44,965 Americans die by suicide each year and is the 10th cause of death in the United States. With that number increasing daily new treatments and strategies are being created to prevent this(Suicide Prevention, 2018). Cognitive Therapy for Suicide prevention is a cognitive-behavioral psychotherapy program targeted towards adults who have previously attempted or thought of suicide. The format of the therapy is to be provided by a licensed therapist on a one-to-one basis and includes three phases (early, middle and late).
The intervention teaches patients to use alternative ways of thinking and acting during episodes of suicidal crises and helps them in building a network of social supports to prevent future suicide attempts. This psychotherapy includes about 10 to 16 structured sessions; the average time needed to implement the Cognitive-behavioral Therapy as designed is between 6 months to 1 year. (Brown et. a 2005) One study that evaluated this intervention is a Cognitive-Behavioral Family Treatment for Suicide Attempt Prevention.
This study is a randomized controlled trial for adolescents (12-18 years old) with recent ( past 3 months) suicide attempts or other self harm. The youth were randomized to receiving either SAFETY or ( E-TAU1) treatment as usual group enhanced using parental education , support and community treatment . The experimental group received the prevention SAFETY, a safe alternative for teens and youth. It is a cognitive-behavioral, dialectical behavior therapy-informed family treatment targeted to promote Safety .SAFETY emphasizes strengthening familial and social support as well as safer behaviors, coping mechanisms and stress reactions. The SAFETY treatment is unique from the control group because it includes 2 therapists for both parent and youth.
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Outcomes for the groups were evaluated at baseline, 3 months and were followed up through 6 to 12 months.The E-TAU group included (n=22) and the SAFETY group included (n=20) , totaling at 42 participants in the study. (Asarnow et al, 2017) Outcomes were evaluated using various survival analytic techniques and measures. At 3 months, 4 youths from the E-TAU group had made 6 suicide attempts and 1 interrupted attempt. At the same 3 month mark , 0 youths from the SAFETY groups made a suicide attempt and 1 youth reported preparatory SA2 behavior.
The Nonparametric Kaplan-Meier scale estimates survival functions to describe and characterize the probability of an event of interest ( SA, NSSI3, ED4 or hospitalization). Data showed that the probability of survival to the 3-month posttreatment point without a ED visit for suicidality was significantly lower for SAFETY when compared to the E-TAU group . This study shows the efficiency of a psychosocial treatment for reducing SA risk among adolescents with recent SA/SH5. When compared to E-TAU, the SAFETY treatment lowered the probability of an SA, with no SA in the SAFETY condition and an estimated SA risk of .33 in the E- TAU group at 3-months.
Although SAFETY appeared to protect against SAs during the treatment period, benefits weakened after treatment stop, suggesting the need for a longer program. Another limitation in the study is the small sample size and limited statistical power. (Asarnow et al, 2017) The second study being using for comparison is Cognitive-Behavioral Problem Solving in the treatment of patients who repeatedly attempt suicide. It is an older randomized- controlled trial using 20 high risk participants aged 16-65.
The participants were randomly allocated to either a cognitive-behavioral problem solving ( n=12) or a treatment as usual control group (n=8). The study was conducted at a large intercity hospital with very specific criteria; currently not suffering from psychosis, two or more previous SAs, self administered antidepressants as an attempt to overdose and a minimum of 4 on the 6 point scale by Buglass & Horton (1974). Treatment for the experimental group included a problem solving approach (Bancroft, 1989) using a specialized format that provides guidelines and techniques for effective problem solving delivered to the patient’s in their own homes. The problem-solving treatment included generating solutions, strategizing and goal setting and patients completing homework.
The treatment as usual group received therapy and treatment in their own home and then returning to Leeds Hospital as needed. Both groups had 5 sessions of treatment 1 hour each which occurred at the time of the index attempt, 3 days later, 1 week later, 2 weeks later and 1 at month. (Salkovskis & Storer. D ,1990) Upon entry, all the participants completed multiple tests some including Beck Suicidal Ideation scale (Beck et al, 1979) measuring suicide ideation and wish to live The Personal Questionnaire Rapid Scaling Technique (PQRST;Mulhall,1977) which generates the patients current or impending problem and ranks them in order of importance.
Results from the Beck scale showed a significant treatment effect and decrease in suicide ideation and wish, while the control group stayed stagnant. On the PQRST, there was significant effect and better overall results for all three problems compared to the treatment as usual group . There was improved ratings of depression, hopelessness, suicidal ideation and target problems at the end of treatment and at follow-up of up to one year, as well as evidence of an effect on the rates of repetition over the six months distress exhibited by patients at high risk for repeated suicide and impacts the rate of repeated SAs in the short term.
The data suggests that problem-solving treatment may be effective in reducing training in problem solving, and specifically geared towards learning techniques to move through the problem effectively rather than solutions. A limitation of this study has a relatively small sample size. It should also be noted that the delivery of treatment in the patient’s’ own homes may have ensured very good compliance and had an effect on scores. (Salkovskis & Storer. D ,1990)
After reviewing both studies I would implement a cognitive- behavior therapy for high-risk patients who have made repeat SAs. My intervention would involve social and familial support and have a focus on establishing problem solving strategies to enable patients to be able to gain a sense of control over issue. It would comprise 10 therapy and problem-solving intervention sessions and 4 group sessions over a 6 month period. The group sessions open opportunity for the patient to gain social support in a positive environment. I favor the 3 phase treatment model, safety plan and hope kit of the original research design. (Brown et. a 2005).
Phase 1: introduces the cognitive model, phase 2 focuses on teaching positive cognitive-behavioral skills to manage suicidal thoughts; phase 3 comprises skill consolidation and relapse prevention. The manual the original researcher used would be available for use. (Wezel & Brown,2009) This would be difficult for community-based clinicians to deliver because it requires consistency in the therapist and a 1:1 therapist for each patient and would be expensive in a community treatment facility. Also, the intervention does not address any co-occurring disorders and this could become an issue in a community treatment facility due to high comorbidity rates of substance abuse.(NIDA, 2011)
References
- National Suicide Prevention Lifeline
- Cognitive Therapy for Suicide Prevention: A Randomized Controlled Trial
- Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
- American Psychological Association: Cognitive-Behavioral Therapy for PTSD
- A review of cognitive therapies for suicidal patients following discharge from acute care
- National Institute of Mental Health: Suicide Prevention
- Cognitive-behavioural therapy in adolescents with borderline personality disorder – an open pilot study
- American Psychological Association
