Article

Effect of crisis response planning vs. contracts for safety on suicide risk in U.S. Army Soldiers: A randomized clinical trial

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Abstract

Objective: To evaluate the effectiveness of crisis response planning for the prevention of suicide attempts. Method: Randomized clinical trial of active duty Army Soldiers (N=97) at Fort Carson, Colorado, presenting for an emergency behavioral health appointment. Participants were randomly assigned to receive a contract for safety, a standard crisis response plan, or an enhanced crisis response plan. Incidence of suicide attempts during follow-up was assessed with the Suicide Attempt Self-Injury Interview. Inclusion criteria were the presence of suicidal ideation during the past week and/or a lifetime history of suicide attempt. Exclusion criteria were the presence of a medical condition that precluded informed consent (e.g., active psychosis, mania). Survival curve analyses were used to determine efficacy on time to first suicide attempt. Longitudinal mixed effects models were used to determine efficacy on severity of suicide ideation and follow-up mental health care utilization. Results: From baseline to the 6-month follow-up, 3 participants receiving a crisis response plan (estimated proportion: 5%) and 5 participants receiving a contract for safety (estimated proportion: 19%) attempted suicide (log-rank χ(2)(1)=4.85, p=0.028; hazard ratio=0.24, 95% CI=0.06-0.96), suggesting a 76% reduction in suicide attempts. Crisis response planning was associated with significantly faster decline in suicide ideation (F(3,195)=18.64, p<0.001) and fewer inpatient hospitalization days (F(1,82)=7.41, p<0.001). There were no differences between the enhanced and standard crisis response plan conditions. Conclusion: Crisis response planning was more effective than a contract for safety in preventing suicide attempts, resolving suicide ideation, and reducing inpatient hospitalization among high-risk active duty Soldiers.

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... Research examining CRP and SPI suggest that both interventions are efficacious in managing suicidal crises. For instance, in a randomized clinical trial, active duty military personnel who collaboratively created a CRP were 76% less likely to make a suicide attempt during the follow-up period than service members who received treatment as usual (Bryan et al., 2017). Furthermore, the inclusion of reasons for living in CRP, specifically, was associated with increases in positive emotions and quicker reductions in suicidal ideation Rozek et al., 2019), though the inclusion of reasons for living did not incrementally protect against suicide attempts within a 6-month follow-up (Bryan et al., 2017). ...
... For instance, in a randomized clinical trial, active duty military personnel who collaboratively created a CRP were 76% less likely to make a suicide attempt during the follow-up period than service members who received treatment as usual (Bryan et al., 2017). Furthermore, the inclusion of reasons for living in CRP, specifically, was associated with increases in positive emotions and quicker reductions in suicidal ideation Rozek et al., 2019), though the inclusion of reasons for living did not incrementally protect against suicide attempts within a 6-month follow-up (Bryan et al., 2017). Likewise, in examination of the SPI, patients presenting to an emergency department who created a safety plan had 45% fewer instances of suicidal behaviors over a 6-month follow-up and more than double the odds of attending at least one outpatient mental health treatment session than patients who did not receive SPI (Stanley et al., 2018). ...
... Based on a literature review of articles summarizing the tenets of safety planning and its empirical evidence (e.g., Bryan et al., 2017;Stanley et al., 2018), as well as our own clinical experiences and consensus/discussion, we propose seven candidate mechanisms that we believe may be foundational to the efficacy of safety planning. We emphasize, however, that this list is preliminary and not intended to be exhaustive; additional mechanisms may emerge through future research, and some of these proposed mechanisms may not be supported through subsequent empirical work. ...
... The most commonly known SSP has been developed by Stanley and Brown (2012) and includes six primary elements: (1) identifying warning signs of a suicide crisis; (2) internal coping strategies; (3) social supports that can distract from the current crisis; (4) contact information for these social supports; (5) contact information for health care services; and (6) reducing access to lethal means (Stanley & Brown, 2012). SSP was developed as a response to growing recognition that "contracting for safety," an approach involving a verbal contract in which a service user agrees to avoid attempting suicide before reaching out for professional support, was largely ineffective for mitigating suicide risk (Bryan et al., 2017;Egan, 1997;Rudd et al., 2006). SSP is closely aligned with the values and culture of occupational therapy through its emphasis on collaboration and person-centered care (ACOTRO et al., 2021;Egan & Restall, 2022). ...
... (m = 68.2) representing moderate-high quality evidence. See Table 2. S-SSP and E-SSP interventions included in this category were called "crisis response plans" (Bryan et al., 2017(Bryan et al., , 2018a(Bryan et al., , 2018bRozek et al., 2019) and "safety plans" (Green et al., 2018;Stanley et al., 2015Stanley et al., , 2020. S-SSPs included identification of warning signs, self-management and coping strategies, and social supports and healthcare professionals who could help during a suicide crisis. ...
... S-SSPs included identification of warning signs, self-management and coping strategies, and social supports and healthcare professionals who could help during a suicide crisis. Four of these plans also included identifying crisis services (Bryan et al., 2017(Bryan et al., , 2018a(Bryan et al., , 2018bRozek et al., 2019), three included a component of reducing access to lethal means (Green et al., 2018;Stanley et al., 2015Stanley et al., , 2020, and one included a component of identifying places that could serve as a distraction (Green et al., 2018). E-SSPs included the components included in S-SSPs, while also including verbal contracts for safety and identifying reasons for living (Bryan et al., 2017(Bryan et al., , 2018a(Bryan et al., , 2018bRozek et al., 2019). ...
Article
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Background. Suicide safety planning (SSP) is a suicide prevention approach that involves developing a collaborative plan between a service provider such as an occupational therapist and a person who is at risk of suicide. Purpose. To synthesize effectiveness studies on SSP. Method. Using the Joanna Briggs Institute methodology, we conducted a systematic review of effectiveness studies including a: (1) title and abstract screening; (2) full-text review; (3) critical appraisal; and (4) narrative synthesis. Findings. We included 22 studies. Critical appraisal scores ranged from 38.5 to 92.3 (m = 63.7). The types of interventions included were: standard and enhanced SSP (n = 11); electronically delivered SSP (n = 5); and SSP integrated with other approaches (n = 6). Only three studies identified meaningful activity as a component of SSP. Evidence across a range of studies indicates that SSP is effective for reducing suicide behavior (SB) and ideation (SI). While some studies have demonstrated effectiveness for reducing symptoms of mental illness, promoting resilience and service use, the number of studies exploring these outcomes is currently limited. Implications. Occupational therapists support individuals expressing SI, and SSP is a necessary skill for practice.
... 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 series of secondary data analyses were performed on a randomized clinical trial sample consisting of 97 active-duty U.S. Army personnel who voluntarily presented with active suicide ideation (i.e., past week) and/or a lifetime suicide attempt history to a military medical clinic for an emergency behavioral health evaluation (Bryan et al., 2017). The only exclusion criterion was a psychiatric or medical condition that would impair mental status and thus preclude informed consent (e.g., acute intoxication, psychosis, mania). ...
... SD = 5.78). For a detailed description of participant characteristics, inclusion criteria, and overall study design, see Bryan et al. (2017). ...
Article
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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.
... The CSP is intended to increase a patient's ability to cope with a suicidal "dark moment" effectively averting suicidal behaviors. Importantly, the CSP is not the same as a "nosuicide" contract, which is essentially just a short-term promise initiated by the clinician to get a patient to not engage in suicidal behaviors (Rudd et al., 2006), and in recent years no-suicide contracts have been proven to be ineffective when compared to Crisis Response Plans (Bryan et al., 2017) and Safety Planning (Stanley et al., 2018). In other words, stabilization planning emphasizes what a patient will do versus promising what they will not do as we see with traditional no-harm/no-suicide contracts. ...
... The supportive individuals on the CSP may sometimes be invited by the clinician to attend a CAMS therapy session with the patient. In some cases, the use of a "Crisis Support Plan" can be established with a spouse or supportive friend to have guidance as to how to best support the patient (Bryan et al., 2017). ...
... Conceptually, the CSP may be considered a "cousin" of the Stanley and Brown Safety Plan and the Rudd and Bryan Crisis Response Plan as these approaches share similar elements (Bryan et al., 2017;Stanley et al., 2018). But while the CSP shares key elements and techniques used in other safety planning methods (e.g., lethal means counseling, coping skills, and relational supports), what sets CAMS apart is that the CSP exists within an evidence-based treatment of suicidal risk that is supported by extensive clinical trial research. ...
Article
Full-text available
The Collaborative Assessment and Management of Suicidality (CAMS) provides clinicians with an evidence-based suicide-focused therapeutic framework to help patients understand and manage suicidal thoughts and behaviors. A key component in CAMS suicide-focused treatment planning is the development and use of the CAMS Stabilization Plan (CSP). The CSP is used to ensure between-session safety and stability by helping patients learn to cope differently, enabling clinicians to care for suicidal patients on an outpatient basis, and thereby rendering suicidal-oriented coping obsolete. While implementing and maintaining the CSP, clinicians work to identify, target, and treat patient-identified suicidal drivers aimed at lowering the patient's suicide risk. The CSP employs a collaborative, flexible, and problem-focused approach creating a unique dynamic between clinician and patient as they work together to address the patient's suicidal struggle. CAMS allows clinicians to be flexible in their approach to treating suicidal behavior, utilizing techniques and tools they know, while providing them with a unique framework to engage their suicidal patients. Additionally, there is an overt and ongoing emphasis on encouraging patients to cultivate purpose and meaning in their lives with plans, goals, and hope for the future-ultimately leading patients to discover a life worth living, which is the final focus in CAMS-guided care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... 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; G. K. 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 problem-solving based psychotherapies (Salkovskis et al., 1990) are recommended in these guidelines, the evidence is not as strong for these therapies compared with CT-SP and BCBT. However, these guidelines do not provide information on how to manage comorbid PTSD in high-risk individuals nor do they discuss whether PTSD is managed by these interventions. ...
... This may mean that, similar to DBT-PTSD, the integration of different content elements of BCBT or PACT into CPT or PE to create a modified or new treatment for high-risk individuals at risk for suicide may be a promising treatment avenue. Alternatively, foundational components of suicide-specific treatments that are referenced in clinical practice guidelines (VA/DoD, 2019), including crisis response planning (CRP; Bryan et al., 2017) and the safety plan intervention (SPI; Stanley & Brown, 2012), are interventions that can be easily integrated into many treatments and are main components of suicide-specific interventions (i.e., BCBT and PACT). These interventions have been shown to reduce suicidal behaviors by 45%-76% when administered as standalone interventions and to improve other protective factors (Bryan et al., 2017;Rozek et al., 2019;Stanley et al., 2018). ...
... Alternatively, foundational components of suicide-specific treatments that are referenced in clinical practice guidelines (VA/DoD, 2019), including crisis response planning (CRP; Bryan et al., 2017) and the safety plan intervention (SPI; Stanley & Brown, 2012), are interventions that can be easily integrated into many treatments and are main components of suicide-specific interventions (i.e., BCBT and PACT). These interventions have been shown to reduce suicidal behaviors by 45%-76% when administered as standalone interventions and to improve other protective factors (Bryan et al., 2017;Rozek et al., 2019;Stanley et al., 2018). Preliminary work has suggested that using a CRP during trauma-focused treatment is feasible . ...
Preprint
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.
... 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. However, these guidelines do not provide information on how to manage comorbid PTSD in high-risk individuals, nor do they discuss whether PTSD is managed by these interventions. ...
... including Crisis Response Planning (CRP; Bryan et al., 2017) and the Safety Plan Intervention (SPI; Stanley & Brown, 2012) are interventions that can be easily integrated into many treatments and are main components of suicide-specific treatments (i.e., BCBT and PACT). ...
... These interventions have been shown to reduce suicidal behaviors by 45-76% as a stand-alone intervention and improve other protective factors (Bryan et al., 2017;Rozek et al., 2019;Stanley et al., 2018). Preliminary work has suggested using a CRP during trauma-focused treatment is feasible . ...
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.
... However, there are currently no published studies demonstrating that WET reduces suicidal thoughts and behaviors. Given its otherwise similar performance to other evidence-based PTSD treatments, WET combined with brief interventions that focus on selfinjurious thoughts and behaviors, such as Crisis Response Planning for suicide [16], is a promising treatment for high-risk patients. ...
... Based on prior work demonstrating 1) the effectiveness of WET on changes in PTSD severity [14], and 2) the strong relationship between reductions in PTSD and concomitant reductions in suicidal thoughts and behaviors [6][7][8], and 3) CRP is associated with large changes in all of the suicide-related outcomes of interest [16], we expect WET-S to have a large effect on outcomes of interest over and above TAU. Given tempered expectations in this yet unstudied population, we powered the study to detect a small to medium-sized effect in differences between the two groups' suicidal ideation and PTSD severity pre-post change scores, given that those effects are well established in related populations. ...
... 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]). Specifically, CRP has shown to reduce suicide attempts among active duty military personnel by 76% compared with typical suicide risk-management strategies [16]. ...
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.
... 208 Brief interventions, focused on the identification of warning signs, coping skills, social support, professional help and crisis planning, have been shown to be effective in preventing suicidal thoughts and behaviour. 209 The brief intervention and contact examined in the WHO Multisite Intervention Study on Suicidal Behaviours (SUPRE-MISS) randomized controlled trial showed a significant decrease in suicide after 18-month follow-up in comparison with usual care. 177 Similar to the psychosocial intervention literature, there was limited discussion about lifestyle and peerbased interventions. ...
... LGBTQ populations, may be particularly vulnerable during public health crises such as the COVID-19 pandemic as previous studies suggest they tend to have physical and mental health concerns. 209 Effective interventions for populations such as these need to consider factors such lifetime victimization, stigma, and distinct social support networks. 210 Pandemic specific services identified in the literature for these populations referred to delivery of psychotherapy through electronic means with directives to clients about keeping routine, stress management, and sleep hygiene. ...
Technical Report
Full-text available
This is the CIHR Report on COVID-19 mental and physical health interventions for the population in post-pandemic recovery
... We integrated a brief MBI and CRP because previous research has shown that treatment effects on SI and behaviors are larger when interventions directly target SI and behavior. 31 CRP is a single-session, 30-minute intervention, collaboratively developed between the patient and provider, which helps patients to identify and select self-regulation strategies that can avert or attenuate suicidal crises. CRP has been shown to reduce suicide attempts by 76% compared to usual treatment. ...
... CRP has been shown to reduce suicide attempts by 76% compared to usual treatment. 31,32 Owing to its efficacy, CRP is recommended for use with suicidal veterans in the VA/DoD Clinical Practice Guideline as a standard care practice. Secondary aims include the determination of whether there were pre-to post-intervention changes in measures of suicide risk, mindfulness, and emotional regulation. ...
Article
Introduction This study was a preliminary evaluation of a manualized, brief mindfulness-based intervention (MB-SI) for veterans with suicidal ideation (SI), admitted into an inpatient psychiatric unit (IPU). Materials and Methods A randomized, controlled pilot study of 20 veterans aged 18-70 years with SI, admitted into a psychiatric unit, assigned to treatment as usual (TAU) or MB-SI groups. Outcome data were collected at three time points: preintervention (beginning of first session), postintervention (end of last session), and 1-month postintervention. Primary outcomes were safety and feasibility. Secondary outcome measures were SI and behavior, mindfulness state and trait, cognitive reappraisal, and emotion regulation. Additionally, psychiatric and emergency department admissions were examined. Data analysis included Generalized Linear Models, Wilcoxon Signed-Rank, Mann–Whitney U, and Fisher’s exact tests for secondary outcomes. Results Mindfulness-based intervention for suicidal ideation was feasible to implement on an IPU, and there were no associated adverse effects. Mindfulness-based intervention for suicidal ideation participants experienced statistically significant increase in Toronto Mindfulness Scale curiosity scores 1-month postintervention compared to preintervention and greater Toronto Mindfulness Scale decentering scores 1-month postintervention compared to TAU. Emotion Regulation Questionnaire Reappraisal scores significantly increased for the MB-SI group and significantly decreased for TAU over time. IPU and emergency department admissions were not statistically different between groups or over time. Both TAU and MB-SI participants experienced a significant reduction in Columbia-Suicide Severity Rating Scale-SI scores after the intervention. MB-SI participants experienced a higher increase in Five-Facet Mindfulness Questionnaire scores postintervention compared to TAU. Conclusions Mindfulness-based intervention for suicidal ideation is feasible and safe to implement among veterans during an inpatient psychiatric admission with SI, as it is not associated with increased SI or adverse effects. Preliminary evidence suggests that MB-SI increases veterans’ propensity to view experiences with curiosity while disengaging from experience without emotional overreaction. Further, more rigorous research is warranted to determine efficacy of MB-SI. Trial registration The clinicaltrials.gov registration number is NCT04099173 and dates are July 16, 2019 (initial release) and February 24, 2022 (most recent update).
... A recent randomized controlled trial in active duty Army soldiers found those in either response planning groups had a 76 percent reduction in attempts, a decline in ideation, fewer overall inpatient hospital stays, and a reduction in negative emotion states compared to the control safety contract group. 89 Depending on an patient's category of risk, there are numerous levels of care that may be appropriate for a patient with elevated suicide risk, including inpatient hospitalization, intensive outpatient programs (individual/ group therapy 3 to 4 times per week), as well as engagement in weekly, outpatient, evidence-based treatments such as cognitive behavioral therapy (CBT), acceptance commitment therapy (ACT), or dialectical behavioral therapy (DBT). [90][91][92][93][94][95] There is a growing consensus in the suicide behavior literature that treatment interventions should address coping deficiencies and symptoms of psychological distress in patients who have attempted suicide. ...
... 105 Whether co-located or more fully integrated, a growing body of research indicates that collaborative behavioral-primary care results in improved patient outcomes. 89 Interprofessional training for mental and behavioral health collaboration with chiropractors is largely unreported at this time and is a potential opportunity to enhance the chiropractor's role in evidenced-based tertiary suicide prevention. ...
Article
Full-text available
Objective: To provide the practicing chiropractor foundational knowledge to enhance the understanding of relevant primary, secondary, and tertiary public health measures for suicide prevention. Methods: A descriptive literature review was performed using keywords low back pain, neck pain, psychosocial, pain, public health, suicide, suicide risk factors, and suicide prevention. English language articles pertaining to suicide prevention and the chiropractic profession were retrieved and evaluated for relevance. Additional documents from the Centers for Disease Control, Veterans Health Administration, and the World Health Organization were reviewed. Key literature from the clinical social work and clinical psychology fields were provided by authorship team subject matter experts. Conclusion: No articles reported a position statement regarding suicide prevention specific to the chiropractic profession. Risk, modifiable, and protective factors associated with self-directed violence are important clinical considerations. A proactive approach to managing patients at-risk includes developing interprofessional and collaborative relationships with mental health care professionals.
... Several innovative suicide-specific evidence-based practices have been developed that have shown effectiveness in reducing suicide risk. These psychotherapy interventions include but are not limited to Dialectical Behavior Therapy (DBT: Linehan, Cochran, & Kehrer, 2001), Cognitive Therapy for Suicide Prevention (CT-SP: Brown et al., 2005), Brief Cognitive Behavior Therapy for Suicide Prevention (Bryan & Rudd, 2018) and the Collaborative Assessment and Management of Suicidality (CAMS: Jobes, Wong, Conrad, Drozd, & Neal-Walden, 2005), as well as brief interventions, such as the Safety Planning Intervention (SPI: Stanley & Brown, 2012), Crisis Response Planning (CRP: Bryan et al., 2017) and counseling on access to lethal means (CALM: Suicide Prevention Resource Center, 2009). While brief remote follow-up interventions (e.g., caring contacts) for reducing suicide risk has been shown to be acceptable and promising (Milner, Carter, Pirkis, Robinson, & Spittal, 2015), evidence-based interventions for suicide have historically been delivered face-to-face. ...
Article
Background: This PRISMA scoping review explored worldwide research on the delivery of suicide-specific interventions through an exclusive telehealth modality. Research over telehealth modalities with suicidal individuals highlights the importance of facilitating participants' access to treatments despite location and circumstances (e.g., rural, expenses related to appointments, etc.). Aim: The review sought evidence of outcomes of trials or projects in which both the patient and therapist attended sessions conjointly and openly discussed suicide over a telehealth modality (e.g., phone, zoom). Method: To explore this topic the authors searched for research trials and quality improvement projects using Ovid Medline, Ovid Embase, Ovid PsycINFO, EBSCO Social Services Abstracts, and Web of Science on 3/3/2021. Results: Nine different articles were included that each spanned distinct treatments, with eight being research studies and one being a quality improvement project. Limitations: Publications featuring ongoing or upcoming research in which complete study results were not available did not meet inclusion criteria for this review. Conclusion: Several important research gaps were identified. While this approach has been largely understudied, exclusive telehealth delivery of suicide-specific interventions has great potential for the prevention of suicidality, especially in the era of COVID-19 and beyond.
... Key performance elements (KPEs) and adherence measurements for these interventions either do not exist, are designed for implementation of research protocols and unwieldly, are buried in guidance documents, and/or are intended for use when delivering a specific evidence-based protocol (e.g. Safety Planning (Stanley & Brown, 2012), Crisis Response Planning (Bryan, 2010;Bryan et al., 2017), or Stabilization Planning (Jobes, 2012)) but are ill-suited for use in many real-world settings that combine a range of different evidence-based procedures. ...
Article
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Objective: Evidence-based suicide prevention interventions directed to those seeking psychiatric crisis services for suicidality in the emergency department (ED) can reduce death by suicide and related suffering. Best practice guidelines for the care of suicidal patients in the ED exist but are not accompanied by fidelity tools for use in determining whether the interventions were applied, particularly when more than one intervention is delivered concurrently. We sought to develop a universal, treatment-agnostic Suicide Care Fidelity Checklist comprised of Key Performance Elements (KPE) across the recommended suicide-specific ED interventions. Method: A comprehensive review of published care standards was first conducted to determine suicide-specific ED best practice treatment domains and KPEs. Subject matter experts (SMEs) were identified for each domain. Using the Delphi Consensus method, SMEs iteratively revised and refined the KPEs within their domain until achieving KPE item consensus. Results: A total of three iterations was required to obtain consensus in five of six domains: comprehensive suicide assessment, lethal means counseling, suicide crisis planning, behavioral skills training, and psychoeducation about suicidality. Consensus was not fully attained for the domain involving engagement with people with lived experience. Conclusions: We successfully identified six intervention domains and 74 KPEs across domains (60 deemed essential, and 14 deemed optional), with full consensus reached for 70 KPEs. While replication of the initial findings is required, the Suicide Care Fidelity Checklist can be used as a fidelity checklist to verify delivery of suicide-specific ED interventions.HIGHLIGHTSApplied Delphi Consensus method with suicide-specific subject matter experts.Generated a treatment-agnostic, universal set of suicide prevention KPEs for EDs.Expert-derived KPEs help real-world settings to assess suicide care fidelity.
... Exclusionary criteria will be comprised of: (1) persons who are not actively employed in the fire department (e.g., former firefighters, retired firefighters), (2) persons with current (past month) suicidal or homicidal ideation with intent and plan (i.e., participants in imminent danger), and (3) persons who are unable or unwilling to provide verbal or written consent. Participants who endorse current (past month) suicidal ideation with intent and plan, assessed using the Beck Scale for Suicide Ideation -5 (BSS-5) [30], will be contacted via phone by fire department staff psychologists within 24 h of their response and a suicide risk assessment will be conducted per empirical recommendations [31]. Fire department staff psychologists utilize department-specific resources to ensure immediate safety of the participant. ...
Article
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Mindfulness-based interventions have demonstrated efficacy with regard to diverse psychological symptoms across populations. Few studies have evaluated the efficacy of mindfulness-based interventions for firefighters. This pilot randomized clinical trial (RCT) is designed to determine the preliminary efficacy, feasibility, and acceptability of a novel mindfulness-based workshop (entitled “Healthy Action Zone Mindful Attention Training” [HAZMAT]) developed for firefighters (Clinical Trials Identifier: NCT04909216). An anticipated sample size of 100 firefighters from a large fire department in the southern U.S. will be recruited. Firefighters will be randomized to: (1) HAZMAT workshop or (2) waitlist comparison condition. Outcomes will be assessed at baseline and five follow-up time-points: post-workshop, 1-week follow-up, 1-month follow-up, 3-month follow-up, and 6-month follow-up. First, we will evaluate the acceptability of the HAZMAT workshop as defined by firefighters’ self-reported satisfaction with the workshop. Feasibility will be defined by the proportion of firefighters who start and complete the full workshop. Second, we will examine the efficacy of the HAZMAT workshop, as compared to waitlist, on psychological symptom reduction, as defined by: self-reported symptom severity of PTSD, depression, anxiety, suicidal ideation, and alcohol use at each follow-up time-point. Third, we will evaluate the impact of the HAZMAT workshop, as compared to waitlist, on putative treatment targets, indexed via self-reported levels of (1) mindful attention and (2) nonjudgmental acceptance each follow-up time-point.
... Another possibility is that, when suicidal intent is disclosed to clinicians, clinicians have the opportunity to engage in suicide-specific interventions that mitigate, at least in part, subsequent suicide risk. Several psychological interventions, including safety planning (Bryan et al., 2017;Stanley and Brown, 2012), lethal means counseling (Betz et al., 2016), and the Collaborative Assessment and Management of Suicidality (CAMS; Jobes, 2006), directly target suicidal thoughts and behaviors; it is possible that clinicians may have used one or more of these interventions, thereby potentially reducing subsequent symptoms and suicide risk among patients who disclosed intent to clinicians. Likewise, it is possible that additional pharmacological interventions were utilized, or that level of care was intensified among patients disclosing suicidal intent to clinicians. ...
Article
Several patient and setting characteristics have been found to predict disclosure of suicidality to clinicians versus researchers. Less understood, however, is whether differential disclosure of suicidality predicts concurrent indirect indicators of suicide risk and future suicide-related outcomes. The present study examined differential disclosure of suicidal intent in clinical versus research settings as a predictor of (1) concurrent symptoms of the Suicide Crisis Syndrome (SCS); and (2) suicidal ideation and attempts within one month in patients (n = 1039) and their clinicians (n = 144), who completed a battery of self-report and interview measures at baseline. Patients who reported suicidal intent to anyone had higher concurrent SCS symptoms than those who denied suicidal intent, with no differences between those who reported intent to clinicians versus researchers only. Severity of suicidal ideation and rates of suicide attempts at one-month follow-up were higher among those who disclosed suicidal intent to a research assistant than among those who did not—regardless of whether suicidal intent was disclosed to their clinician. Overall, an improved understanding of the factors contributing to differential disclosure will improve both scientific inquiry and patient safety.
... Typically, safety plans include internal (e.g., distraction, self-soothing) and external (e.g., calling a crisis line) coping strategies that are specifically aimed at reducing the intensity of suicidal thoughts and urges (Stanley & Brown, 2012). Stand-alone safety and crisis response planning interventions have demonstrated effectiveness in reducing suicidal behavior in adults (Bryan et al., 2017;Stanley et al., 2018), suggesting that coping in this way can be effective in reducing suicide risk. Other studies involving veterans have shown that coping specifically with suicidal thoughts also protected against suicidal events within a 90day period, even after adjusting for previous suicide attempts, suicidal thoughts, and other well-known risk factors (Interian et al., 2019). ...
Article
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Background Youth suicide has been increasing at an alarming rate. Identifying how youth at risk for suicide cope with daily distress and suicidal thoughts could inform prevention and intervention efforts. We investigated the relationship between previous‐day coping and next‐day suicidal urge intensity in a high‐risk adolescent sample for a 4‐week period. We also investigated the influence of adolescents' average coping levels, over 4 weeks, on daily severity of suicidal urges. Methods A total of 78 adolescents completed daily diaries after psychiatric hospitalization (n = 1621 observations). Each day, adolescents reported their use of specific coping strategies, overall coping helpfulness, and intensity of suicidal urges. Results Greater professional support seeking from providers/crisis lines and perceptions of coping helpfulness on the previous day were associated with lower next‐day suicidal urges. Adolescents who reported greater average use of cognitive strategies, personal support seeking from family/friends, and higher average perceptions of coping helpfulness, relative to others, had lower daily suicidal urges. Noncognitive strategy use was not related to daily suicidal urge intensity. Conclusion Findings point to the benefit of intervention efforts focusing on strengthening personal and professional supportive relationships, assisting youth with developing a broader coping repertoire, and working with adolescents to identify strategies they perceive to be helpful.
... Safety planning should not be confused with a "contract for safety/no-suicide contract, " which has been shown to be ineffective (73). Safety planning requires that practice managers designate a work-flow to accomplish this when needed, and allow for building in mental health support staff based on local resources (68); practices without behavioral health support should determine in advance who will create the safety plan with the patient (e.g., nursing staff, trained medical assistants, PCPs). ...
Article
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Importance Suicide prevention implementation in primary care is needed due to the increasing rate of suicide in the past few decades, particularly for young and marginalized people. Primary care is the most likely point of contact for suicidal patients in the healthcare system. Attention to the level of medical integration with behavioral health is vital to suicide prevention and is applied throughout this review. Methods A narrative review was performed. Observations Many interventions help improve suicide prevention care. PCP education, screening, safety planning/lethal means reduction, care transitions, psychotherapy, and medication management are all evidence-based strategies. Additionally, the pragmatic topics of financing suicide prevention, supporting providers, enacting suicide postvention, and preparing for future directions in the field at each level of primary care/behavioral health integration are discussed. Conclusions and Relevance The findings are clinically relevant for practices interested in implementing evidence-based suicide prevention strategies by attending to the behavioral health/medical interface. Leveraging the patient/provider relationship to allow for optimal suicide prevention care requires clinics to structure provider time to allow for emotionally present care. Defining clear roles for staff and giving attention to provider well being are also critical factors to supporting primary care-based suicide prevention efforts.
... As suggested by the National Action Alliance for Suicide Prevention [74], one of the main aspects of CBT-SP is represented by the Crisis Response Planning (CRP) [19] for short-term suicide risk management. The CRP is a brief procedure in which the clinician and the patient collaboratively write down a list of strategies that the individual can implement to better recognize early indicators of suicidal crises and to employ adaptive self-regulatory techniques to reduce emotional suffering [84]. ...
... Alternative to the SPI, Crisis Response Planning (CRP) has been also shown to be effective on reduction of inpatient hospitalizations and suicidal ideations in U.S. army soldiers compared to the contract for safety (43). Like SPI, personal warning signs, coping strategies, social and professional crisis support as well as individual reasons for living are outlined. ...
Article
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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.
... Short-term psychosocial interventions often focus on helping individuals to become aware of suicidal behavior, motivating them to seek help and engage in safety planning, as well as developing management strategies for future suicidal crises [17]. Brief intervention and contact and safety planning intervention or crisis response planning, have been shown to reduce the risk of suicide [75][76][77]. Volitional help sheet was found to be effective in reducing the repetition of self-harm following a suicide attempt [78] while the Attempted Suicide Short Intervention program reduced the number of suicide attempts [79]. The expert panel considered that the use of no-suicide contract does not guarantee suicide deterrence and may even obscure the actual suicide risk of the patient -patients may not disclose their suicidal intention due to concerns over disappointing their clinicians by breaking the contract. ...
Article
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Background The high prevalence of suicidal behavior among individuals with major depressive disorder (MDD) in Southeast Asia (SEA) underscores the need for optimized management to address depressive symptoms, reduce suicide risk and prevent suicide in these individuals. Given the lack of clear guideline recommendations for assessing and managing these patients, regional consensus-based recommendations which take into account diverse local contexts across SEA may provide useful guidance for clinical practice. Methods A narrative literature review and pre-meeting survey were conducted prior to the consensus meeting of an SEA expert panel comprising 13 psychiatrists with clinical experience in managing patients with MDD with suicidal behavior. Utilizing the RAND/UCLA Appropriateness Method, the expert panel developed consensus-based recommendations on the assessment and treatment of adult patients with MDD with suicidal behavior under 65 years. Results Screening of adult patients under 65 years with MDD for suicide risk using both a validated assessment tool and clinical interview is recommended. An improved suicide risk stratification – incorporating both severity and temporality, or using a prevention-focused risk formulation – should be considered. For a patient with an MDD episode with low risk of suicide , use of antidepressant monotherapy, and psychotherapy in combination with pharmacological treatment are both recommended approaches. For a patient with an MDD episode with high risk of suicide , or imminent risk of suicide requiring rapid clinical response , or for a patient who had received adequate AD but still reported suicidal behavior , recommended treatment strategies include antidepressant augmentation, combination use of psychotherapy or electroconvulsive therapy with pharmacological treatment, and inpatient care. Suicide-specific psychosocial interventions are important for suicide prevention and should also be part of the management of patients with MDD with suicidal behavior. Conclusions There are still unmet needs in the assessment of suicide risk and availability of treatment options that can deliver rapid response in patients with MDD with suicidal behavior. These consensus recommendations on the management of adult patients with MDD with suicidal behavior under 65 years may serve as a useful guidance in diverse clinical practices across the SEA region. Clinical judgment based on careful consideration of individual circumstances of each patient remains key to determining the most appropriate treatment option.
... Safety planning also involves a conversation around restricting the patient's access to lethal means (Stanley & Brown, 2012). Although safety planning has primarily been tested with high-risk active-duty soldiers (e.g., Bryan et al., 2017) and veterans presenting to emergency departments for a suicidal crisis (e.g., Currier et al., 2015), safety planning may have applicability in primary care settings as well. ...
Article
Primary care is an important setting for improving identification and treatment of people at risk for suicide. However, there are few standardized protocols for management of suicide risk in primary care. In this paper, we outline evidence-based practice considerations for behavioral health consultants (BHCs) tasked with conducting suicide risk assessments and safety planning interventions in integrated primary care behavioral health (PCBH) settings. Specifically, we highlight the importance of a nonjudgmental and direct approach to suicide risk assessment, a supportive therapeutic relationship, and a stepped care approach wherein suicide risk is managed in the least restrictive setting possible.
... The papers also contribute to our scientific knowledge of how individual's responses during brief treatments can impact the intervention itself. Safety planning interventions were developed to provide high-risk individuals with tools that would enable them to resist suicidal urges for brief periods of time (22), and there is growing support for their efficacy and effectiveness (23)(24)(25). In a small study of warning signs among individuals who received Crisis Response Planning (CRP), a safety planning intervention, Bauder et al. did not find systematic differences in warning signs across important demographic categories and gun ownership. ...
... These interventions include dialectical behavioral therapy (Linehan, 1993), rumination-focused cognitive-behavioral therapy (Watkins, 2016), and mindfulness-based therapies (Chesin et al., 2016;Forkmann et al., 2014), among others, in addition to or in conjunction with anxiolytic and antipsychotic medications (Calati, Nemeroff, Lopez-Castroman, Cohen, & Galynker, 2020). Finally, targeting ruminative flooding through empirically-validated brief interventions for suicidal behavior, including safety planning (Stanley & Brown, 2012) and crisis response planning (Bryan et al., 2017), that identify and recommend activities that distract from and/or interrupt perseverative thought processes (e.g., mentally engaging activities with close others) may be useful in averting suicidal crises. Lethal means counseling (Barber & Miller, 2014) may similarly mitigate the risk of acting on suicidal urges during moments in which individuals are experiencing ruminative flooding. ...
Article
Previous research has identified both goal orientation and ruminative flooding as potential risk factors for suicidal thoughts and behaviors, as well as positive associations between goal orientation and rumination. The present study examined whether the association between goal orientation and suicidal thoughts and behaviors, assessed one month later, was accounted for by ruminative flooding. A sample of 924 psychiatric outpatients (Mage = 39.09 years, SD = 14.82, range = 18 to 84; 61.7% female; 37.0% White) completed self-report and interview measures at baseline and provided information about suicide-related outcomes at one-month follow-up. Goal orientation was positively associated with ruminative flooding, and both goal orientation and ruminative flooding were associated with suicidal thoughts and behaviors at one-month follow-up. Controlling for lifetime suicidal thoughts and behaviors, as well as patient age and sexual orientation, ruminative flooding accounted for the relationship between goal orientation and suicidal thoughts and behaviors at one-month follow-up. These findings were especially relevant for individuals with a history of multiple suicide attempts. Overall, this study provided evidence that difficulties with goal orientation may relate to suicidal thoughts and behaviors through intense ruminations perceived as a loss of cognitive control. Interventions that address ruminative thinking and cognitive flexibility may, in turn, assist in reducing emotion dysregulation and managing suicidality among those who struggle with goal orientation.
... Specifically, directors often reported that their institution's approach to safety planning involved a "contracting for safety" approach, which is considered a suboptimal or even harmful approach to the care of young people at risk of suicide. [47][48][49][50][51] PEDs might consider employing the expertise of their local mental health specialists and existing quality improvement infrastructure in helping to select which best practices to implement and how to ensure adherence to best practice recommendations. ...
Article
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Objective: To assess pediatric emergency departments' (PEDs) current suicide prevention practices and climate for change to improve suicide prevention for youth. Methods: We conducted an explanatory, sequential mixed-methods study. First, we deployed a national, cross-sectional survey of PED leaders identified through publicly available data in Fall 2020, and then we conducted follow-up interviews with those who expressed interest. The survey queried each PED's suicide prevention practices and measured readiness for change to improve suicide prevention practices using questions scored on a 5-point Likert scale. Interviews gathered further, in-depth descriptions of PEDs' practices and culture. Interviews were audio-recorded, transcribed verbatim, and analyzed using a rapid analysis approach. Results: Of 135 PED directors eligible to complete the survey, 64 responded (response rate 47%). A total of 64% of PEDs had a mental health specialist available 24 hours/day, 7 days/week; 80% reported practicing mental health disposition planning, and 41% reported practicing psychiatric medication management. Altogether 91% of directors agreed or strongly agreed that their PED had a positive culture and 92% agreed/strongly agreed that their PED was ready for change. However, 31% disagreed/strongly disagreed that their PED had tools for evaluation and quality measurement. Resources needed for change (including budget, staffing, training, and facilities) varied across institutions. Interviews with our convenience sample of 21 directors revealed varying suicide prevention practices and confirmed that standardization, evaluation, and quality improvement initiatives were needed at most institutions. Leaders reported a high interest in improving care. Conclusions: PED leaders reported high motivation to improve suicide prevention services for young people, and reported needing quality improvement infrastructure to monitor and guide improvement.
... Cisgender man served as tde reference group for dummy-coded gender identity. physical access to individuals' potential suicide methods is warranted, though this should particularly be done in conjunction with other empirically supported interventions to manage suicidal crises (Barber & Miller, 2014;Betz et al., 2016;Bryan et al., 2017;Stanley & Brown, 2012). More broadly, interventions that increase one's opportunity (i.e., time, cognitive capacity) to consider and enact behavioral alternatives in the context of low psychological distance to suicide methods may have particular utility (Olson et al., 2022). ...
Article
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Previous evidence has highlighted the potential roles of both physical and psychological distance to suicide methods as an important factor in conferring suicide risk; however, less is known about the temporal stability of and associations between these constructs, other facets of capability for suicide, and suicide-related outcomes. The present study examined fluctuations in and associations between physical and psychological distance to suicide methods, fearlessness about death, and suicidal intent using ecological momentary assessment. A sample of 237 adults at high risk for suicide (61.6% female, Mage = 27.12 years) responded to six prompts daily for 2 weeks assessing their physical and psychological distance to preferred suicide methods, fearlessness about death, and suicidal intent. Results indicated that physical and psychological distance to suicide methods exhibited both trait- and state-like properties, that lower physical and psychological distance and higher fearlessness about death were associated with higher concurrent suicidal intent, and that lower psychological distance was uniquely predictive of higher subsequent time-point suicidal intent, controlling for concurrent suicidal intent. Suicide attempt history and preferred suicide methods were explored as potential moderating factors. Overall, these findings highlight the importance of assessing and intervening upon psychological distance to suicide methods, in addition to physical proximity to these methods, in lethal means counseling. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
... The core of response planning is the development of a crisis response plan. Crisis response plans are a short series of steps that can be taken when suicidal thoughts are triggered to provide proximal risk reduction (Rudd et al., 2001), and have been shown to be an effective prevention technique (Bryan et al., 2017). Some of the steps in crisis response planning are therapeutic in nature (identifying problematic cognitions) and not suitable for law enforcement intervention but other aspects can be incorporated into the modified crisis response plan (M-CRP) proposed below. ...
Thesis
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BACKGROUND Modern Child Sexual Exploitation Material (CSEM) offences predominantly occur within a technological ecosystem. The behaviours and cognitions of CSEM offenders influence, and are influenced by, their choice of facilitative technologies that form that ecosystem. OBJECTIVES This thesis will review the prior research on cognitive distortions present in and technology usage by CSEM offenders, and present a new theory, Lawless Space Theory (LST), to explain those interactions. The cognitions and technical behaviours of previously convicted CSEM offenders will be examined in a psychosocial context and recommendations for deterrence, investigative, and treatment efforts made. PARTICIPANTS AND SETTING Data was collected using an online survey collected from two samples, one from a reference population of the general public (n=524) and one from a population of previously convicted CSEM offenders (n=78), both of which were composed of adults living in the United States. METHODS Two reviews were conducted using a PRISMA methodology - a systematic review of the cognitive distortions of CSEM offenders and an integrative review of their technology usage. A theoretical basis for LST was developed, and then seven investigations of the survey data were conducted evaluating the public’s endorsement of lawless spaces; the public’s perceptions of CSEM offenders; the self-perceptions of CSEM offenders; the suicidality of the offender sample; the use of technology and countermeasures by the offender sample; the collecting and viewing behaviours of the offender sample; and the idiographic profiles of the offender sample. RESULTS The reviews found that the endorsement of traditional child contact offender cognitive distortions by CSEM offenders was low, and that they continued to use technology beyond its normative lifecycle. LST was developed to explain these behaviours, and the view of the Internet as generally lawless was endorsed by the reference and offender samples. The public sample showed biased beliefs that generally overestimated the prevalence of, and risk associated with, CSEM offending when compared to the offender sample. Offenders were found to have viewed investigators as having a lack of understanding and compassion, and they exhibited very high suicidal ideation following their interaction with law enforcement. Offenders exhibited similar technical abilities and lower technophilia than the reference sample, chose technologies to both reduce psychological strain and for utility purposes, and many exhibited cyclic deletions of their collections as part of a guilt/shame cycle. CONCLUSIONS AND IMPLICATIONS Understanding CSEM offenders’ technological behaviours and cognitions can inform more effective investigative, deterrence, and treatment efforts. Law enforcement showing compassion during investigations may generate more full disclosures while facilitating offender engagement with resources to reduce suicidality. Deterrence efforts focused on establishing capable guardianship and reducing perceived lawlessness provide the potential to reduce offending. Treatment of criminogenic needs for the majority of CSEM offenders is not supported by evidence, but noncriminogenic treatment warrants broader consideration.
Article
The interpersonal theory of suicide posits people are more likely to consider suicide when they perceive themselves as alone and as a burden. However, there is limited research on whether these self-perceptions reflect caregiver experiences. As part of a larger study of collaborative safety planning, 43 Veteran/caregiver dyads (N = 86 individuals) completed measures of belongingness and burdensomeness, caregiver burden, family problem solving, and suicide-related coping. We conducted dyad-level actor interdependence models allowing two types of social coping (i.e., general problem solving and suicide-specific coping) to predict Veteran’s self-views and caregiver interpersonal perceptions. Results suggested that Veteran social coping predicted lower Veteran thwarted belonginess and burdensomeness and caregiver involvement in problem solving was similarly associated with their own lower caregiver emotional burden. But examination of cross-partner effects demonstrated that greater Veteran coping was associated with greater time burden for caregivers. Findings suggest that social coping is associated with positive perceptions at the individual level (i.e., Veterans and caregivers to themselves) but does not indicate positive effects at the partner level. Clinicians working with Veterans may wish to involve supports in care to encourage effective collaboration that meets both caregiver/recipient needs.
Article
Firefighters are chronically exposed to trauma as well as occupational and relational stressors. Furthermore, firefighters are faced with cultural and structural barriers in accessing psychological treatment services. Symptoms of posttraumatic stress disorder, depression, anxiety, and alcohol use disorder are prevalent, and suicidal ideation and behavior pose a significant public health concern. Awareness of fire culture is necessary for developing and enhancing evidence-based treatment services and increasing treatment initiation and adherence in this resilient, vulnerable, and understudied population. An overview of the mental health landscape of the fire service is provided, and major assessment and treatment issues are explored.
Article
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Purpose of Review There are a number of evidence-based therapies for posttraumatic stress disorder (PTSD; e.g., cognitive processing therapy; prolonged exposure therapy). Many patients with PTSD present to treatment at elevated risk for suicide. In such circumstances, navigating evidence-based treatment for PTSD can be challenging, requiring nuanced approaches to ensure optimal therapeutic outcome while ensuring patient safety. Recent Finding This manuscript describes the evidence for treating PTSD in the context of elevated risk for suicide. Methods of navigating clinical complexity (e.g., multimorbidity, psychosocial stressors) while maintaining fidelity to evidence-based protocols are discussed. Summary We conclude by noting gaps in understanding, as well as necessary future research directions to ensure optimal care for this clinical population.
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
Objectives The purpose of the current study was to examine the possibility that there are multiple pathways to suicidal behavior by conducting a fine-grained investigation of the relationship between suicidal thought content and suicidal behavior. Methods Six thousand two hundred US adults completed self-report measures of suicidal thoughts and behaviors. Descriptive statistics and logistic regression were used to examine the relationship between suicidal thoughts and behaviors. Results About 36.0% of participants with a lifetime suicide attempt denied ever experiencing any active suicidal thoughts and 11.0% denied ever experiencing any suicidal thoughts; 53.8% of recent attempters denied recent active suicidal thoughts and 22.6% denied any recent suicidal thoughts. Additionally, the sole presence of passive suicidal ideation was associated with increased odds of lifetime and past-month suicide attempts. Conclusions These findings suggest that there are likely multiple pathways to suicide, some of which do not involve progressively worsening suicidal thoughts.
Article
Background Suicide is the 10th leading cause of death in the United States, with >47,000 deaths in 2019. Most people who died by suicide had contact with the health care system in the year before their death. Health care provider training is a top research priority identified by the National Action Alliance for Suicide Prevention; however, evidence-based approaches that target skill-building are resource intensive and difficult to implement. Advances in artificial intelligence technology hold promise for improving the scalability and sustainability of training methods, as it is now possible for computers to assess the intervention delivery skills of trainees and provide feedback to guide skill improvements. Much remains to be known about how best to integrate these novel technologies into continuing education for health care providers. Objective In Project WISE (Workplace Integrated Support and Education), we aim to develop e-learning training in suicide safety planning, enhanced with novel skill-building technologies that can be integrated into the routine workflow of nurses serving patients hospitalized for medical or surgical reasons or traumatic injury. The research aims include identifying strategies for the implementation and workflow integration of both the training and safety planning with patients, adapting 2 existing technologies to enhance general counseling skills for use in suicide safety planning (a conversational agent and an artificial intelligence–based feedback system), observing training acceptability and nurse engagement with the training components, and assessing the feasibility of recruitment, retention, and collection of longitudinal self-report and electronic health record data for patients identified as at risk of suicide. Methods Our developmental research includes qualitative and observational methods to explore the implementation context and technology usability, formative evaluation of the training paradigm, and pilot research to assess the feasibility of conducting a future cluster randomized pragmatic trial. The trial will examine whether patients hospitalized for medical or surgical reasons or traumatic injury who are at risk of suicide have better suicide-related postdischarge outcomes when admitted to a unit with nurses trained using the skill-building technology than those admitted to a unit with untrained nurses. The research takes place at a level 1 trauma center, which is also a safety-net hospital and academic medical center. Results Project WISE was funded in July 2019. As of September 2021, we have completed focus groups and usability testing with 27 acute care and 3 acute and intensive care nurses. We began data collection for research aims 3 and 4 in November 2021. All research has been approved by the University of Washington institutional review board. Conclusions Project WISE aims to further the national agenda to improve suicide prevention in health care settings by training nurses in suicide prevention with medically hospitalized patients using novel e-learning technologies. International Registered Report Identifier (IRRID) DERR1-10.2196/33695
Article
Objective: Failing to account for temporal dynamics can hinder our understanding of suicidal ideation and the potential mechanisms underlying increased risk for suicide death and suicide attempts associated with posttraumatic stress disorder (PTSD). To address these limitations, this study used an analytic approach based on Dynamical Systems Theory to describe temporal patterns associated with multiple dimensions of suicidal ideation in a treatment-seeking sample of military personnel diagnosed with PTSD. Method: We performed a secondary analysis of archived data from 742 active-duty military personnel (90% male, 57% white, mean age = 33 ± 7.4 years) enrolled in three clinical trials to examine the dimensional measurement properties of the first 5 items of the Scale for Suicidal Ideation (SSI). Results: Findings indicated two change dynamics for suicidal ideation: homeostatic (i.e., the tendency for suicidal ideation to return to a stable point) and cyclical (i.e., the tendency for suicidal ideation to switch back and forth between higher and lower values). Cycling was the dominant dynamic and was related to variables other from suicidal ideation. Conclusion: The cyclic nature of suicidal ideation suggests that assessment timing and context could influence observed associations with other variables. Analytic approaches and clinical methods that do not account for the temporal dynamics of suicide risk could miss these properties, thereby hindering efforts to identify mechanisms underlying the relationship between PTSD and suicidal thoughts and behaviors and limiting opportunities for proactive and timely intervention. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
Chapter
The rising number of mass casualty incidents in the United States has exposed hospital personnel to more traumatic events on the job than ever before, with research citing a lack of mental health support following such events. It is often assumed that the advanced training of medical professionals serves as a protective factor against PTSD and other mental health disorders resulting from occupational trauma. However, this notion is false, and if left untreated, these mental health issues may extend beyond personal distress and negatively impact patient care. Furthermore, not all hospital personnel who are directly exposed to mass casualty incidents have advanced medical training, and many of these individuals have had no experience with these types of traumas. This chapter outlines planning and implementation measures that hospitals can take prior to a mass casualty incident occurring, followed by steps, strategies, and supports that can be deployed once a hospital has become a treating facility for victims of a mass casualty incident.
Article
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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.
Article
Objective: Implementation of evidence-based suicide prevention is critical to prevent death by suicide. Contrary to previously held beliefs, interventions including contracting for safety, no-harm contracts, and no-suicide contracts are not best practices and are considered contraindicated. Little is known about the current use of best practices and contraindicated interventions for suicide prevention in community settings. Methods: Data were collected from 771 individuals enrolled in a suicide prevention training. Both mental health clinicians (n = 613) and mental health allies (e.g., teachers, first responders) (n = 158) reported which best practices (i.e., safety plan, crisis response plan) and contraindicated interventions (i.e., contracting for safety, no-harm contract, no-suicide contract) they use with individuals who presents with risk for suicide. Results: The majority of both mental health clinicians (89.7%) and mental health allies (67.1%) endorsed using at least one evidence-based practice. However, of those who endorsed using evidence-based interventions, ∼40% of both mental health clinicians and allies endorsed using contraindicated interventions as well. Conclusion: Contraindicated interventions are being used at high rates and suicide prevention trainings for evidence-based interventions should include a focus on de-implementation of contraindicated interventions. This study examined only a snapshot of what clinicians and allies endorsed using. Additional in depth information about each intervention and when it is used would provide helpful information and should be considered in future studies. Future research is needed to ensure only evidence-based interventions are being used to help prevent death by suicide.Highlights:The majority of both mental health clinicians and mental health allies use evidence-based practices for suicide prevention. This indicates good implementation rates of evidence-based interventions for suicide prevention.Approximately 40% of both mental health clinicians and mental health allies who endorsed using evidence-based practices for suicide preventions also endorsed using contraindicated interventions.A focus on de-implementation of contraindicated suicide interventions is warranted and should be part of the focus on suicide prevention efforts.
Article
Background: Disability status is associated with correlates of suicide risk (perceived burdensomeness, thwarted belongingness, negative future disposition, felt stigma, suicidal ideation, and suicide attempts). Aims: This study aimed to examine whether suicide-related correlates differ significantly as a function of disability type. Methods: Individuals with mobility and vision disabilities (N = 102) completed semistructured interviews and online-based questionnaires. Analysis of variance/analysis of covaiance and Fisher's exact tests were conducted to examine whether mean levels of suicide-related correlates differed significantly between individuals with blindness/low vision (n = 63) versus mobility-related (n = 39) disabilities. Results: No significant between-group differences were observed for most outcomes; however, individuals with vision disabilities reported higher mean levels of felt stigma and positive future disposition than those with mobility-related disabilities. Limitations: The limited representation of disabilities among participants precludes generalization to individuals with other forms of disability and the cross-sectional design prevents inference about causality. Conclusions: Interventions targeting cognitive processes that underlie suicide risk may be applicable to people with mobility and vision disabilities.
Article
Suicide is a problem on the rise in the United States. One significant avenue to help reverse the trend is through family medicine and interventions within primary care clinics. This can be a significant stressor for many family medicine physicians to manage patients experiencing suicidal ideation within their busy schedule. Motivational Interviewing is an evidence-based method of interacting with patients in a healthy and collaborative manner. The literature is growing on how to use Motivational Interviewing in assessments of suicidal ideation. Additionally, Self-Determination Theory proposes that individuals have three basic needs: a sense of connection, a level of autonomy, and a degree of competence. These needs and the associated principles of intrinsic and extrinsic motivation help to explain why Motivational Interviewing can be so helpful in the change process. By examining the principles of Motivational Interviewing and Self-Determination Theory residents will be able to better create an environment conducive to collaborative sharing, honest discussion, and meaningful assessment to ensure safety for patients in primary care.
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.
Article
Objective: To describe how and why patient contracts are used for the management of chronic medical conditions. Data sources: A scoping review was conducted in the following databases: MEDLINE, Embase, AMED, PsycInfo, Cochrane Library, CINAHL, and Nursing & Allied Health. Literature from 1997 to 2017 was included. Study selection: Articles were included if they were written in English and described the implementation of a patient contract by a health care provider for the management of a chronic condition. Articles had to present an outcome as a result of using the contract or an intervention that included the contract. Synthesis: Of the 7528 articles found in the original search, 76 met the inclusion criteria for the final review. Multiple study types were included. Extensive variety in contract elements, target populations, clinical settings, and cointerventions was found. Purposes for initiating contracts included behaviour change and skill development, including goal development and problem solving; altering beliefs and knowledge, including motivation and perceived self-efficacy; improving interpersonal relationships and role clarification; improving quality and process of chronic care; and altering objective and subjective health indices. How contracts were developed, implemented, and assessed was inconsistently described. Conclusion: More research is required to determine whether the use of contracts is accomplishing their intended purposes. Questions remain regarding their rationale, development, and implementation.
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.
Chapter
Written by internationally recognized experts, this comprehensive CBT clinician's manual provides disorder-specific chapters and accessible pedagogical features. The cutting-edge research, advanced theory, and attention to special adaptations make this an appropriate reference text for qualified CBT practitioners, students in post-graduate CBT courses, and clinical psychology doctorate students. The case examples demonstrate clinical applications of specific interventions and explain how to adapt CBT protocols for a range of diverse populations. It strikes a balance between core, theoretical principles and protocol-based interventions, simulating the experience of private supervision from a top expert in the field.
Chapter
The chapter discusses the mental health problems/mental disorders faced by adolescents in the Indian as well as global context. Factors related to mental health problems in adolescents are explained. The many trends in mental health problems, such as stress, suicidal tendencies, substance use and abuse, etc., in adolescents are discussed highlighting the symptomatology, diagnostic criteria, prevalence of the disorder, causes, and treatment measures. Further, emotional and behavioural disorders, risk-taking behaviours, eating disorders, anxiety disorder, and schizophrenia are also discussed.
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Objective: Analyze responses to a national request for information (RFI) to uncover gaps in policy, practice, and understanding of veteran suicide to inform federal research strategy. Data source: An RFI with 21 open-ended questions generated from Presidential Executive Order #1386, administered nationally from July 3 to August 5, 2019. Study design: Semi-structured, open-ended responses analyzed using a collaborative qualitative and text-mining data process. Data extraction methods: We aligned traditional qualitative methods with natural language processing (NLP) text-mining techniques to analyze 9040 open-ended question responses from 722 respondents to provide results within 3 months. Narrative inquiry and the medical explanatory model guided the data extraction and analytic process. Results: Five major themes were identified: risk factors, risk assessment, prevention and intervention, barriers to care, and data/research. Individuals and organizations mentioned different concepts within the same themes. In responses about risk factors, individuals frequently mentioned generic terms like “illness” while organizations mentioned specific terms like “traumatic brain injury.” Organizations and individuals described unique barriers to care and emphasized ways to integrate data and research to improve points of care. Organizations often identified lack of funding as barriers while individuals often identified key moments for prevention such as military transitions and ensuring care providers have military cultural understanding. Conclusions: This study provides an example of a rapid, adaptive analysis of a large body of qualitative, public response data about veteran suicide to support a federal strategy for an important public health topic. Combining qualitative and text-mining methods allowed a representation of voices and perspectives including the lived experiences of individuals who described stories of military transition, treatments that worked or did not, and the perspective of organizations treating veterans for suicide. The results supported the development of a national strategy to reduce suicide risks for veterans as well as civilians.
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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.
Article
The purpose of this pilot study was to determine if the efficacy of imaginal exposure for symptoms of posttraumatic stress disorder (PTSD) could be improved by adding aerobic exercise. We hypothesized that aerobic exercise would enhance the efficacy of exposure therapy. Active duty service members with clinically significant symptoms of posttraumatic stress (PTSD Checklist—Stressor-Specific Version, [PCL-S], ≥25) were randomized into one of four conditions: exercise only; imaginal exposure only; imaginal exposure plus exercise; no exercise/no exposure therapy (control). Participants (N = 72) were primarily male, Army, noncommissioned officers ranging in age from 22 to 52. PTSD symptom severity decreased over time (p < .0001); however, there were no significant differences between the experimental conditions. The prediction that imaginal exposure augmented with aerobic exercise would be superior to either imaginal exposure alone or aerobic exercise alone was not supported, suggesting that engaging in exercise and imaginal exposure simultaneously may not be any better than engaging in either activity alone. A better understanding of individually administered and combined exercise and exposure therapy interventions for PTSD is warranted.
Article
Written by internationally recognized experts, this comprehensive CBT clinician's manual provides disorder-specific chapters and accessible pedagogical features. The cutting-edge research, advanced theory, and attention to special adaptations make this an appropriate reference text for qualified CBT practitioners, students in post-graduate CBT courses, and clinical psychology doctorate students. The case examples demonstrate clinical applications of specific interventions and explain how to adapt CBT protocols for a range of diverse populations. It strikes a balance between core, theoretical principles and protocol-based interventions, simulating the experience of private supervision from a top expert in the field.
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Background: Attempted suicide is the main risk factor for suicide and repeated suicide attempts. However, the evidence for follow-up treatments reducing suicidal behavior in these patients is limited. The objective of the present study was to evaluate the efficacy of the Attempted Suicide Short Intervention Program (ASSIP) in reducing suicidal behavior. ASSIP is a novel brief therapy based on a patient-centered model of suicidal behavior, with an emphasis on early therapeutic alliance. Methods and findings: Patients who had recently attempted suicide were randomly allocated to treatment as usual (n = 60) or treatment as usual plus ASSIP (n = 60). ASSIP participants received three therapy sessions followed by regular contact through personalized letters over 24 months. Participants considered to be at high risk of suicide were included, 63% were diagnosed with an affective disorder, and 50% had a history of prior suicide attempts. Clinical exclusion criteria were habitual self-harm, serious cognitive impairment, and psychotic disorder. Study participants completed a set of psychosocial and clinical questionnaires every 6 months over a 24-month follow-up period. The study represents a real-world clinical setting at an outpatient clinic of a university hospital of psychiatry. The primary outcome measure was repeat suicide attempts during the 24-month follow-up period. Secondary outcome measures were suicidal ideation, depression, and health-care utilization. Furthermore, effects of prior suicide attempts, depression at baseline, diagnosis, and therapeutic alliance on outcome were investigated. During the 24-month follow-up period, five repeat suicide attempts were recorded in the ASSIP group and 41 attempts in the control group. The rates of participants reattempting suicide at least once were 8.3% (n = 5) and 26.7% (n = 16). ASSIP was associated with an approximately 80% reduced risk of participants making at least one repeat suicide attempt (Wald χ21 = 13.1, 95% CI 12.4-13.7, p < 0.001). ASSIP participants spent 72% fewer days in the hospital during follow-up (ASSIP: 29 d; control group: 105 d; W = 94.5, p = 0.038). Higher scores of patient-rated therapeutic alliance in the ASSIP group were associated with a lower rate of repeat suicide attempts. Prior suicide attempts, depression, and a diagnosis of personality disorder at baseline did not significantly affect outcome. Participants with a diagnosis of borderline personality disorder (n = 20) had more previous suicide attempts and a higher number of reattempts. Key study limitations were missing data and dropout rates. Although both were generally low, they increased during follow-up. At 24 months, the group difference in dropout rate was significant: ASSIP, 7% (n = 4); control, 22% (n = 13). A further limitation is that we do not have detailed information of the co-active follow-up treatment apart from participant self-reports every 6 months on the setting and the duration of the co-active treatment. Conclusions: ASSIP, a manual-based brief therapy for patients who have recently attempted suicide, administered in addition to the usual clinical treatment, was efficacious in reducing suicidal behavior in a real-world clinical setting. ASSIP fulfills the need for an easy-to-administer low-cost intervention. Large pragmatic trials will be needed to conclusively establish the efficacy of ASSIP and replicate our findings in other clinical settings. Trial registration: ClinicalTrials.gov NCT02505373.
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Dialectical behavior therapy (DBT) is an empirically supported treatment for suicidal individuals. However, DBT consists of multiple components, including individual therapy, skills training, telephone coaching, and a therapist consultation team, and little is known about which components are needed to achieve positive outcomes. To evaluate the importance of the skills training component of DBT by comparing skills training plus case management (DBT-S), DBT individual therapy plus activities group (DBT-I), and standard DBT which includes skills training and individual therapy. We performed a single-blind randomized clinical trial from April 24, 2004, through January 26, 2010, involving 1 year of treatment and 1 year of follow-up. Participants included 99 women (mean age, 30.3 years; 69 [71%] white) with borderline personality disorder who had at least 2 suicide attempts and/or nonsuicidal self-injury (NSSI) acts in the last 5 years, an NSSI act or suicide attempt in the 8 weeks before screening, and a suicide attempt in the past year. We used an adaptive randomization procedure to assign participants to each condition. Treatment was delivered from June 3, 2004, through September 29, 2008, in a university-affiliated clinic and community settings by therapists or case managers. Outcomes were evaluated quarterly by blinded assessors. We hypothesized that standard DBT would outperform DBT-S and DBT-I. The study compared standard DBT, DBT-S, and DBT-I. Treatment dose was controlled across conditions, and all treatment providers used the DBT suicide risk assessment and management protocol. Frequency and severity of suicide attempts and NSSI episodes. All treatment conditions resulted in similar improvements in the frequency and severity of suicide attempts, suicide ideation, use of crisis services due to suicidality, and reasons for living. Compared with the DBT-I group, interventions that included skills training resulted in greater improvements in the frequency of NSSI acts (F1,85 = 59.1 [P < .001] for standard DBT and F1,85 = 56.3 [P < .001] for DBT-S) and depression (t399 = 1.8 [P = .03] for standard DBT and t399 = 2.9 [P = .004] for DBT-S) during the treatment year. In addition, anxiety significantly improved during the treatment year in standard DBT (t94 = -3.5 [P < .001]) and DBT-S (t94 = -2.6 [P = .01]), but not in DBT-I. Compared with the DBT-I group, the standard DBT group had lower dropout rates from treatment (8 patients [24%] vs 16 patients [48%] [P = .04]), and patients were less likely to use crisis services in follow-up (ED visits, 1 [3%] vs 3 [13%] [P = .02]; psychiatric hospitalizations, 1 [3%] vs 3 [13%] [P = .03]). A variety of DBT interventions with therapists trained in the DBT suicide risk assessment and management protocol are effective for reducing suicide attempts and NSSI episodes. Interventions that include DBT skills training are more effective than DBT without skills training, and standard DBT may be superior in some areas. clinicaltrials.gov Identifier: NCT00183651.
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Describes the rationale, development, and validation of the Scale for Suicide Ideation, a 19-item clinical research instrument designed to quantify and assess suicidal intention. In a sample with 90 hospitalized Ss, the scale was found to have high internal consistency and moderately high correlations with clinical ratings of suicidal risk and self-administered measures of self-harm. Furthermore, it was sensitive to changes in levels of depression and hopelessness (Beck Depression Inventory and Hopelessness Scale, respectively) over time. Its construct validity was supported by 2 studies by different investigators testing the relationship between hopelessness, depression, and suicidal ideation and by a study demonstrating a significant relationship between high level of suicidal ideation and "dichotomous" attitudes about life and related concepts on a semantic differential test. Factor analysis yielded 3 meaningful factors: Active Suicidal Desire, Specific Plans for Suicide, and Passive Suicidal Desire. (29 ref)
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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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The no-suicide contract is widely recommended as an important intervention in the care of suicidal patients; however, there are no data demonstrating its effectiveness or its acceptance in the professional community. This study examines the use of no-suicide contracts by psychiatrists in Minnesota. A postcard questionnaire was mailed to 514 psychiatrists in Minnesota inquiring about their practices and experiences with no-suicide contracts. There were 267 responses, yielding a response rate of 52%. No-suicide contracts were used by 152 (57%) of the respondents. Within this group, 62 (41%) of the psychiatrists had patients who committed suicide or made serious attempts after entering into a no-suicide contract. Among the respondents to the questionnaire, slightly more than half used no-suicide contracts, indicating that such contracts are not universally accepted as standard practice among these psychiatrists. More data are needed to determine the effectiveness of no-suicide contracts in preventing suicide.
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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.
Article
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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.
Article
The Centers for Disease Control and Prevention recently reported that the nation’s mortality rate climbed in 2015 for the first time in a decade. This surprising result is linked to increases in the rate of several causes of death, including suicide. Indeed, the death rate for suicide has been rising steadily for over a decade. By now we are almost inured to news reports about high or rising rates among veterans, American Indian/Alaska Native young people, and other groups. At the same time, we hear frequently that research investments in suicide prevention are inadequate. Former National Institute on Mental Health Director Tom Insel has pointed out that research investments for suicide prevention lag far behind those for other causes of death in absolute terms and also considering the number of people affected.
Conference Paper
These guidelines review what is known about the epidemiology, causes, management, and prevention of suicide and attempted suicide in young people. Detailed guidelines are provided concerning the assessment and emergency management of the children and adolescents who present with suicidal behavior. The guidelines also present suggestions on how the clinician may interface with the community. Crisis hotlines, method restriction, educational programs, and screening/case-finding suicide prevention strategies are examined, and the clinician is advised on media counseling. Intervention in the community after a suicide, minimization of suicide contagion or imitation, and the training of primary care physicians and other gatekeepers to recognize and refer the potentially suicidal child and adolescent are discussed.
Article
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.
Article
IMPORTANCE: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multicomponent study designed to generate actionable recommendations to reduce Army suicides and increase knowledge of risk and resilience factors for suicidality. OBJECTIVES: To present data on prevalence, trends, and basic sociodemographic and Army experience correlates of suicides and accident deaths among active duty Regular Army soldiers between January 1, 2004, and December 31, 2009, and thereby establish a foundation for future Army STARRS investigations. DESIGN, SETTING, AND PARTICIPANTS: Analysis of trends and predictors of suicide and accident deaths using Army and Department of Defense administrative data systems. Participants were all members of the US Regular Army serving at any time between 2004 and 2009. MAIN OUTCOMES AND MEASURES: Death by suicide or accident during active Army service. RESULTS: The suicide rate rose between 2004 and 2009 among never deployed and currently and previously deployed Regular Army soldiers. The accident death rate fell sharply among currently deployed soldiers, remained constant among the previously deployed, and trended upward among the never deployed. Increased suicide risk was associated with being a man (or a woman during deployment), white race/ethnicity, junior enlisted rank, recent demotion, and current or previous deployment. Sociodemographic and Army experience predictors were generally similar for suicides and accident deaths. Time trends in these predictors and in the Army’s increased use of accession waivers (which relaxed some qualifications for new soldiers) do not explain the rise in Army suicides. CONCLUSIONS AND RELEVANCE: Predictors of Army suicides were largely similar to those reported elsewhere for civilians, although some predictors distinct to Army service emerged that deserve more in-depth analysis. The existence of a time trend in suicide risk among never-deployed soldiers argues indirectly against the view that exposure to combat-related trauma is the exclusive cause of the increase in Army suicides.
Article
These guidelines review what is known about the epidemiology, causes, management, and prevention of suicide an attempted suicide in young people. Detailed guidelines are provided concerning the assessment and emergency management of the children and adolescents who present with suicidal behavior. The guidelines also present suggestions on how the clinician may interface with the community. Crisis hotlines, method restriction, educational programs, and screening case-finding suicide prevention strategies are examined, and the clinician is advised on media counseling. Intervention in the community after a suicide, minimization of suicide contagion or imitation, and the training of primary care physicians and other gatekeepers to recognize and refer the potentially suicidal child and adolescent are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
The usual care for suicidal patients who are seen in the emergency department (ED) and other emergency settings is to assess level of risk and refer to the appropriate level of care. Brief psychosocial interventions such as those administered to promote lower alcohol intake or to reduce domestic violence in the ED are not typically employed for suicidal individuals to reduce their risk. Given that suicidal patients who are seen in the ED do not consistently follow up with recommended outpatient mental health treatment, brief ED interventions to reduce suicide risk may be especially useful. We describe an innovative and brief intervention, the Safety Planning Intervention (SPI), identified as a best practice by the Suicide Prevention Resource Center/American Foundation for Suicide Prevention Best Practices Registry for Suicide Prevention (www.sprc.org), which can be administered as a stand-alone intervention. The SPI consists of a written, prioritized list of coping strategies and sources of support that patients can use to alleviate a suicidal crisis. The basic components of the SPI include (a) recognizing warning signs of an impending suicidal crisis; (b) employing internal coping strategies; (c) utilizing social contacts and social settings as a means of distraction from suicidal thoughts; (d) utilizing family members or friends to help resolve the crisis; (e) contacting mental health professionals or agencies; and (f) restricting access to lethal means. A detailed description of SPI is described and a case example is provided to illustrate how the SPI may be implemented.
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 No Harm Contract has been widely accepted in clinical practice, yet there is no broad consensus as to its value. This paper examines the contract and offers recommendations for its use as well as cautions about its misuse. After a literature review, the No Harm Contract is examined from diagnostic, therapeutic, and medicolegal perspectives. Diagnostically, the No Harm Contract can be used to assess the nature and severity of a patient's suicidality, uncover specific troubling issues precipitating suicidal thoughts, and evaluate the patient's competency to contract. Therapeutically, the contract affords an opportunity to initiate a therapeutic alliance, establish the limits of the psychotherapeutic framework, and reduce both patient and clinician anxiety. Medicolegally, the contract is not legally binding and grants no suicide malpractice suit protection. Although the No Harm Contract is a frequently used clinical tool that can provide diagnostic information and therapeutic advantage, it can also short-circuit comprehensive suicidal assessment and disposition decisions.
Article
The rapid growth of managed care has accelerated the evolution of the clinical record. Previously used for process notations, global assessment, and treatment planning, the record is increasingly used to demonstrate accountability to third-party payers and to the legal system. This article discusses the documentation of accountability in the case of potential client suicide or violence toward others.
Article
In the managed care era, mental health professionals increasingly rely upon suicide prevention contracts in the management of patients at suicide risk. Although asking a patient if he or she is suicidal and obtaining a written or oral contract against suicide can be useful, these measures by themselves are insufficient. "No harm" contracts cannot take the place of formal suicide risk assessments. Obtaining a suicide prevention contract from the patient tends to be an event whereas suicide risk assessment is a process. The suicide prevention contract is not a legal document that will exculpate the clinician from malpractice liability if the patient commits suicide. The contract against self-harm is only as good as the underlying soundness of the therapeutic alliance. The risks and benefits of suicide prevention contracts must be clearly understood.
Article
No-suicide contracts, in their various forms, can deepen commitment to a positive action, strengthen the therapeutic alliance, facilitate communication, lower anxiety, aid assessment, and document precautions. Conversely, they can anger or inhibit the client, introduce coercion into therapy, be used disingenuously, and induce false security in the clinician. Research on no-suicide contracts (frequency surveys, assessments of behavior after contracting, and opinions of users) has limitations common to naturalistic studies, and is now ready for more rigorous methods. Mental health professions should be trained to deal with suicidal individuals, including how to use no-suicide contracts. Good contracts are specific, individualized, collaborative, positive, context-sensitive, and copied. However, they are not a thorough assessment, a guarantee against legal liability, nor a substitute for a caring, sensitive therapeutic interaction. No-suicide contracts are no substitute for sound clinical judgment.
Article
This article describes the development, administration, and reliability of the Cornell Services Index (CSI), a new instrument that measures health service use. The CSI was developed to create a standardized measure of the quantity and characteristics (for example, site and provider) of services used by adults. Descriptive data are provided to illustrate the application of the CSI in a community sample of adults who were newly admitted to outpatient mental health clinics. These data provide information about the pathways to care. The interrater and test-retest reliability of the CSI were evaluated by using a sample of 40 adults who were seeking mental health treatment. Descriptive data on service use in a sample of 1,279 adults seeking care in outpatient mental health clinics was provided to demonstrate the application of the CSI. The CSI is a portable, easy to use, and brief assessment of service use. It has good interrater and test-retest reliability among adults without cognitive impairment. In the three months before seeking care, 31 percent of the adults interviewed had made a mental health visit, 36 percent had been hospitalized, and more than half (59 percent) had made a medical visit. Twenty-three percent of adults had sought care from a hospital's emergency department. The CSI is a reliable method to assess health service use for adults. The measure can extend assessment of use beyond the traditional mental health service use questions and provide a snapshot of service use patterns across types, providers, and sites of service among adults who seek mental health care.
Article
This article reviews the literature on the use of "no-suicide contracts" in clinical practice, including conceptual discussions, patient and clinician surveys, and a few empirical studies on clinical utility. Our primary conclusion is that no-suicide contracts suffer from a broad range of conceptual, practical, and empirical problems. Most significantly, they have no empirical support for their effectiveness in the clinical environment. The authors provide and illustrate the commitment to treatment statement as a practice alternative to the no-suicide contract.
Self-directed violence surveillance: uniform definitions and recommended data elements. centers for disease control and prevention
  • A E Crosby
  • L Ortega
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