinced statistically significant DIF across age, gender, sexual orientation, or PHP referral source (i.e., outpatient step-up vs. inpatient step-down). These findings suggest that the DSI-SS is a psychometrically sound self-report measure that can be used in real-world clinical settings and research contexts to reliably and validly assess suicidal ideation severity. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... PB einen stabilen Prädiktor suizidalen Erlebens und Verhaltens darstellt [Chu et al., 2017;Forkmann, 2021], könnte der Einsatz der IHS in Ergänzung zum INQ sinnvoll sein, um ein gemeinsames Assessment aller Konstrukte der Interpersonalen Theorie suizidalen Verhaltens zu ermöglichen. Allgemeine Hoffnungslosigkeit kann durch psychotherapeutische Interventionen reduziert werden [Rush et al., 1981;Brown et al., 2005;Rudd et al., 2015]. Hagan et al. [2016] gehen zudem davon aus, dass Hoffnung in Bezug auf eine interpersonale Variable (z.B. ...
Article
b> Hintergrund: Angesichts des angenommenen Einflusses interpersonaler Hoffnungslosigkeit für die Entstehung aktiver Suizidgedanken, wie von der Interpersonalen Theorie Suizidalen Verhaltens [Joiner. Why people die by suicide. 2005] postuliert, zielt diese Studie darauf ab, erstmals eine deutsche Version der Interpersonalen Hoffnungslosigkeitsskala [IHS; Tucker et al. Psychiatry Res. 2018;259:427–32], die IHS-d, vorzustellen und psychometrisch zu überprüfen. Material und Methoden: N = 437 Teilnehmende (75.1% weiblich) zwischen 18 und 71 Jahren (M = 29.75, SD = 11.25) nahmen an einer querschnittlichen Online-Studie teil. Die Faktorstruktur der IHS-d wurde mittels konfirmatorischer Faktorenanalyse überprüft. Zusätzlich wurden Konstruktvalidität und Reliabilität evaluiert. Ergebnis: Es ergab sich eine signifikant bessere Datenpassung für ein 2-Faktor-Modell als für das 1-Faktor-Modell. Die identifizierten Subskalen (Interpersonale Hoffnungslosigkeit hinsichtlich perceived burdensomeness und hinsichtlich thwarted belongingness) erzielten hohe Faktorladungen ≥0.75; Inter-Item-Korrelationen, r ≥ 0.60, Item-Skala-Korrelationen, r <sub> it </sub> ≥ 0.71 und interne Konsistenzen, α <sub> PB </sub> = 0.93; α <sub> TB </sub> = 0.92. Diskussion: Die postulierte einfaktorielle Struktur der englischen Version konnte für die IHS-d nicht reproduziert werden. Die beiden identifizierten Subskalen zeigten jedoch gute psychometrische Eigenschaften. Schlussfolgerung: Der Einsatz der IHS-d erweitert die Möglichkeiten der Messung des wichtigen Konstrukts Hoffnungslosigkeit und kann daher die Suizidrisikoabschätzung sinnvoll ergänzen.
... Accumulating evidence suggests that group-based telehealth interventions, for example, represent an effective and low-cost method to bolster social support and reduce loneliness in high-risk populations (Gentry et al., 2019). Similarly, suicide-specific cognitive-behavioral interventions, such as cognitive-behavioral therapy for suicide prevention (Stanley et al., 2009), have shown promising preliminary results for decreasing prospective risk for suicidal ideation and suicide attempts among active duty service members and veterans (Rudd et al., 2015). While converging lines of research suggest that gratitude interventions have positive outcomes on measures of depression and well-being (O'Leary & Dockray, 2015), additional research is needed to determine whether therapeutic treatments designed to enhance gratitude (e.g., gratitude journaling) may decrease prospective risk for suicidal behavior among veterans, active duty service members, and other high-risk groups. ...
Article
Background: Population-based data on risk factors for suicide attempts among veterans remains limited. Methods: A national probability sample of 2307 veterans was followed over the course of four timepoints spanning seven years to examine how a range of baseline risk factors predict incident suicide attempt. Suicide attempt data were aggregated into a single follow-up timepoint. Results: Sixty-two veterans (3.1%) reported attempting suicide during the 7-year period. The strongest risk factors for suicide attempts were higher baseline levels of loneliness, lower baseline levels of adaptive psychosocial traits (e.g., dispositional gratitude), baseline thoughts of self-harm, and greater post-baseline trauma exposures (12.3%–41.3% of explained variance). Veterans with multiple co-occurring risk factors were at greatest risk for attempts; of veterans with 0, 1, 2, 3, and all 4 of these factors, the predicted probability of suicide attempt was 2.0%, 5.3%, 13.5%, 30.4%, and 55.0%, respectively. Conclusions: Baseline loneliness, dispositional gratitude, thoughts of self-harm, and new-onset traumas emerged as the strongest risk factors for suicide attempts among veterans, underscoring the potential importance of targeting these factors in prevention efforts. Veterans with multiple co-occurring risk factors have substantially greater risk for suicide attempts, suggesting that examination of multiple coinciding vulnerability factors may help improve suicide risk prediction models.
... As such, military self-stigma may warrant attention in clinical risk assessment and therapeutic formulation when working with military Veterans in suicide-specific treatment. Self-stigma may be addressed through clinical interview or focus as an element of military Veteran suicide narratives in early stages of VA/DoD recommended therapies, such as Brief Cognitive Behavioral Therapy for Suicide (Rudd et al., 2015) or Dialectical Behavior Therapy (Goodman et al., 2016). Idealism, as a reflection of pride in military service and to the country, as a protective aspect of military identity may also be valuable in suicide prevention initiatives. ...
Article
US military Veterans are at greater risk for suicide than those who have never served in the US military. Recent federal calls include the need to investigate military-specific suicide risk and protective factors among military-affiliated populations. To date, no study has examined the link between military identity, self-stigma, and suicide risk. The current study used a nationally representative sample of post-Vietnam US military Veterans (N = 1,461) in order to determine relationships between military identity, self-stigma, and suicide risk. Idealism (OR = 0.86) with less odds of elevated suicide risk, whereas individualism (OR = 1.15) and military self-stigma (OR = 1.39) were associated with increased odds of elevated suicide risk. Military self-stigma was found to mediate the relationship between military identity components and suicide risk. Implications for conceptualization of military Veteran identity, suicide prevention, and future research are discussed.
... 73 In the context of patients with comorbid MDD and insomnia, one study showed that CBTi may be linked to reductions in depression and SI while improving sleep. 74 Given that the efficacy of brief CBT (bCBT) for reducing SA has been supported by 2 independent randomized clinical trials, 75,76 Roberge and colleagues 77 hypothesized that bCBT could have the same effect on both insomnia and suicidality. The authors reported that bCBT led to clinically significant reductions in insomnia symptoms that persisted for at least 12 months. ...
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KEY POINTS • Cognitive-behavioral therapy (CBT) has been shown to be effective for a range of psychiatric conditions, including severe mental illness and suicidality. • A significant body of research suggest that CBT leads to significant clinical im-provements and can be as effective as, or more effective than, other forms of psycho-logical therapy, alone or in combination with psychiatric medications. • Perspectives for the future include administering CBT online or through mobile phone apps and combining it with other techniques such as mindfulness.
... Referral to community-based universal interventions based on a public health perspective can be valuable components of such communications [67]. However, soldiers identified as high-risk by our model may also benefit from additional enhanced case management or higher-intensity interventions [5,[68][69][70] in the transitionary period depending on acuity and cost-effectiveness considerations [16,71]. Guidance in this regard might be provided by subsequent analyses of the experiences of high-risk soldiers after leaving or being released from active duty that more proximally predict SA. ...
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Suicide risk is elevated among military service members who recently transitioned to civilian life. Identifying high-risk service members before this transition could facilitate provision of targeted preventive interventions. We investigated the feasibility of doing this by attempting to develop a prediction model for self-reported suicide attempts (SAs) after leaving or being released from active duty in the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS). This study included two self-report panel surveys (LS1: 2016–2018, LS2: 2018–2019) administered to respondents who previously participated while on active duty in one of three Army STARRS 2011–2014 baseline self-report surveys. We focus on respondents who left active duty >12 months before their LS survey (n = 8899). An ensemble machine learning model using predictors available prior to leaving active duty was developed in a 70% training sample and validated in a 30% test sample. The 12-month self-reported SA prevalence (SE) was 1.0% (0.1). Test sample AUC (SE) was 0.74 (0.06). The 15% of respondents with highest predicted risk included nearly two-thirds of 12-month SAs and over 80% of medically serious 12-month SAs. These results show that it is possible to identify soldiers at high post-transition self-report SA risk before the transition. Future model development is needed to examine prediction of SAs assessed by administrative data and using surveys administered closer to the time of leaving active duty.
... After decades of lower suicide rates in this group, U.S. military suicide rates are now equal to the general population (Hoge, 2019). Existing military prevention efforts focus primarily on identifying and treating those who are already suicidal or at high risk (Comtois et al., 2019;Rudd et al., 2015). Although this approach is clearly necessary and has undoubtedly saved lives, it is also insufficient on its own (Rose, 1985;Brown et al., 2007;Wyman, 2014). ...
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U.S. military suicides are increasing and disrupted relationships frequently precede them. Group-level interventions are needed that reduce future suicide vulnerability among healthy members and also ameliorate risk among those already suicidal. We examined whether our Wingman-Connect Program (W-CP) strengthened Air Force relationship networks and socially integrated at-risk members. Air Force personnel classes in training were randomized to W-CP or active control (cluster RCT), followed up at 1 and 6 months (94% and 84% retention). Data were collected in 2017–2019 and analyzed in 2020–2021. Participants were 1485 male and female Airmen in 215 technical training classes. W-CP training involved strengthening group bonds, skills for managing career and personal stressors, and diffusion of healthy norms. Active control was stress management training. Primary outcomes were social network metrics based on Airmen nominations of valued classmates after 1 month. Baseline CAT-SS >34 defined elevated suicide risk. W-CP increased social network integration, with largest impact for Airmen already at elevated suicide risk (n = 114, 7.7%). For elevated risk Airmen, W-CP improved all network integration metrics, including 53% average gain in valued connection nominations received from other Airmen (RR = 1.53, 95% CI = 1.12, 2.08) and eliminated isolation. No elevated risk Airmen in W-CP were isolates with no valued connections after 1-month vs. 10% among controls (P < .035). In contrast to at-risk controls, at-risk W-CP Airmen increased connections after intervention. W-CP's effect on a key indicator, ≥2 connections, was still greater 2–4 months after classes disbanded (6-months). Wingman-Connect Program built enhanced suicide protection into unit relationship networks and counteracted standard drift towards disconnection for at-risk Airmen, despite no explicit content targeting connections specifically to at-risk Airmen. Findings support a growing case for the unique contribution of group-level interventions to improve social health of broader military populations while also ameliorating risk among individuals already at elevated suicide risk.
... The main psychological treatments based on manualized treatment protocols, with at least one well-conducted study that yielded significant effects in reducing suicidal behavior in high-risk patients, are Cognitive Behavioral Therapy (CBT, BCBT), Dialectical Behavioral Therapy (DBT), the Attempted Suicide Short Intervention Program (ASSIP), and the Collaborative Management of Suicidality (CAMS). The lengths of follow-up in these randomized studies range from six months [59] to 18 [60] and 24 months [61,62]. ...
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Theoretical models of suicide are based on risk factors associated with suicide, such as psychiatric pathology, genetics, epigenetics, functional brain disorders, and impaired decision making. In current clinical practice, the predominant risk model is the medical model, which posits that treating suicide risk is primarily a matter of treating psychiatric disorders. However, even comprehensive risk factor models cannot overcome the basic problem that, by their nature, they cannot accommodate the suicidal person’s psychological experience of suicidality. Risk factor models do not translate into effective treatment models. Suicide risk is highly personal and fluid, and is related to individual vulnerabilities and to person-specific events triggering suicidal thoughts and actions. Clinicians need treatment models that are meaningful to suicidal patients. Understanding the single person’s suicidality requires a patient-centered approach. Therapeutic interventions that effectively reduce the risk of suicidal behavior have been developed from general principles of psychotherapy. Therapy process factors associated with effective therapies are working alliance, validation of the individual patient’s thoughts and feelings, active treatment engagement. Psychological therapies need patients who are active participants in a collaborative working relationship between therapist and patient. The goal must be to jointly develop a meaningful understanding of the suicidal crisis. In view of the limited personal resources in health care systems it is important that effective therapies are brief and effective. Future research must aim to improve our understanding of the factors involved in effective therapies in order to optimize treatments for individuals at risk. This may also include the integration of biological risk factors in psychological treatment models.
... During study conceptualization and development, we gave considerable thought regarding how to optimally address the acute and chronic suicide risk of hospitalized service members, veterans, and military beneficiaries. We decided to include CRP in our intervention due to its brevity and ability to integrate as part of a larger protocol [36]. Crisis response plans have a broad evidence base in the treatment of suicide risk (e.g., [16,37,38]). ...
Article
Studies of active duty service members have shown that military personnel who screen positive for posttraumatic stress disorder (PTSD) are more than twice as likely to make a suicide attempt. Evidence-based PTSD treatments can reduce suicidal ideation; however, it can be challenging to provide evidence-based, trauma-focused, PTSD treatment to high-risk patients on an acute psychiatric inpatient unit because the priority of care is stabilization. Treatment for PTSD requires more time and resources than are typically afforded during inpatient hospitalizations. Written Exposure Therapy is an evidence-based, five-session, trauma-focused treatment for PTSD that may overcome the implementation challenges of providing PTSD treatment in an acute inpatient psychiatric treatment setting. This paper describes the design, methodology, and protocol of a randomized clinical trial. The goal of the study is to determine if five 60-min sessions of Written Exposure Therapy enhanced with Crisis Response Planning for suicide risk reduces the presence, frequency, and severity of suicidal ideation, suicidal behavior, rehospitalization, and non-suicidal, self-injurious behaviors. The study also will determine if Written Exposure Therapy for Suicide reduces posttraumatic stress symptom severity among military service members, veterans, and other adult military beneficiaries admitted to an acute psychiatric inpatient unit for comorbid suicide ideation or attempt and PTSD symptoms compared with Treatment as Usual. The study is designed to enhance the delivery of care for those in acute suicidal crisis with comorbid PTSD symptoms.
... DIGITAL BIBLIOTHERAPY FOR SUICIDE evidence that targeting these risk factors provides benefits to people at risk for suicide (Heisel et al., 2009;Rudd et al., 2015), and they also highlight digital support communities as platforms that can target these risk factors as mechanisms of change. Self-injurious individuals engage with online communities at a higher rate than age-matched peers (Tseng & Yang, 2015), and so clarifying specific ways that online communities can offer support to suicidal users helps pave the way to develop future interventions targeting these same mechanisms, and can also guide the efforts of digital support community content moderators. ...
Article
Objective: Suicide is a major public health concern in the United States, but few effective and scalable interventions exist to help those with suicidal thoughts. We hypothesized that reading first-person narratives about working through suicidal thoughts would reduce the desire to die among adults and that this effect would be mediated by increased perceived shared experience and optimism. Method: Using a randomized waitlist-controlled trial, we tested the effect of digital narrative-based bibliotherapy among 528 adults visiting a social media platform dedicated to providing mental health support. Participants were randomized to either a treatment condition (n = 266), in which they read one suicide narrative per day for 14 days or to a waitlist control condition (n = 262). The primary outcome was a measure of desire to die assessed daily for the 14-day trial period and at 2-week follow-up. Results: Participants in the treatment condition reported lower desire to die than participants in the control condition during the 14-day trial period (β = -0.26, p = .001) and at 2-week follow-up (t = -2.82, p = .005). Increased perceived shared experience (indirect effect b = -0.55, p < .001) and optimism (indirect effect b = -0.85, p < .001) mediated the effect of treatment on desire to die. Conclusions: Digital narrative-based bibliotherapy may be an effective intervention for those at risk for suicide, and may work in part by increasing feelings of perceived shared experience and optimism. Future research is needed to test the generalizability of these results to other platforms, groups, and conditions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
... Moreover, as noted above, recent research by Ross and colleagues [66] indicates that the specificity (86%), sensitivity (82%) and PPV values (4%) corresponding to a cut score of 6 or higher on the DRS exceed the threshold accuracy values necessary for cost-effective implementation of suicide risk prediction with safety planning and follow-up. Consideration should also be given to ensuring that patients in the highest-risk groups have access to more intensive and long-term cognitive behavioral treatment approaches that have also been shown to reduce the occurrence of suicidal behavior [71][72]. Importantly, a cut score of 9 or greater on the DRS (corresponding to high-risk group status or approximately top 5% of scores) produces specificity (96%), sensitivity (58%), and PPV (10%) values that exceed the threshold accuracy values identified by Ross and colleagues [66] as necessary for suicide risk prediction to be combined with cognitive behavioral therapy for suicide prevention to become cost-effective from a healthcare sector perspective. ...
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Background Worldwide, nearly 800,000 individuals die by suicide each year; however, longitudinal prediction of suicide attempts remains a major challenge within the field of psychiatry. The objective of the present research was to develop and evaluate an evidence-based suicide attempt risk checklist [i.e., the Durham Risk Score (DRS)] to aid clinicians in the identification of individuals at risk for attempting suicide in the future. Methods and findings Three prospective cohort studies, including a population-based study from the United States [i.e., the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) study] as well as 2 smaller US veteran cohorts [i.e., the Assessing and Reducing Post-Deployment Violence Risk (REHAB) and the Veterans After-Discharge Longitudinal Registry (VALOR) studies], were used to develop and validate the DRS. From a total sample size of 35,654 participants, 17,630 participants were selected to develop the checklist, whereas the remaining participants ( N = 18,024) were used to validate it. The main outcome measure was future suicide attempts (i.e., actual suicide attempts that occurred after the baseline assessment during the 1- to 3-year follow-up period). Measure development began with a review of the extant literature to identify potential variables that had substantial empirical support as longitudinal predictors of suicide attempts and deaths. Next, receiver operating characteristic (ROC) curve analysis was utilized to identify variables from the literature review that uniquely contributed to the longitudinal prediction of suicide attempts in the development cohorts. We observed that the DRS was a robust prospective predictor of future suicide attempts in both the combined development (area under the curve [AUC] = 0.91) and validation (AUC = 0.92) cohorts. A concentration of risk analysis found that across all 35,654 participants, 82% of prospective suicide attempts occurred among individuals in the top 15% of DRS scores, whereas 27% occurred in the top 1%. The DRS also performed well among important subgroups, including women (AUC = 0.91), men (AUC = 0.93), Black (AUC = 0.92), White (AUC = 0.93), Hispanic (AUC = 0.89), veterans (AUC = 0.91), lower-income individuals (AUC = 0.90), younger adults (AUC = 0.88), and lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) individuals (AUC = 0.88). The primary limitation of the present study was its its reliance on secondary data analyses to develop and validate the risk score. Conclusions In this study, we observed that the DRS was a strong predictor of future suicide attempts in both the combined development (AUC = 0.91) and validation (AUC = 0.92) cohorts. It also demonstrated good utility in many important subgroups, including women, men, Black, White, Hispanic, veterans, lower-income individuals, younger adults, and LGBTQ individuals. We further observed that 82% of prospective suicide attempts occurred among individuals in the top 15% of DRS scores, whereas 27% occurred in the top 1%. Taken together, these findings suggest that the DRS represents a significant advancement in suicide risk prediction over traditional clinical assessment approaches. While more work is needed to independently validate the DRS in prospective studies and to identify the optimal methods to assess the constructs used to calculate the score, our findings suggest that the DRS is a promising new tool that has the potential to significantly enhance clinicians’ ability to identify individuals at risk for attempting suicide in the future.
... There is a growing body of evidence emerging to understand suicidal ideation and behavior in greater depth, and significant efforts made in developing effective suicide specific treatment, and preventative interventions for the general population. Dialectical Behavioural Therapy [25], Cognitive Behavioural Therapy (CBT) [26], Brief CBT for suicidal risk [27], the Collaborative Assessment and Management of Suicidality [28,29], and the Attempted Suicide Short Intervention Programme [30] are the primary approaches for which there is evidence that they can be efficacious in reducing suicidal ideation and preventing suicide. ...
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Background: The homeless population are among the most vulnerable groups to experience suicide ideation and behavior. Several studies have shown that people who are homeless experience more significant suicidal ideation and behavior than the general population. However, there is limited information about what suicide interventions exist, to what extent they are grounded in robust research, and which intervention components effectively reduce suicidal ideation and behavior in the homeless community. This research aimed to characterise the current evidence base in the area of suicide prevention for homeless individuals. Methods: A scoping review guided by Arksey and O'Malley's five-stage framework was conducted and a narrative synthesis was performed. Pubmed, EMBASE, PsychInfo, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Open Grey, and Bielefeld Academic Search Engine were searched up to 8 May 2020. Results: A total of 3209 records were identified through database and grey literature searching. Three studies are included in this review. Key outcomes identify suicide intervention prevention programmes; similarities and differences across interventions, and examples of staff training. A quality review of the studies was completed. Conclusion: A stark gap in the evidence of suicide specific prevention interventions targeted at homeless populations.
... To test BCBT efficacy, Rudd and colleagues conducted an RCT study including 152 active-duty militaries from Fort Carson, Colorado, in 2015 [86]. The sample was randomized, 76 soldiers were assigned to a TAU group, while the other 76 were assigned to the BCBT group. ...
... A systematic review of 10 randomized controlled trials (RCT) on attempted suicide, that aimed to compare the efficacy of CBT with care as usual, found that CBT halved the risk of repeated suicide attempts in follow-up; given the large effect size noted and given that 'antidepressants increase suicide risk at all ages', the authors concluded that CBT should be preferred over antidepressants in this population [17]. One of the trials included in this review, conducted on serving military personnel with a recent suicide-related event (ideation with intent to die in the past week and/or suicide attempt in past month) randomized participants to either treatment as usual or treatment as usual plus brief 12-session outpatient individual CBT-based therapy sessions [18]. The primary outcome was occurrence and number of suicide attempts during the 24-month follow-up period; secondary outcomes included suicide ideation, symptoms of depression, anxiety, and posttraumatic stress. ...
Article
Purpose of review: Suicide is a major, global, public health issue. Those who attempt suicide represent a high-risk subgroup for eventual death by suicide. We provide an update on emerging evidence for interventions for attempted suicide to reduce subsequent suicidal behavior. Recent findings: Major approaches that have been examined recently include pharmacological, psychosocial, brief active contact and outreach interventions, and digitally driven interventions. Notwithstanding the limited evidence base for most of these approaches, brief contact and follow-up interventions appear to have more robust effects on reduction of repeat suicidal behavior, including attempts; such approaches may have especial significance in emergency settings because of their brevity. Digital interventions for self-harm appear promising in the short-term whereas the evidence for pharmacological and psychosocial strategies remain inconclusive. Summary: Although current evidence supports the use of brief interventions, contact, and outreach for reducing risk of subsequent suicide attempts and suicidal behavior, there are large gaps and limitations in the evidence base related to trial design, lack of long-term efficacy data, and implementational challenges. More robustly designed long-term trials that examine integrated intervention approaches with well defined outcomes are needed to develop recommendations in this area.
Article
Patients with posttraumatic stress disorder (PTSD) are at an elevated risk of suicide. For patients hospitalized for suicide risk, psychosocial treatment and stabilization are routinely offered; however, the availability of evidence-based, manualized therapeutic interventions for PTSD is sparse. Typically, the short duration of hospitalization makes it difficult to accommodate evidence-based, trauma-focused treatments. This article presents the clinical course of four active-duty service members with PTSD who were hospitalized in a psychiatric inpatient unit for acute suicide risk and treated with Written Exposure Therapy for Suicide (WET-S). WET-S is a brief, five-session therapy based upon Written Exposure Therapy and augmented with Crisis Response Planning for Suicide Prevention. Both posttraumatic stress symptoms and suicidal ideation were reduced from pre- to posttreatment for three of the four patients treated. WET-S shows promise as a manualized therapeutic intervention that can be delivered on an inpatient psychiatric unit.
Article
Suicide is a persistent issue in the United States and across the globe. A large body of published research finds that PTSD increases risk for suicidal ideation, suicidal behaviors, and death by suicide. However, the existing literature examining why that association might pertain is widely dispersed across disciplines (i.e., psychology, nursing, etc.) and lacks an integrative theoretical framework, making it difficult to conceptualize the current state of science in this area. Therefore, the primary aims of this narrative review were (1) to provide a comprehensive and interdisciplinary critique of the current state of knowledge regarding mechanisms that underlie the PTSD-suicide association, and (2) to organize that knowledge according to a specified theoretical framework. The framework guiding this review is Fluid Vulnerability Theory, a diathesis-stress model of suicide that emphasizes the dynamic nature of suicide risk across cognitive, emotional, behavioral, and physiological domains. A summary of findings, including patterns that emerged, gaps that remain, and recommendations for the advancement of science and practice in this area are addressed in this narrative review.
Article
Zusammenfassung Das „Collaborative Assessment and Management of Suicidality“ (CAMS) ist einer von mehreren Interventionsansätzen zur Behandlung von suizidalen Patienten und Patientinnen und wurde weltweit seit 3 Jahrzehnten untersucht und weiterentwickelt. Das CAMS ist auf die Etablierung einer tragenden therapeutischen Beziehung auf Augenhöhe zu einer suizidalen Person ausgerichtet. Der Patient wird aktiv an der Einschätzung seines Suizidrisikos beteiligt und zum „Mitverfasser“ seines eigenen suizidspezifischen Behandlungsplans. Das konkrete therapeutische Vorgehen wird durch ein vielseitig anwendbares Instrument, die sogenannte Suizidstatusform (SSF), strukturiert und geleitet. Das CAMS kann von verschiedenen therapeutischen Berufsgruppen sowie bei Patienten und Patientinnen mit unterschiedlichen Diagnosen angewandt werden. Die Wirksamkeit im Hinblick auf eine Verringerung von Suizidgedanken, der allgemeinen psychischen Belastung und Depressivität sowie auf eine Zunahme von Hoffnung und Zuversicht ist mittlerweile empirisch gut belegt.
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Background and Aim: In response to the increasing rate of suicides in the world's armies, which also has significant statistics, attention and focus on the development and implementation of suicide prevention interventions have increased. Accordingly, the present study intends to evaluate the effectiveness of brief cognitive-behavioral therapy on reducing suicidal ideation of a group of soldiers. Methods: In a quasi-experimental study based on a pre-and post-test design and control group, 24 soldiers were first selected using purposive sampling and then randomly divided into two experimental and control groups of 12 people. Brief cognitive-behavioral therapy was performed in the form of 10 sessions on a weekly basis for the experimental group. Data collection tools were Beck Scale for Suicidal Ideation (BSSI). The collected data were analyzed using univariate analysis of covariance methods in SPSS (V21.0) software. Results: Data analysis showed that brief cognitive-behavioral therapy was significantly effective in reducing soldiers' suicidal ideation after the intervention (P <0.05). Conclusion: Based on the research findings, it can be concluded that brief cognitive-behavioral therapy is effective in reducing soldiers' suicidal ideation. Therefore, the intervention used in the present study can be used as an appropriate method to reduce suicidal ideation, especially in soldiers and militaries, in psychological centers.
Article
Background PTSD is an established risk factor for suicide attempts and suicide death, but the mechanisms underlying this association remain unknown. The present study examined associations among delayed reward discounting—the balance between smaller immediate available rewards versus larger delayed rewards—self-reported PTSD symptoms, and recent suicide attempts among individuals reporting suicide ideation within the past year. Methods A cross-sectional survey of U.S. adults completed the Primary Care PTSD Screen for DSM-5, the 21-item Monetary Choice Questionnaire, and the Self-Injurious Thoughts and Behaviors Interview-Revised. Analyses of variance and multinomial regression models were used to test associations among variables. Results Among participants reporting suicide ideation within the past year, discount rates were significantly higher among those reporting more PTSD symptoms and a past-year suicide attempt, suggesting these participants expressed a preference for immediately available rewards. Conclusions Choice behavior among individuals reporting many PTSD symptoms and a recent suicide attempt is influenced to a greater degree by immediately available rewards. Sensitivity to immediate rewards at the expense of larger delayed rewards may reflect a vulnerability for suicidal behavior among individuals screening positive for PTSD.
Article
Objective: US military veterans have high rates of suicide relative to civilians. However, little is known about the prevalence and correlates of suicidal behaviors in the general US veteran population. Methods: Data were from the National Health and Resilience in Veterans Study, a representative survey of US veterans conducted in 2019-2020 (n = 4,069). Analyses (1) estimated the prevalence of current suicidal ideation, lifetime suicide plans, and lifetime suicide attempts; (2) identified associated sociodemographic, military, DSM-5 psychiatric, and other risk correlates; and (3) examined mental health treatment utilization among veterans with suicidal ideation, suicide plans, or suicide attempts. Results: The prevalence of current suicidal ideation, lifetime suicide plans, and lifetime suicide attempts was 9.0%, 7.3%, and 3.9%, respectively. Suicidal behaviors were most prevalent among veterans aged 18-44 years, with 18.2%, 19.3%, and 11.1%, respectively, endorsing suicidal ideation, suicide plans, and suicide attempts. Major depressive disorder (MDD), age, posttraumatic stress disorder, and adverse childhood experiences (ACEs) emerged as the strongest correlates of suicidal ideation and suicide plans, while MDD, age, alcohol use disorder, and ACEs were the strongest correlates of suicide attempts. Only 35.5% of veterans with current suicidal ideation were engaged in mental health treatment, with veterans who used the US Veterans Administration (VA) as their primary source of health care more than twice as likely as VA non-users to be engaged in such treatment (54.7% vs 23.8%). Conclusions: Suicidal behaviors are highly prevalent among US veterans, particularly among young veterans. Results suggest that nearly two-thirds of veterans with current suicidal ideation are not engaged in mental health treatment, signaling the need for enhanced suicide prevention and outreach efforts.
Article
A history of suicide attempt (SA) is a strong predictor of future suicide re-attempts or suicide. The aim of this systematic review is to evaluate the efficacy of psychotherapeutic interventions specifically designed for the prevention of suicide re-attempts. A systematic search from 1980 to June 2020 was performed via the databases PubMed and Google Scholar. Only randomized controlled trials were included which clearly differentiated suicidal self-harm from non-suicidal self-injury in terms of intent to die. Moreover, psychotherapeutic interventions had to be focused on suicidal behaviour and the numbers of suicide re-attempts had to be used as outcome variables. By this procedure, 18 studies were identified. Statistical comparison of all studies revealed that psychotherapeutic interventions in general were significantly more efficacious than control conditions in reducing the risk of future suicidal behaviour nearly by a third. Separate analyses revealed that cognitive-behavioural therapy as well as two different psychodynamic approaches were significantly more efficacious than control conditions. Dialectical behaviour therapy and elementary problem-solving therapy were not superior to control conditions in reducing the number of SAs. However, methodological reasons may explain to some extent these negative results. Considering the great significance of suicidal behaviour, there is unquestionably an urgent need for further development of psychotherapeutic techniques for the prevention of suicide re-attempts. Based on the encouraging results of this systematic review, it can be assumed that laying the focus on suicidal episodes might be the key intervention for preventing suicide re-attempts and suicides.
Article
Rates of suicide in the US Army continue to rise, and by some accounts exceed the general population. This increase has renewed efforts to identify protective factors that may inform novel suicide prevention strategies. Previous research has demonstrated that a sense of purpose in life and perceived cohesion with military peers are related to a reduction in the severity of suicidal ideation (SI). Additionally, research in military samples supports decreased SI in Soldiers who endorse that their leaders convey a sense of purpose and meaning in their shared mission. However, no work has investigated whether these leadership styles relate to a sense of felt purpose and perceived cohesion in Soldiers and thus the indirect effect of these leadership styles on SI. Active duty Army Soldiers (n = 1,160) completed self-report measures of purpose in life (PiL), perceived cohesion, ethical leadership, loneliness, and SI. Indirect effect analyses were conducted to determine how leadership behaviors indirectly relate to SI through PiL and perceived cohesion. Indirect effect analyses revealed that ethical leadership had an indirect effect on reduced SI through increased PiL. In the same parallel indirect effect analysis, ethical leadership was related to less SI through increased perceived cohesion and decreased loneliness sequentially. Enhanced leadership training that effectively increases Soldier purpose may be an important primary prevention tool to mitigate the effect of suicide risk factors. This primary prevention strategy may help augment existing suicide surveillance and clinical prevention efforts to reduce Soldier risk for suicide.
Chapter
Affective disorders, including major depressive disorder, persistent depressive disorder, and bipolar spectrum disorders, are common, recurrent, and debilitating disorders. In this review, we present updated research on these mood disorders, including their phenomenology, epidemiology, risk factors, and theory and evidence for the role of behavioral/motivational, cognitive, interpersonal/psychodynamic, and neurobiological mechanisms in their etiology and course. We also present treatments for affective disorders derived from the various theoretical perspectives on their etiology and evidence regarding the efficacy of these interventions as well as directions for future research.
Hospitalized patients after suicide attempts gave informed consent to a postvention project after discharge. A continuous caregiver contacted the subjects monthly by phone for a period of 1 year. In case of significant worsening and reoccurrence of suicidal ideations, immediate re-admission was possible. Ten subjects 65 years and older and hospitalized because of suicide attempts were included. The sample was presumed to be at high risk for repeated suicides because of somatic comorbidities and social isolation. Affective state was monitored using the PHQ-9. At the end, the social situation was assessed using the MILVA inventory. Of 16 patients screened for participation only 10 gave informed consent. Six subjects completed the study per protocol. Three subjects died (one suicide, two deaths by natural causes) and one dropped out for other reasons. At the end of the study, all completers appreciated the continuous guidance. While the affective state remained relatively stable in most subjects during the observed period, activities and social isolation could not be modified. Only one patient was readmitted during the project. Phone contacts proved to be feasible in the follow-up after suicide attempts especially in old age, because of the limited mobility of this vulnerable population.
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Statement of Problem: US Navy suicide is an ongoing concern, with more than half of suicide deaths each year related to firearms. Although decreasing firearms access by those who are at risk for suicide has been well-established as a tactic for reducing risk, implementation of firearms restrictions has a significant cultural and occupational impact among service members that may increase the stigma of seeking mental health care. During a recent Deep Dive review of all previous year suicide deaths, subject matter experts from across the US Navy identified significant variability in command utilization of firearms restriction. Methodology: Based on this finding, a review was conducted to identify best practice for firearms restriction related to suicide risk across the US military services and municipal police departments. Findings: Findings from this review suggested that the Department of the Navy may benefit from adopting consistent standards for disarming and rearming service members at risk for suicide, base decisions on objective suicide risk rather than routine stressors, decrease access primarily when service members are off duty, and engage with service members to decrease core drivers of suicide behavior through command channels. Implications: Implementing these recommendations may be a crucial step in balancing precautions to decrease suicide risk with the stigma of firearms restriction in military settings.
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Ide bunuh diri merupakan fase awal dari perilaku bunuh diri yang menyebabkan risiko besar kematian. Terapi kognitif perilaku merupakan terapi yang sudah lama dikembangkan untuk menangani masalah berkaitan dengan proses berpikir sehingga dinilai dan telah terbukti efektif untuk menurunkan ide bunuh diri. Terapi ini memiliki keterbatasan dibandingkan terapi lainnya karena beberapa hal di dalam dan di luar sesi terapi. Maka dari itu, studi dengan metode systematic literature review ini ingin memperoleh gambaran tentang proses terapi kognitif perilaku berdasarkan database terbaru. Penelitian ini menggunakan 7 database (Sage Journals, ScienceDirect, Psychiatry online, JAMA Network, Pubmed, Wiley Online Library, dan BMJ Open) dari 2010 hingga 2020. Terdapat 7 artikel dari 5.416 artikel yang diduga layak untuk ditelaah, pencarian dilakukan dari tanggal 1 Januari 2021 hingga tanggal 20 Februari 2021. Artikel-artikel tersebut menunjukkan bahwa terapi kognitif perilaku terbukti dapat menurunkan ide bunuh diri di beberapa populasi seperti tentara, pengguna layanan kesehatan, dan masyarakat umum yang bersedia untuk mendapatkan bantuan professional. Systematic literature review ini memaparkan variasi modul dan teknik terapi kognitif perilaku sehingga dapat menyesuaikan dengan kondisi, kebutuhan, dan waktu yang dimiliki oleh pasien. Terdapat 3 fase utama terapi kognitif perilaku, fase pertama berisi edukasi dan memahami kondisi klien, fase kedua menggunakan teknik kognitif untuk menangani pikiran otomatis, dan fase ketiga merancang strategi untuk mencegah kekambuhan.
Article
The Veterans Crisis Line (VCL) is a core component of VA's suicide prevention strategy. Despite the availability and utility of the VCL, many Veterans do not utilize this resource during times of crisis. A brief, psychoeducational behavioral intervention (termed Crisis Line Facilitation [CLF]) was developed to increase utilization of the VCL and reduce suicidal behaviors in high-risk Veterans. The therapist-led session includes educational information regarding the VCL, as well as a chance to discuss the participant's perceptions of contacting the VCL during periods of crisis. The final component of the session is a practice call placed to the VCL by both the therapist and the participant. The CLF intervention was compared to Enhanced Usual Care (EUC) during a multi-site randomized clinical trial for 307 Veteran participants recently hospitalized for a suicidal crisis who reported no contact with the VCL in the prior 12 months. Initial analyses indicated that participants randomized to the CLF intervention were less likely to report suicidal behaviors, including suicide attempts compared to participants randomized to receive EUC over 12-months of follow-up (χ² = 18.48/p < 0.0001), however this effect was not sustained when analyses were conducted on an individual level. No significant differences were found between conditions on VCL utilization. Initial evidence suggests a brief CLF intervention has an impact on preventing suicidal behaviors in Veterans treated in inpatient mental health programs; however, it may not change use of the VCL. This brief intervention could be easily adapted into clinical settings to be delivered by standard clinical staff.
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Recent research suggests that treating only mental disorders may not be sufficient to reduce the risk for future suicidal behavior in patients with a suicide attempt(s). It is therefore necessary to pay special therapeutic attention to past suicidal acts. Thus, the newly developed RISE (Relapse Prevention Intervention after Suicidal Event) program was built on the most effective components of existing psychotherapeutic and psychosocial interventions according to our current meta-analysis. The RISE program consists of five individual sessions designed for the acute psychiatric inpatient setting. The main goals of the treatment are to decrease future suicidal events and to improve patients' ability to cope with future suicidal crises. In the present study, feasibility and acceptance of the RISE program were investigated as well as its clinical effects on suicidal ideations, mental pain, self-efficacy and depressive symptoms. We recruited a sample of 27 inpatients of the Department of Psychiatry and Psychotherapy, University Hospital Jena, Germany. The final sample consisted of 20 patients hospitalized for a recent suicide attempt, including 60 percent of multiple attempters. The data collection included a structured interview and a comprehensive battery of questionnaires to evaluate the feasibility and acceptance of the RISE program as well as associated changes in clinical symptoms. A follow-up examination was carried out after 6 months. Considering the low dropout rate and the overall positive evaluation, the RISE program was highly accepted in a sample of severely impaired patients. The present study also demonstrated that the levels of suicidal ideations, mental pain, depressive symptoms, and hopelessness decreased significantly after RISE. Since all of these clinical parameters are associated with the risk of future suicidal behavior, a potential suicide-preventive effect of the intervention can be inferred from the present findings. The positive results of the follow-up assessment after 6 months point in the same direction. In addition, RISE treatment increased self-efficacy in patients, which is an important contributor for better coping with future suicidal crises. Thus, present study demonstrate that RISE is a suitable therapy program for the treatment of patients at high risk for suicidal behavior in an acute inpatient setting.
Article
Background Approximately half of patients who attempt or die by suicide screened negative for suicidal ideation during their most recent medical visit. Maladaptive beliefs and schemas can increase cognitive vulnerability to suicidal behavior, even among patients without recent or past suicidal thoughts and behaviors. Assessing these beliefs could improve the detection of patients who will engage in suicidal behavior after screening negative for elevated suicide risk. Methods Primary care patients who completed the Patient Health Questionnaire-9 and the Suicide Cognitions Scale-Revised (SCS-R) during routine clinic visits and denied suicidal ideation at baseline (N = 2417) were included in the study sample. Suicidal behaviors during the 12 months after baseline were assessed. Logistic regression analyses examined the association of baseline SCS-R scores with later suicidal behavior. Results In both univariate and multivariate analyses, SCS-R total scores were associated with significantly increased risk of suicidal behavior within 90, 180, and 365 days post-baseline. Results were unchanged when patients who reported prior suicidal behavior were excluded (N = 2178). In item-level analyses, all 16 SCS-R items significantly differentiated patients with and without follow-up suicidal behavior. Limitations Study limitations included missing follow-up data, restriction of sample to U.S. military medical beneficiaries, and inability to assess representativeness of the sample relative to the full primary care population. Conclusions SCS-R scores are elevated among patients who attempt suicide after denying both suicidal ideation and prior suicide attempts, suggesting the scale may reflect enduring suicide risk. The SCS-R could enhance suicide risk screening and assessment.
Chapter
Suicide prevention efforts require coordination and collaboration among multiple sectors of society, both public and private, including health and non-health sectors such as education, labor, agriculture, business, justice, law, defense, politics, and the media (“Preventing suicide,” 2014). These efforts must be comprehensive, integrated, and synergistic, as no single approach alone can impact a complex issue such as suicide. For this reason, many suicide research units have been set up and also there are academic courses that focus on suicide prevention. To provide practical help, non-specialized health professionals are being used to improve the assessment of suicidal behaviours, for example, self-help groups of bereaved families have been established in many places, and trained volunteers are helping with online and telephone counseling.
Chapter
This chapter reviews the epidemiology and neurobiology of major depressive disorder and suicide. Depression and suicide rates in different countries around the world have changed over the years partly because the onset of major depression is earlier in individuals who are born more recently and partly because of major social changes influencing suicide risk such as per capita alcohol consumption and levels of treatment of major depression. Data are reviewed on gene–environment interactions explaining environmental effects on depression and suicide rates and their neurobiology. The biological basis of resilience is reviewed in an effort to understand how it differs from the diathesis or tendency to depression and suicide. The neurobiology of depression and suicide is described in terms of brain circuits involved and at the cellular and molecular level. Therapeutic approaches are linked to known pathogenesis, and future directions for research and treatment are proposed.
Article
Background: Military suicide rates have risen over the past two decades, with a notable spike in recent years. To address this issue, military mental health providers must be equipped with the skills required to provide timely and effective care; yet little is known about the suicide-specific training experiences or needs of these professionals. Methods: Thirty-five mental health care providers who treat active duty personnel at military treatment facilities participated in this mixed-methods study. All participants completed a survey assessing training and clinical experiences, comfort and proficiency in working with patients at risk for suicide, and perceived barriers to obtaining suicide-specific training. A sub-set of participants (n = 8) completed a telephone interview to further describe previous experiences and perceived challenges to obtaining training. Results: The majority of participants (79.4%) had 6+ years of clinical experience, had a patient who had attempted suicide (85.3%), and completed at least one suicide-related training since finishing their education (82.4%). Survey results showed the leading barrier to enrolling in suicide-specific trainings was perceived lack of training opportunities (40.7% reported it was a barrier "quite often" or more), followed by lack of time (25%). Interview results revealed lack of time, location and logistical issues, and low perceived need for additional training among providers could impede enrollment. Conclusions: Study results identified several modifiable barriers to receiving suicide-specific continuing education among military mental health providers. Future efforts should develop accessible training programs that can be easily integrated into routine clinical operations to mount the best defense against suicide. HIGHLIGHTSMilitary mental health providers report significant experience and relatively high degrees of comfort and proficiency working with patients at high risk for suicide.Most providers reported receiving training in suicide assessment and screening; few reported prior training in management of suicidality.Study results identified several modifiable barriers to receiving suicide-prevention continuing education among military mental health care providers; future efforts should seek to develop accessible training programs that can be easily integrated into routine clinical operations to mount the best defense against suicide.
Article
A gap between psychotherapy research and practice exists, and many social workers may not be informed about evidence-based techniques used in cognitive behavioral therapy (CBT) for suicide prevention. Therefore, the purpose of this brief article is to introduce social workers to CBT targeting suicide risk in both outpatient and inpatient settings. Three clinical techniques incorporated into CBT for suicide are introduced: hope building, social support, and lethal means counseling. Practical tips, resources, and recommendations are offered to empower social workers to integrate these clinical tools into their current practice when working with clients at risk for suicide.
Article
ZUSAMMENFASSUNG Der Psychotherapie suizidaler Patienten kommt unter den individuumszentrierten Ansätzen zur Suizidprävention besondere Bedeutung bei. Als effektiv erwiesen haben sich vor allem die kognitive Verhaltenstherapie (KVT) und die dialektisch-behaviorale Therapie (DBT). Vor diesem Hintergrund werden in diesem CME-Beitrag zentrale Interventionen zur Risikoabschätzung und Krisenintervention, zur Aufarbeitung suizidfördernder Faktoren und zur Rückfallprävention praxisnah dargestellt.
Article
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Zusammenfassung Suizidversuche gelten als einer der wichtigsten Risikofaktoren für Suizide. Vor diesem Hintergrund wurden in den letzten Jahren diverse Psychotherapieangebote für Personen nach einem Suizidversuch entwickelt und untersucht. Im Rahmen dieses Artikels wird der aktuelle Stand der Effektivitätsforschung zusammengefasst, es werden Beispiele für erfolgreiche suizidfokussierte Psychotherapieprogramme gegeben und der gegenwärtige Forschungs- und Wissensstand wird kritisch reflektiert. Die Ergebnisse von 2 aktuellen Cochrane-Reviews zur Psychotherapie nach selbstverletzendem Verhalten im Kindes‑, Jugend- und Erwachsenenalter sowie Befunde aus 14 weiteren Metaanalysen zur psychologischen Suizidprävention, die in den vergangenen 5 Jahren publiziert wurden, werden überblicksartig dargestellt. Die kognitive Verhaltenstherapie (KVT) und die dialektisch-behaviorale Therapie (DBT) haben sich als effektiv erwiesen. Insgesamt sind die gemittelten Effektstärken jedoch von geringer Größe und diverse methodische Probleme verunmöglichen weitreichende Schlussfolgerungen. Grundsätzlich kommt der suizidspezifischen Psychotherapie in der individuumszentrierten Suizidprävention besondere Bedeutung zu; die empirische Fundierung und Dissemination entsprechender Programme sind jedoch noch unzureichend.
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Background: Self‐harm (SH; intentional self‐poisoning or self‐injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most counties, often repeated, and associated with suicide. There has been a substantial increase in both the number of trials and therapeutic approaches of psychosocial interventions for SH in adults. This review therefore updates a previous Cochrane Review (last published in 2016) on the role of psychosocial interventions in the treatment of SH in adults. Objectives: To assess the effects of psychosocial interventions for self‐harm (SH) compared to comparison types of care (e.g. treatment‐as‐usual, routine psychiatric care, enhanced usual care, active comparator) for adults (aged 18 years or older) who engage in SH. Search methods: We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020). Selection criteria: We included all randomised controlled trials (RCTs) comparing interventions of specific psychosocial treatments versus treatment‐as‐usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, or a combination of these, in the treatment of adults with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow‐up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide. Data collection and analysis: We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratio (ORs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated mean differences (MDs) or standardised mean differences (SMDs) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post‐intervention) was appraised for each intervention using the GRADE approach. Main results: We included data from 76 trials with a total of 21,414 participants. Participants in these trials were predominately female (61.9%) with a mean age of 31.8 years (standard deviation [SD] 11.7 years). On the basis of data from four trials, individual cognitive behavioural therapy (CBT)‐based psychotherapy may reduce repetition of SH as compared to TAU or another comparator by the end of the intervention (OR 0.35, 95% CI 0.12 to 1.02; N = 238; k = 4; GRADE: low certainty evidence), although there was imprecision in the effect estimate. At longer follow‐up time points (e.g., 6‐ and 12‐months) there was some evidence that individual CBT‐based psychotherapy may reduce SH repetition. Whilst there may be a slightly lower rate of SH repetition for dialectical behaviour therapy (DBT) (66.0%) as compared to TAU or alternative psychotherapy (68.2%), the evidence remains uncertain as to whether DBT reduces absolute repetition of SH by the post‐intervention assessment. On the basis of data from a single trial, mentalisation‐based therapy (MBT) reduces repetition of SH and frequency of SH by the post‐intervention assessment (OR 0.35, 95% CI 0.17 to 0.73; N = 134; k = 1; GRADE: high‐certainty evidence). A group‐based emotion‐regulation psychotherapy may also reduce repetition of SH by the post‐intervention assessment based on evidence from two trials by the same author group (OR 0.34, 95% CI 0.13 to 0.88; N = 83; k = 2; moderate‐certainty evidence). There is probably little to no effect for different variants of DBT on absolute repetition of SH, including DBT group‐based skills training, DBT individual skills training, or an experimental form of DBT in which participants were given significantly longer cognitive exposure to stressful events. The evidence remains uncertain as to whether provision of information and support, based on the Suicide Trends in At‐Risk Territories (START) and the SUicide‐PREvention Multisite Intervention Study on Suicidal behaviors (SUPRE‐MISS) models, have any effect on repetition of SH by the post‐intervention assessment. There was no evidence of a difference for psychodynamic psychotherapy, case management, general practitioner (GP) management, remote contact interventions, and other multimodal interventions, or a variety of brief emergency department‐based interventions. Authors' conclusions: Overall, there were significant methodological limitations across the trials included in this review. Given the moderate or very low quality of the available evidence, there is only uncertain evidence regarding a number of psychosocial interventions for adults who engage in SH. Psychosocial therapy based on CBT approaches may result in fewer individuals repeating SH at longer follow‐up time points, although no such effect was found at the post‐intervention assessment and the quality of evidence, according to the GRADE criteria, was low. Given findings in single trials, or trials by the same author group, both MBT and group‐based emotion regulation therapy should be further developed and evaluated in adults. DBT may also lead to a reduction in frequency of SH. Other interventions were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to the use of these interventions is inconclusive at present.
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A randomized clinical trial was conducted to evaluate the effectiveness of a cognitive-behavioral therapy, ie, dialectical behavior therapy, for the treatment of chronically parasuicidal women who met criteria for borderline personality disorder. The treatment lasted 1 year, with assessment every 4 months. The control condition was "treatment as usual" in the community. At most assessment points and during the entire year, the subjects who received dialectical behavior therapy had fewer incidences of parasuicide and less medically severe parasuicides, were more likely to stay in individual therapy, and had fewer inpatient psychiatric days. There were no between-group differences on measures of depression, hopelessness, suicide ideation, or reasons for living although scores on all four measures decreased throughout the year.
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To determine the risk factors for suicide, 6,891 psychiatric outpatients were evaluated in a prospective study. Subsequent deaths for the sample were identified through the National Death Index. Forty-nine (1%) suicides were determined from death certificates obtained from state vital statistics offices. Specific psychological variables that could be modified by clinical intervention were measured using standardized scales. Univariate survival analyses revealed that the severity of depression, hopelessness, and suicide ideation were significant risk factors for eventual suicide. A multivariate survival analysis indicated that several modifiable variables were significant and unique risk factors for suicide, including suicide ideation, major depressive disorder, bipolar disorder, and unemployment status.
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Suicide attempts constitute a major risk factor for completed suicide, yet few interventions specifically designed to prevent suicide attempts have been evaluated. To determine the effectiveness of a 10-session cognitive therapy intervention designed to prevent repeat suicide attempts in adults who recently attempted suicide. Randomized controlled trial of adults (N = 120) who attempted suicide and were evaluated at a hospital emergency department within 48 hours of the attempt. Potential participants (N = 350) were consecutively recruited from October 1999 to September 2002; 66 refused to participate and 164 were ineligible. Participants were followed up for 18 months. Cognitive therapy or enhanced usual care with tracking and referral services. Incidence of repeat suicide attempts and number of days until a repeat suicide attempt. Suicide ideation (dichotomized), hopelessness, and depression severity at 1, 3, 6, 12, and 18 months. From baseline to the 18-month assessment, 13 participants (24.1%) in the cognitive therapy group and 23 participants (41.6%) in the usual care group made at least 1 subsequent suicide attempt (asymptotic z score, 1.97; P = .049). Using the Kaplan-Meier method, the estimated 18-month reattempt-free probability in the cognitive therapy group was 0.76 (95% confidence interval [CI], 0.62-0.85) and in the usual care group was 0.58 (95% CI, 0.44-0.70). Participants in the cognitive therapy group had a significantly lower reattempt rate (Wald chi2(1) = 3.9; P = .049) and were 50% less likely to reattempt suicide than participants in the usual care group (hazard ratio, 0.51; 95% CI, 0.26-0.997). The severity of self-reported depression was significantly lower for the cognitive therapy group than for the usual care group at 6 months (P= .02), 12 months (P = .009), and 18 months (P = .046). The cognitive therapy group reported significantly less hopelessness than the usual care group at 6 months (P = .045). There were no significant differences between groups based on rates of suicide ideation at any assessment point. Cognitive therapy was effective in preventing suicide attempts for adults who recently attempted suicide.
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Dialectical behavior therapy (DBT) is a treatment for suicidal behavior and borderline personality disorder with well-documented efficacy. To evaluate the hypothesis that unique aspects of DBT are more efficacious compared with treatment offered by non-behavioral psychotherapy experts. One-year randomized controlled trial, plus 1 year of posttreatment follow-up. University outpatient clinic and community practice. One hundred one clinically referred women with recent suicidal and self-injurious behaviors meeting DSM-IV criteria, matched to condition on age, suicide attempt history, negative prognostic indication, and number of lifetime intentional self-injuries and psychiatric hospitalizations. One year of DBT or 1 year of community treatment by experts (developed to maximize internal validity by controlling for therapist sex, availability, expertise, allegiance, training and experience, consultation availability, and institutional prestige). Trimester assessments of suicidal behaviors, emergency services use, and general psychological functioning. Measures were selected based on previous outcome studies of DBT. Outcome variables were evaluated by blinded assessors. Dialectical behavior therapy was associated with better outcomes in the intent-to-treat analysis than community treatment by experts in most target areas during the 2-year treatment and follow-up period. Subjects receiving DBT were half as likely to make a suicide attempt (hazard ratio, 2.66; P = .005), required less hospitalization for suicide ideation (F(1,92) = 7.3; P = .004), and had lower medical risk (F(1,50) = 3.2; P = .04) across all suicide attempts and self-injurious acts combined. Subjects receiving DBT were less likely to drop out of treatment (hazard ratio, 3.2; P < .001) and had fewer psychiatric hospitalizations (F(1,92) = 6.0; P = .007) and psychiatric emergency department visits (F(1,92) = 2.9; P = .04). Our findings replicate those of previous studies of DBT and suggest that the effectiveness of DBT cannot reasonably be attributed to general factors associated with expert psychotherapy. Dialectical behavior therapy appears to be uniquely effective in reducing suicide attempts.
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The authors describe the development of the Suicide Attempt Self-Injury Interview (SASII), an instrument designed to assess the factors involved in nonfatal suicide attempts and intentional self-injury. Using 4 cohorts of participants, authors generated SASII items and evaluated them with factor and content analyses and internal consistency statistics. The final measure was assessed for reliability and validity with collateral measures. The SASII assesses variables related to method, lethality and impulsivity of the act, likelihood of rescue, suicide intent or ambivalence and other motivations, consequences, and habitual self-injury. The SASII was found to have very good interrater reliability and adequate validity.
Book
Being deployed to a war zone can result in numerous adverse psychological health conditions. It is well documented in the literature that there are high rates of psychological disorders among military personnel serving in Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom in Iraq as well as among the service members' families. For service members' families, the degree of hardship and negative consequences rises with the amount of the service members' exposure to traumatic or life-altering experiences. Adult and child members of the families of service members who experience wartime deployments have been found to be at increased risk for symptoms of psychological disorders and to be more likely to use mental health services. In an effort to provide early recognition and early intervention that meet the psychological health needs of service members and their families, DOD currently screens for many of these conditions at numerous points during the military life cycle, and it is implementing structural interventions that support the improved integration of military line personnel, non-medical caregivers, and clinicians, such as RESPECT-Mil (Re-engineering Systems of Primary Care Treatment in the Military), embedded mental health providers, and the Patient-Centered Medical Home. Preventing Psychological Disorders in Service Members and Their Families evaluates risk and protective factors in military and family populations and suggests that prevention strategies are needed at multiple levels - individual, interpersonal, institutional, community, and societal - in order to address the influence that these factors have on psychological health. This report reviews and critiques reintegration programs and prevention strategies for PTSD, depression, recovery support, and prevention of substance abuse, suicide, and interpersonal violence. © 2014 by the National Academy of Sciences. All rights reserved.
Article
This article describes a set of “common elements” underlying a new approach to the clinical management and treatment of suicidality and provides a general description of brief cognitive behavioral therapy (BCBT) in treating suicidality in military populations. BCBT was developed and adapted to the unique treatment environment of a military setting, one that limits the ability to offer intensive and enduring psychotherapy. BCBT offers a unique alternative to traditional psychotherapy, to reduce suicidal behavior and improve the patient’s ability to more fully participate in longer-term therapy for targeted Axis I and II disorders like post-traumatic stress disorder and/or major depression. (PsycINFO Database Record (c) 2013 APA, all rights reserved)
Article
Treatment completion (commonly referred to as termination) is a routine and essential component of the treatment process. Although the relevant literature has discussed how to complete treatment, much less discussion and guidance exists regarding when, and under what conditions, treatment should be considered complete. The current article reviews various approaches to defining treatment completion, identifying three general patterns within the psychotherapy literature: clinician judgment, patient outcomes, and number of sessions attended. We propose defining treatment completion in terms of patient skill mastery and competency, and provide an overview of how patient competency is used to define treatment progress and completion within Brief Cognitive Behavioral Therapy for suicidal patients. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Suicide is a leading cause of deaths of U.S. service members. Medical care providers may play a role in suicide prevention. We summarized the outpatient experiences of service members prior to suicide or self-inflicted injury and compared them with service members without suicidal behavior. During 2001-2010, 45 percent of individuals who completed suicide and 75 percent of those who injured themselves had outpatient encounters within 30 days prior to suicide/self-harm. Primary care was the most frequently visited clinical service prior to suicide/self-harm. As compared to their counterparts, service members with suicidal behavior had especially excessive outpatient visit rates within, but not prior to, 60 days of their deaths/injuries. The finding suggests that there may be one or more "triggering" events that lead to care-seeking. These results may help identify individuals that should be screened for suicide risk.
Article
The authors reviewed 29 studies that provide prevalence estimates of posttraumatic stress disorder (PTSD) among service members previously deployed to Operations Enduring and Iraqi Freedom and their non-U.S. military counterparts. Studies vary widely, particularly in their representativeness and the way PTSD is defined. Among previously deployed personnel not seeking treatment, most prevalence estimates range from 5 to 20%. Prevalence estimates are generally higher among those seeking treatment: As many as 50% of veterans seeking treatment screen positive for PTSD, though much fewer receive a PTSD diagnosis. Combat exposure is the only correlate consistently associated with PTSD. When evaluating PTSD prevalence estimates among this population, researchers and policymakers should carefully consider the method used to define PTSD and the population the study sample represents.
Article
This chapter focuses on a review of randomized clinical trials of both psychosocial and behavioral interventions designed to directly reduce rates of suicide and parasuicidal behavior, including suicide attempts. It begins with an overview of the definitional difficulties in this field and then proceeds to an overview of treatment issues and a comprehensive review of treatment studies aiming to reduce suicidal behavior among suicidal individuals. Twenty studies are discussed. Eighteen studies randomly assigned subjects to the experimental and control condition; the other two studies assigned subjects in an alternating sequential fashion. Analyses showed that four psychosocial intervention studies and one pharmacotherapy study have reported efficacious results when compared to treatments-as-usual or placebo controls. From another perspective, when outpatient psychosocial interventions were examined, the strongest predictor of whether the experimental treatment would be more effective than the control was whether high-risk suicidal individuals were included. Psychosocial interventions appear to be most effective with the more high-risk individuals.
Article
Scales for measuring current suicide ideation (SSI-C), suicide ideation at its worst point in the patient's life (SSI-W), and hopelessness (BHS) were administered to 3,701 outpatients seeking psychiatric treatment. Thirty patients from this sample eventually committed suicide, within a mean of 4 years from the initial assessment. Based on cut-off scores derived from receiver operating characteristic (ROC) analyses, the SSI-W had an odds ratio of 13.84 for predicting suicide, whereas the SSI-C and the BHS had odds ratios of 5.42 and 6.43, respectively. The assessment of suicide ideation at its worst point identifies a subgroup of patients at relatively high risk for eventual suicide. Robust interventions and periodic monitoring for suicide ideation and hopelessness are recommended to reduce long-term suicide risk.
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