Changes in problem-solving appraisal after cognitive therapy for the prevention of suicide

Digital safety plan effectiveness and use: Findings from a three-month longitudinal study

Few studies have examined the effectiveness of self-guided smartphone apps for suicide safety planning, despite their increasing use. Participants (n = 610) were self-selected users of the Beyond Now suicide prevention safety planning app with a history of suicidal thoughts and behaviours. Surveys were completed (baseline, one and three months), safety plan content and app usage data was shared. Repeated-measures ANOVAs examined changes in suicidal ideation and suicide-related coping over three months. Multiple regression models were used to predict suicidal ideation and suicide-related coping at one- and three-month follow-ups with plan-related variables: perceived usefulness, personalised content, app use time and co-authoring of the plan with a third party. Significant reductions in suicidal ideation and increases in suicide-related coping were found over three months. Higher suicide-related coping at three months predicted lower suicidal ideation. Higher perceived usefulness and personalised content at three months were associated with higher suicide-related coping, but not suicidal ideation. App use time and co-authoring were not significantly related to suicidal ideation or suicide-related coping. Practitioners should empower clients to create safety plans with personalised (not generic) strategies that a client perceives to be useful. Such plans may strengthen beliefs about coping with suicidal ideation, which in turn reduces suicidal ideation over time.

The role of problem-solving skills in the prevention of suicidal behaviors: A systematic review and meta-analysis

BACKGROUND

This meta-analysis was conducted to assess the association between problem-solving skills and suicidal behaviors and elucidate the potential role of problem-solving skills in influencing the occurrence of suicidal behaviors.

METHODS

PubMed, Web of Science, and Scopus were searched until August 16, 2023. Studies addressing the associations between problem-solving skills and suicidal behaviors were included. The I2 statistics were used to examine between-study heterogeneity. The Begg and Egger tests were used to determine the possibility of publication bias. Using a random-effects model, the overall effect size was presented as an odds ratio (OR) or standard mean difference (SMD) with 95% confidence intervals (CIs).

RESULTS

Of 8040 identified studies, 29 (including 974,542 participants) were eligible. Based on observational studies, problem-solving skills were found to be inversely related to suicidal ideation (OR = 0.64; 95% CI: 0.50, 0.82); suicide attempts (OR = 0.75; 95% CI: 0.63, 0.89), and suicide death (OR = 0.02; 95% CI: 0.01, 0.03). The overall score of problem-solving skills was higher in those who did not attempt suicide than those who did (SMD = 0.84; 95% CI: 54, 1.13). Based on randomized clinical trials, problem-solving therapy was found to reduce the risk of suicide (OR = 0.51; 95% CI: 0.29, 0.87). Furthermore, the overall risk of suicide was lower among those who received problem-solving therapy than those who did not (SMD = -0.02; 95% CI: -0.29, 0.25).

CONCLUSIONS

This meta-analysis revealed an inverse association between problem-solving skills and suicidal behaviors. However, further research is needed to better understand the complex relationship between problem-solving skills and suicidal behaviors.

Heterogeneous trajectories of suicidal ideation among homeless youth: predictors and suicide-related outcomes

The current study examined heterogeneous trajectories of suicidal ideation among homeless youth experiencing suicidal ideation over 9 months in a randomized controlled intervention study. Suicidal homeless youth (N = 150) were randomly assigned to Cognitive Therapy for Suicide Prevention (CTSP) + Treatment as Usual (TAU) or TAU alone. Youth reported their suicidal ideation four times during a 9-month period. We also assessed pretreatment mental health, demographic information and session attendance as predictors of the subgroups, as well as suicide-related factors as outcomes at the 9-month follow-up. Growth mixture models suggested three distinct trajectory groups among youth: Fast Declining (74.7%), Chronic (19.3%), and Steadily Declining (6.0%). Youth in the Chronic group used more substances at baseline than the Steadily Declining group, were more likely to be White, non-Hispanic than the Fast Declining group, and attended more CTSP sessions than other groups. Contrastingly, youth in the Steadily Declining group all experienced childhood abuse. Finally, youth in the Chronic group showed significant higher risk for future suicide compared to those in the Fast Declining group at 9 months. Findings support the heterogeneity of treatment responses in suicide intervention among homeless youth, with implications to improve treatment efforts in this very high-risk population.

Psychometric properties of the 52-, 25-, and 10-item English and Spanish versions of the Social Problem-Solving Inventory-Revised

Objective

The Social Problem-Solving Inventory-Revised (SPSI-R) is a widely used instrument to assess problem-solving ability. This study examined the factor structure of the 52-, 25-, and 10-item versions of the SPSI-R and assessed factorial invariance across English- and Spanish-speaking participants. In addition, the internal consistency, test-retest reliability and sensitivity to detect change in problem-solving skills over time were assessed across the three different versions of the SPSI-R.

Methods

Data from three randomized controlled trials, in which caregivers of children with cancer (N = 1,069) were assigned to either a problem-solving skills intervention (N = 728) or a control condition (N = 341), were combined. The SPSI-R was administered at baseline (T1) and immediately post intervention (T2). Reliability and multigroup analyses were performed with confirmatory factor analysis (CFA). Sensitivity to change analyses were performed using repeated measures ANOVA.

Results

Confirmatory factor analysis at T1 showed good fit statistics and internal consistency for the 52- and the 25-item versions, but not for the 10-item version. Factorial invariance was demonstrated across time (T1-T2) and language (Spanish-English) for both the 52- and 25-item versions. Adequate sensitivity to change over time was shown.

Conclusion

The 52- and 25-item versions of the SPSI-R appear reliable and valid for assessment of problem-solving skills in English- and Spanish-speaking caregivers of children with newly diagnosed cancer. The 25-item SPSI-R can be used as a short version measuring problem-solving ability; the 10-item version cannot be considered a reliable measure for this population.

Improving Suicide Prevention Through Evidence-Based Strategies: A Systematic Review

Objective

The authors sought to identify scalable evidence-based suicide prevention strategies.

Methods

A search of PubMed and Google Scholar identi- fied 20,234 articles published between September 2005 and December 2019, of which 97 were randomized controlled trials with suicidal behavior or ideation as primary outcomes or epidemiological studies of limiting access to lethal means, using educational approaches, and the impact of antidepressant treatment.

Results

Training primary care physicians in depression rec- ognition and treatment prevents suicide. Educating youths on depression and suicidal behavior, as well as active out- reach to psychiatric patients after discharge or a suicidal crisis, prevents suicidal behavior. Meta-analyses find that antidepressants prevent suicide attempts, but individual randomized controlled trials appear to be underpowered. Ketamine reduces suicidal ideation in hours but is untested for suicidal behavior prevention. Cognitive-behavioral therapy and dialectical behavior therapy prevent suicidal behavior. Active screening for suicidal ideation or behavior is not proven to be better than just screening for depression. Education of gatekeepers about youth suicidal behavior lacks effectiveness. No randomized trials have been reported for gatekeeper training for prevention of adult suicidal behavior. Algorithm-driven electronic health record screening, Internet-based screening, and smartphone passive monitoring to identify high-risk patients are under-studied. Means restriction, including of firearms, prevents suicide but is sporadically employed in the United States, even though firearms are used in half of all U.S. suicides.

Conclusions

Training general practitioners warrants wider implementation and testing in other nonpsychiatrist physi- cian settings. Active follow-up of patients after discharge or a suicide-related crisis should be routine, and restricting firearm access by at-risk individuals warrants wider use. Combination approaches in health care systems show promise in reducing suicide in several countries, but evaluating the benefit attributable to each component is essential. Further suicide rate reduction requires evaluating newer approaches, such as electronic health record-derived algorithms, Internet-based screening methods, ketamine's potential benefit for preventing attempts, and passive monitoring of acute suicide risk change.Reprinted from Am J Psychiatry 2021; 178:611-624, with permission from American Psychiatric Association Publishing. Copyright © 2021.

Revised Attentional Fixation on Suicide Experiences Questionnaire and its relationship with suicidal ideation and behavior: A cross-sectional study

INTRODUCTION

The Attentional Fixation on Suicide Experiences Questionnaire (AFSEQ) was developed to measure attentional fixation on suicide, a cognitive process characterized by a preoccupation with suicide as a solution. This study investigated a revised version (AFSEQ-R) and examined differences between those who made a recent suicide attempt and those with suicidal ideation (SI).

METHOD

Participants were 57 inpatients who attempted suicide within 14 days of study participation and 57 inpatients who presented with SI but no suicidal behavior within the past year. Analyses examined the internal reliability, multidimensionality, and construct validity of the AFSEQ-R, and whether attentional fixation moderated the correlation between SI and attempt status.

RESULTS

Exploratory factor analysis revealed a two-factor structure, and subscale and total scores demonstrated excellent internal consistency. Cognitive Stuckness (and total score) correlated with SI, anxiety, impulsivity, and specific problem-solving deficits, while Cognitive Dysfunction correlated with anxiety and acted as a moderator of the correlation between Stuckness and SI. AFSEQ-R scores did not moderate the relationship between SI and attempt status.

CONCLUSION

AFSEQ-R is a psychometrically sound and valid measure of attentional fixation. Attentional fixation on suicide is correlated with SI, and prospective studies are needed to uncover its directional effect on suicidal crises.

Meaning of life as a resource for coping with psychological crisis: Comparisons of suicidal and non-suicidal patients

Introduction

Meaning is an important psychological resource both in situations of accomplishment and in situations of ongoing adversity and psychological crisis. Meaning in life underlies the reasons for staying alive both in everyday and in critical circumstances, fulfilling a buffering function with respect to life adversities.

Aim

The aim of the present study was to reveal the role of both meaningfulness, including specific sources of meaning and reasons for living, and meaninglessness (alienation) in patients suffering from profound crisis situations with or without suicidal intentions and behavior.

Methods

The sample included 148 patients (all Caucasian) who were referred to a crisis center in Moscow, Russia. Seventy-seven patients (54 females, mean age 32.00 ± 11.98 years) reported a current crisis situation in their life but denied suicidal thoughts or behavior. Twenty-nine patients (21 females, mean age 31.55 ± 13.76 years) reported suicidal ideations but denied suicidal attempts or self-harming behavior. Forty-two patients (31 females, mean age 30.64 ± 11.38 years) had episodes of suicidal attempts or self-harming behavior accompanied by suicidal intentions. There were no significant gender or age differences between groups.

Participants completed a number of measures of different aspects of meaning and meaninglessness, well-being, ill-being and psychological resources. For some patients (N = 74), a clinical checklist was completed by their doctors assessing 28 various characteristics associated with the patient’s clinical status.

Results and discussion

Meaningfulness and reasons for living were more helpful in distinguishing between reactions to profound crisis situations (suicidal intentions versus non-suicidal behavior) than were measures of well-being, ill-being, meaning crisis or personality resources. In both suicidal and non-suicidal crisis patients meaningfulness predicted more positive reasons for living. The relationship between meaningfulness and most reasons for living remained significant after controlling for clinically appraised suicidal “readiness,” acute stress and lack of social support. Self-transcendence was the major specific source of meaning predicting higher reasons for living after adjusting for general meaningfulness.

Conclusion

The data cast some light on the psychological meaning of suicide. It follows that prevention efforts are to be focused not on eliminating the factors “pushing” one to suicidal behavior, but rather on supporting inner strengths conducive of a positive decision, to be, through enhancing meaningfulness and reasons for living.

The causal effect of education and cognitive performance on risk for suicide attempt: A combined instrumental variable and co-relative approach in a Swedish national cohort

BACKGROUND

The aim of this study was to clarify the possible causal associations between education phenotypes and non-fatal suicide attempts. In particular, we evaluated the roles of academic achievement (school grades), cognitive performance (IQ), and educational attainment (education level).

METHODS

Based on longitudinal Swedish registry data, we included 2,335,763 individuals (48.7% female) with available school grades, 1,448,438 men with IQ measures, and 4,352,989 individuals (48.4% female) with available data on education level. We combined two different approaches to aid in causal inference: 1) instrumental variables analysis, using month of birth as an instrument related to education but not suicide attempt, to control for measured and unmeasured confounders, and 2) co-relative analysis, comparing pairs of different genetic relatedness (cousins, half, and full siblings) to control for genetic and environmental influences.

RESULTS

High education was associated with reduced risk of suicide attempt. Instrumental variable analysis indicated evidence of a likely causal association between higher school grades and lower risk of suicide attempts (HR = 0.71). Co-relative analyses supported the causality between the three predictors and suicide attempt risk (school grades, HR = 0.80, IQ, HR = 0.83, education level, HR = 0.76). Finally, we examined the specificity of education phenotypes and found that both cognitive (IQ) and non-cognitive (school grades, education level) processes were involved in suicide attempt risk.

LIMITATIONS

IQ was only available in men, limiting the generalizability of this analysis in women.

CONCLUSIONS

Efforts to support causal associations in psychiatric research are needed to offer better intervention. Programs improving education during adolescence would decrease suicide attempt risk.

Illicit Drug Use, Cognitive Distortions, and Suicidal Ideation Among Homeless Youth: Results From a Randomized Controlled Trial

Illicit drug use and cognitive distortions confer significant risks to youth suicidal thoughts and behaviors. However, there has been limited evidence regarding the efficacy of suicide prevention interventions with homeless youth, especially studies testing whether such interventions can reduce the risk for suicidal ideation associated with illicit drug use. Suicidal homeless youth (N = 150) between the ages of 18 to 24 years were recruited from a drop-in center. Youth were randomly assigned to Cognitive Therapy for Suicide Prevention (CTSP) + Treatment as Usual (TAU) or TAU alone. Youth reported their illicit drug use, cognitive distortions, and suicidal ideation 4 times over 9 months. A multiple-group multilevel structural equation model showed that higher illicit drug use at baseline predicted a slower reduction in cognitive distortions and suicidal ideation in the TAU group. These associations were not found in the CTSP + TAU group, suggesting an interruption of such risk from illicit drug use. Findings suggest that CTSP can reduce the risk of illicit drug use as a treatment barrier towards cognitive distortions and suicidal ideation among homeless youth, with implications to improve treatment efforts and to reduce premature mortality in a vulnerable population.

Decision-making in suicidal behavior: A systematic review and meta-analysis

Impaired decision-making (DM) is well-known in suicidal behavior (SB). We aimed to review the evidence on DM and its mediating factors in SB and perform a meta-analysis on DM assessed using the Iowa Gambling Task (IGT). We conducted a search on databases of papers published on DM and SB up to 2020: 46 studies were included in the systematic review, and 18 in the meta-analysis. For meta-analysis, we compared DM performance between suicide attempters (SAs) and patients (PCs) or healthy controls (HCs). The systematic review showed that SAs have greater difficulties in all DM domains. The meta-analysis found worse IGT performance among SAs in comparison with PCs and HCs. A meta-regression did not find differences for age, gender, psychiatric disorder, and clinical status. Our findings indicate that SAs exhibited deficits in DM under conditions of risk though not ambiguity. Worse DM was independent of age, gender, psychiatric disorder, and suggested that DM impairment could be considered a cognitive trait of suicidal vulnerability, a risk factor and an attribute of SAs.

Improving Suicide Prevention Through Evidence-Based Strategies: A Systematic Review

OBJECTIVE

The authors sought to identify scalable evidence-based suicide prevention strategies.

METHODS

A search of PubMed and Google Scholar identified 20,234 articles published between September 2005 and December 2019, of which 97 were randomized controlled trials with suicidal behavior or ideation as primary outcomes or epidemiological studies of limiting access to lethal means, using educational approaches, and the impact of antidepressant treatment.

RESULTS

Training primary care physicians in depression recognition and treatment prevents suicide. Educating youths on depression and suicidal behavior, as well as active outreach to psychiatric patients after discharge or a suicidal crisis, prevents suicidal behavior. Meta-analyses find that antidepressants prevent suicide attempts, but individual randomized controlled trials appear to be underpowered. Ketamine reduces suicidal ideation in hours but is untested for suicidal behavior prevention. Cognitive-behavioral therapy and dialectical behavior therapy prevent suicidal behavior. Active screening for suicidal ideation or behavior is not proven to be better than just screening for depression. Education of gatekeepers about youth suicidal behavior lacks effectiveness. No randomized trials have been reported for gatekeeper training for prevention of adult suicidal behavior. Algorithm-driven electronic health record screening, Internet-based screening, and smartphone passive monitoring to identify high-risk patients are understudied. Means restriction, including of firearms, prevents suicide but is sporadically employed in the United States, even though firearms are used in half of all U.S. suicides.

CONCLUSIONS

Training general practitioners warrants wider implementation and testing in other nonpsychiatrist physician settings. Active follow-up of patients after discharge or a suicide-related crisis should be routine, and restricting firearm access by at-risk individuals warrants wider use. Combination approaches in health care systems show promise in reducing suicide in several countries, but evaluating the benefit attributable to each component is essential. Further suicide rate reduction requires evaluating newer approaches, such as electronic health record-derived algorithms, Internet-based screening methods, ketamine's potential benefit for preventing attempts, and passive monitoring of acute suicide risk change.

Social Problem-Solving and Suicidal Ideation Among Homeless Youth Receiving a Cognitive Therapy Intervention: A Moderated Mediation Analysis

Despite the high prevalence of suicidal ideation and attempts among homeless youth, little research has examined how suicide prevention interventions influence suicide-related risk and protective factors, and ultimately produce positive outcome in suicidality in this population. Drawing on the Diathesis-Stress Model and the Interpersonal Theory of Suicide, the current study examined whether participation in Cognitive Therapy for Suicide Prevention (CTSP) moderated the mediation link between social problem-solving, perceived burdensomeness and thwarted belongingness, and suicidal ideation among a sample of homeless youth experiencing suicidal ideation. Social problem-solving refers to a set of cognitive, emotional, and behavioral coping responses in the face of stressful situations, and it is identified as a potent protective factor in alleviating perceived burdensomeness and thwarted belongingness, and reducing suicidal ideation. Participants included 150 homeless youth (M age = 20.99, range = 18-24; 41% female) who were randomly assigned to Cognitive Therapy for Suicide Prevention (CTSP) + Treatment as Usual (TAU) (n = 75) or Treatment as Usual alone (n = 75). Participants were assessed at baseline, 3, 6, and 9 months post-baseline. Findings showed that perceived burdensomeness mediated the association of social problem-solving with suicidal ideation only among youth participating in the CTSP condition. These findings provide evidence to support the promising effects of CTSP in enhancing the protective effects of social problem-solving on suicidal ideation through the mediating effects of perceived burdensomeness. Findings also have implications for improving intervention effectiveness with a community-based population at high risk of suicide.

Psychosocial interventions for self-harm in adults

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most counties, often repeated, and associated with suicide. There has been a substantial increase in both the number of trials and therapeutic approaches of psychosocial interventions for SH in adults. This review therefore updates a previous Cochrane Review (last published in 2016) on the role of psychosocial interventions in the treatment of SH in adults.

OBJECTIVES

To assess the effects of psychosocial interventions for self-harm (SH) compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator) for adults (aged 18 years or older) who engage in SH.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020).

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing interventions of specific psychosocial treatments versus treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, or a combination of these, in the treatment of adults with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide.

DATA COLLECTION AND ANALYSIS

We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratio (ORs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated mean differences (MDs) or standardised mean differences (SMDs) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach.

MAIN RESULTS

We included data from 76 trials with a total of 21,414 participants. Participants in these trials were predominately female (61.9%) with a mean age of 31.8 years (standard deviation [SD] 11.7 years). On the basis of data from four trials, individual cognitive behavioural therapy (CBT)-based psychotherapy may reduce repetition of SH as compared to TAU or another comparator by the end of the intervention (OR 0.35, 95% CI 0.12 to 1.02; N = 238; k = 4; GRADE: low certainty evidence), although there was imprecision in the effect estimate. At longer follow-up time points (e.g., 6- and 12-months) there was some evidence that individual CBT-based psychotherapy may reduce SH repetition. Whilst there may be a slightly lower rate of SH repetition for dialectical behaviour therapy (DBT) (66.0%) as compared to TAU or alternative psychotherapy (68.2%), the evidence remains uncertain as to whether DBT reduces absolute repetition of SH by the post-intervention assessment. On the basis of data from a single trial, mentalisation-based therapy (MBT) reduces repetition of SH and frequency of SH by the post-intervention assessment (OR 0.35, 95% CI 0.17 to 0.73; N = 134; k = 1; GRADE: high-certainty evidence). A group-based emotion-regulation psychotherapy may also reduce repetition of SH by the post-intervention assessment based on evidence from two trials by the same author group (OR 0.34, 95% CI 0.13 to 0.88; N = 83; k = 2; moderate-certainty evidence). There is probably little to no effect for different variants of DBT on absolute repetition of SH, including DBT group-based skills training, DBT individual skills training, or an experimental form of DBT in which participants were given significantly longer cognitive exposure to stressful events. The evidence remains uncertain as to whether provision of information and support, based on the Suicide Trends in At-Risk Territories (START) and the SUicide-PREvention Multisite Intervention Study on Suicidal behaviors (SUPRE-MISS) models, have any effect on repetition of SH by the post-intervention assessment. There was no evidence of a difference for psychodynamic psychotherapy, case management, general practitioner (GP) management, remote contact interventions, and other multimodal interventions, or a variety of brief emergency department-based interventions.

AUTHORS' CONCLUSIONS

Overall, there were significant methodological limitations across the trials included in this review. Given the moderate or very low quality of the available evidence, there is only uncertain evidence regarding a number of psychosocial interventions for adults who engage in SH. Psychosocial therapy based on CBT approaches may result in fewer individuals repeating SH at longer follow-up time points, although no such effect was found at the post-intervention assessment and the quality of evidence, according to the GRADE criteria, was low. Given findings in single trials, or trials by the same author group, both MBT and group-based emotion regulation therapy should be further developed and evaluated in adults. DBT may also lead to a reduction in frequency of SH. Other interventions were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to the use of these interventions is inconclusive at present.

Effect of assertive case management intervention on suicide attempters with comorbid Axis I and II psychiatric diagnoses: secondary analysis of a randomised controlled trial

BACKGROUND

Most suicide attempters suffer from psychiatric disorders, which are often comorbid with personality disorders. The effects of intervention on patients who have attempted suicide with comorbid Axis I and II diagnoses have not been fully elucidated. We evaluated whether assertive case management can reduce the repetition of suicidal behaviours in patients who had attempted suicide with comorbid Axis I and II diagnoses.

METHODS

This study was a secondary analysis of a randomised controlled trial investigating whether assertive case management could reduce the repetition of suicide attempts, compared with enhanced usual care. Subjects were divided into those who had comorbid Axis I and II diagnoses (Axis I + II group), and those who had an Axis I diagnosis without Axis II comorbidity (Axis I group). Outcome measures were compared between patients receiving a case management intervention and patients receiving enhanced usual care, as allocated. The primary outcome measure was the incidence proportion of the first episode of recurrent suicidal behaviour at 6 months after randomisation. We calculated risk ratios (RR) with 95% confidence intervals (CI) at 6 months and 12 months after randomisation of patients in the Axis I and Axis I + II groups.

RESULTS

Of 914 enrolled patients, 120 (13.1%) were in the Axis I + II group, and 794 (86.9%) were in the Axis I group. Assertive case management was significantly effective for the Axis I group on the primary outcome at 6 months (risk ratio [RR] 0.51, 95% confidence intervals [CI] 0.31 to 0.84). The RR of the Axis I + II group was 0.44 (95% CI 0.14 to 1.40).

CONCLUSIONS

Assertive case management not only had an effect on patients who had attempted suicide with only Axis I disorders but may also have a similar effect on patients with comorbid Axis I and II disorders.

Brief Cognitive-based Psychosocial Intervention and Case Management for Suicide Attempters Discharged from the Emergency Department in Taipei, Taiwan: A Randomized Controlled Study

OBJECTIVE

We examined the effectiveness of brief cognitive-based psychotherapy plus standard case management in the prevention of further suicide attempts, clinical severity, and treatment adherence in a randomized clinical trial compared with standard case management.

METHOD

Among five hundred and ninety-seven patients presenting with suicide attempts, 147 participants were included. They were randomized into two groups. After a 6-session intervention over four months, all participants were re-evaluated at the 6th and 12th months.

RESULTS

At a 6-month assessment, the intervention had approximately halved the odds of following suicide attempts and doubled the odds of outpatient visits in comparison with standard case management, although the differences did not attain statistical significance. At a 12-month assessment, the two groups did not differ significantly in any of the outcome variables. Generalized linear mixed models indicated that intervention did not significantly decrease the subsequent suicide risk and severity of clinical symptoms, but it did increase psychiatric outpatient treatment adherence. The subgroup analysis revealed that the intervention increased the outpatient clinic visits only for repetitive attempters, not for first-time attempters.

CONCLUSIONS

Further studies are needed to test whether more intensive psychotherapy sessions might be more effective in decreasing the probability of further attempt and the severity of symptoms.

Psychological therapies for people with borderline personality disorder

BACKGROUND

Over the decades, a variety of psychological interventions for borderline personality disorder (BPD) have been developed. This review updates and replaces an earlier review (Stoffers-Winterling 2012).

OBJECTIVES

To assess the beneficial and harmful effects of psychological therapies for people with BPD.

SEARCH METHODS

In March 2019, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.

SELECTION CRITERIA

Randomised controlled trials comparing different psychotherapeutic interventions with treatment-as-usual (TAU; which included various kinds of psychotherapy), waiting list, no treatment or active treatments in samples of all ages, in any setting, with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.

MAIN RESULTS

We included 75 randomised controlled trials (4507 participants), predominantly involving females with mean ages ranging from 14.8 to 45.7 years. More than 16 different kinds of psychotherapy were included, mostly dialectical behaviour therapy (DBT) and mentalisation-based treatment (MBT). The comparator interventions included treatment-as-usual (TAU), waiting list, and other active treatments. Treatment duration ranged from one to 36 months. Psychotherapy versus TAU Psychotherapy reduced BPD symptom severity, compared to TAU; standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -0.70 to -0.33; 22 trials, 1244 participants; moderate-quality evidence. This corresponds to a mean difference (MD) of -3.6 (95% CI -4.4 to -2.08) on the Zanarini Rating Scale for BPD (range 0 to 36), a clinically relevant reduction in BPD symptom severity (minimal clinical relevant difference (MIREDIF) on this scale is -3.0 points). Psychotherapy may be more effective at reducing self-harm compared to TAU (SMD -0.32, 95% CI -0.49 to -0.14; 13 trials, 616 participants; low-quality evidence), corresponding to a MD of -0.82 (95% CI -1.25 to 0.35) on the Deliberate Self-Harm Inventory Scale (range 0 to 34). The MIREDIF of -1.25 points was not reached. Suicide-related outcomes improved compared to TAU (SMD -0.34, 95% CI -0.57 to -0.11; 13 trials, 666 participants; low-quality evidence), corresponding to a MD of -0.11 (95% CI -0.19 to -0.034) on the Suicidal Attempt Self Injury Interview. The MIREDIF of -0.17 points was not reached. Compared to TAU, psychotherapy may result in an improvement in psychosocial functioning (SMD -0.45, 95% CI -0.68 to -0.22; 22 trials, 1314 participants; low-quality evidence), corresponding to a MD of -2.8 (95% CI -4.25 to -1.38), on the Global Assessment of Functioning Scale (range 0 to 100). The MIREDIF of -4.0 points was not reached. Our additional Trial Sequential Analysis on all primary outcomes reaching significance found that the required information size was reached in all cases. A subgroup analysis comparing the different types of psychotherapy compared to TAU showed no clear evidence of a difference for BPD severity and psychosocial functioning. Psychotherapy may reduce depressive symptoms compared to TAU but the evidence is very uncertain (SMD -0.39, 95% CI -0.61 to -0.17; 22 trials, 1568 participants; very low-quality evidence), corresponding to a MD of -2.45 points on the Hamilton Depression Scale (range 0 to 50). The MIREDIF of -3.0 points was not reached. BPD-specific psychotherapy did not reduce attrition compared with TAU. Adverse effects were unclear due to too few data. Psychotherapy versus waiting list or no treatment Greater improvements in BPD symptom severity (SMD -0.49, 95% CI -0.93 to -0.05; 3 trials, 161 participants), psychosocial functioning (SMD -0.56, 95% CI -1.01 to -0.11; 5 trials, 219 participants), and depression (SMD -1.28, 95% CI -2.21 to -0.34, 6 trials, 239 participants) were observed in participants receiving psychotherapy versus waiting list or no treatment (all low-quality evidence). No evidence of a difference was found for self-harm and suicide-related outcomes. Individual treatment approaches DBT and MBT have the highest numbers of primary trials, with DBT as subject of one-third of all included trials, followed by MBT with seven RCTs. Compared to TAU, DBT was more effective at reducing BPD severity (SMD -0.60, 95% CI -1.05 to -0.14; 3 trials, 149 participants), self-harm (SMD -0.28, 95% CI -0.48 to -0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD -0.36, 95% CI -0.69 to -0.03; 6 trials, 225 participants). MBT appears to be more effective than TAU at reducing self-harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD -0.58, 95% CI -1.22 to 0.05, 4 trials, 333 participants). All findings are based on low-quality evidence. For secondary outcomes see review text.

AUTHORS' CONCLUSIONS

Our assessments showed beneficial effects on all primary outcomes in favour of BPD-tailored psychotherapy compared with TAU. However, only the outcome of BPD severity reached the MIREDIF-defined cut-off for a clinically meaningful improvement. Subgroup analyses found no evidence of a difference in effect estimates between the different types of therapies (compared to TAU) . The pooled analysis of psychotherapy versus waiting list or no treatment found significant improvement on BPD severity, psychosocial functioning and depression at end of treatment, but these findings were based on low-quality evidence, and the true magnitude of these effects is uncertain. No clear evidence of difference was found for self-harm and suicide-related outcomes. However, compared to TAU, we observed effects in favour of DBT for BPD severity, self-harm and psychosocial functioning and, for MBT, on self-harm and suicidality at end of treatment, but these were all based on low-quality evidence. Therefore, we are unsure whether these effects would alter with the addition of more data.

Adolescent suicide attempts and ideation are linked to brain function during peer interactions

Understanding the neural correlates of social interaction among depressed adolescents with suicidal tendencies might help personalize treatment. We tested whether brain function during social interaction is disrupted for depressed adolescents with (1) high suicide ideation and (2) recent attempts. Depressed adolescents with high suicide ideation, including attempters (n = 45;HS) or low suicide ideation (n = 42;LS), and healthy adolescents (n = 39;HC), completed a version of the Cyberball peer interaction task during an fMRI scan. Groups were compared on brain activity during peer exclusion and inclusion versus a non-social condition. During peer exclusion and inclusion, HS youth showed significantly lower activity in precentral and postcentral gyrus, superior temporal gyrus, medial frontal gyrus, insula, and putamen compared to LS youth; and significantly reduced activity in caudate and anterior cingulate cortex compared to HC youth. In a second analysis, suicide attempters (n = 26;SA) were compared to other groups. SA adolescents showed significantly higher activity in ACC and superior and middle frontal gyrus than all other groups. Brain activity was significantly correlated with negative emotionality, social functioning, and cognitive control. Conclusions: Adolescent suicide ideation and attempts were linked to altered neural function during positive and negative peer interactions. We discuss the implications of these findings for suicide prevention efforts.

Active contact and follow-up interventions to prevent repeat suicide attempts during high-risk periods among patients admitted to emergency departments for suicidal behavior: a systematic review and meta-analysis

BACKGROUND

There is evidence that several intervention types, including psychotherapy, reduce repeat suicide attempts. However, these interventions are less applicable to the heterogeneous patients admitted to emergency departments (EDs). The risk of a repeat suicide attempt is especially high in the first 6 months after the initial attempt. Therefore, it is particularly important to develop effective ED interventions to prevent repeat suicide attempts during this 6-month period.

METHODS

We systematically reviewed randomized controlled trials of ED-initiated interventions for suicidal patients admitted to EDs using the databases MEDLINE, PsychoINFO, CINAHL, and EMBASE up to January 2015 in accordance with an a priori published protocol (PROSPERO: CRD42013005463). Interventions were categorized into four types, including active contact and follow-up interventions (intensive care plus outreach, brief interventions and contact, letter/postcard, telephone, and composite of letter/postcard and telephone), and a meta-analysis was conducted to determine pooled relative risks (RRs) and 95% confidence intervals (CIs) of a repeat suicide attempt within 6 months.

RESULTS

Of the 28 selected trials, 14 were active contact and follow-up interventions. Two of these trials (n = 984) reported results at 6 months (pooled RR = 0.48; 95% CI: 0.31 to 0.76). There were not enough trials of other interventions to perform meta-analysis. Some trials included in the meta-analysis were judged as showing risk of bias.

CONCLUSION

Active contact and follow-up interventions are recommended for suicidal patients admitted to an ED to prevent repeat suicide attempts during the highest-risk period of 6 months.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42013005463 (27 August 2013).

The role of neuroticism in self-harm and suicidal ideation: results from two UK population-based cohorts

BACKGROUND

Self-harm is common, debilitating and associated with completed suicide and increased all-cause mortality, but there is uncertainty about its causal risk factors, limiting risk assessment and effective management. Neuroticism is a stable personality trait associated with self-harm and suicidal ideation, and correlated with coping styles, but its value as an independent predictor of these outcomes is disputed.

METHODS

Prior history of hospital-treated self-harm was obtained by record-linkage to administrative health data in Generation Scotland:Scottish Family Health Study (N = 15,798; self-harm cases = 339) and by a self-report variable in UK Biobank (N = 35,227; self-harm cases = 772). Neuroticism in both cohorts was measured using the Eysenck Personality Questionnaire-Short Form. Associations of neuroticism with self-harm were tested using multivariable regression following adjustment for age, sex, cognitive ability, educational attainment, socioeconomic deprivation, and relationship status. A subset of GS:SFHS was followed-up with suicidal ideation elicited by self-report (n = 3342, suicidal ideation cases = 158) and coping styles measured by the Coping Inventory for Stressful Situations. The relationship of neuroticism to suicidal ideation, and the role of coping style, was then investigated using multivariable logistic regression.

RESULTS

Neuroticism was positively associated with hospital-associated self-harm in GS:SFHS (per EPQ-SF unit odds ratio 1.2 95% credible interval 1.1-1.2, p_FDR 0.0003) and UKB (per EPQ-SF unit odds ratio 1.1 95% confidence interval 1.1-1.2, p_FDR 9.8 × 10^-17). Neuroticism, and the neuroticism-correlated coping style, emotion-oriented coping (EoC), were also associated with suicidal ideation in multivariable models.

CONCLUSIONS

Neuroticism is an independent predictor of hospital-treated self-harm risk. Neuroticism and emotion-orientated coping styles are also predictive of suicidal ideation.

The Flexible Lifestyle Empowering Change (FLEX) intervention for self-management in adolescents with type 1 diabetes: Trial design and baseline characteristics

The Flexible Lifestyle Empowering Change (FLEX) Intervention Study is a multi-site randomized controlled trial to test the efficacy of an adaptive behavioral intervention to promote self-management for youth with type 1 diabetes mellitus (T1D). This paper details FLEX design, demographic characteristics of the sample, and outcome variables at baseline. Participants were randomized to either an intervention or control arm after their baseline standardized measurement visit. Baseline data for the primary (glycemic levels) and secondary outcome variables (e.g., motivation and problem-solving, health-related quality of life, risk factors associated with T1D complications) as well as the potential mediator variables (e.g., self-management behavior, family conflict and responsibility) suggest that the study sample was representative of the general population of adolescents with T1D and their parents. The FLEX adaptive intervention is an innovative application of a tailored treatment intervention designed to be readily adopted in real-world practice to meet each adolescent's individualized T1D self-management goals.

Cognition As a Therapeutic Target in the Suicidal Patient Approach

The current considerations about completed suicides and suicide attempts in different cultures call the attention of professionals to this serious public health problem. Integrative approaches have shown that the confluence of multiple biological and social factors modulate various psychopathologies and dysfunctional behaviors, such as suicidal behavior. Considering the level of intermediate analysis, personality traits and cognitive functioning are also of great importance for understanding the suicide phenomenon. About cognitive factors, we can group them into cognitive schemas of reality interpretation and underlying cognitive processes. On the other hand, different types of primary cognitive alterations are related to suicidal behavior, especially those resulting from changes in frontostriatal circuits. Among such cognitive mechanisms can be highlighted the attentional bias for environmental cues related to suicide, impulsive behavior, verbal fluency deficits, non-adaptive decision-making, and reduced planning skills. Attentional bias consists in the effect of thoughts and emotions, frequently not conscious, about the perception of environmental stimuli. Suicidal ideation and hopelessness can make the patient unable to find alternative solutions to their problems other than suicide, biasing their attention to environmental cues related to such behavior. Recent research efforts are directed to assess the possible use of attention bias as a therapeutic target in patients presenting suicide behavior. The relationship between impulsivity and suicide has been largely investigated over the last decades, and there is still controversy about the theme. Although there is strong evidence linking impulsivity to suicide attempts. Effective interventions address to reduce impulsivity in clinical populations at higher risk for suicide could help in the prevention. Deficits in problem-solving ability also seem to be distorted in patients who attempt suicide. Understanding cognitive changes in patients who attempt suicide open an important perspective in the approach of patients with mental disorders. Identifying cognitive deficits in these patients, along with personality traits, depressive symptoms, and suicidal cognitive schemas may indicate to the psychiatrist the need for emergency care. Behavioral and cognitive interventions have been associated with reductions in suicide ideation, as well as suicide attempts in different populations.

Response to unfairness across the suicide risk spectrum

Suicidal behavior is frequently triggered by social crises, such as familial, romantic, social or work-related conflict. A variety of cognitive and social functioning impairments has been associated with suicidal thoughts and acts. One of the precipitating and perpetuating factors of social conflict is the desire for retribution after a perceived offense, even at one's own detriment. We utilized the Ultimatum Game-a behavioral economic task which examines the behavioral response to perceived unfairness-in order to characterize the response to unfairness across the acute suicide risk spectrum. We examined five groups of adult individuals of both genders (n = 204): High- and Low-Lethality recent Suicide Attempters, Suicidal Ideators, Non-Suicidal Depressed Patients; and Healthy Controls. We also measured demographic and clinical variables. Even though all depressed groups showed similar rejection rates in the Ultimatum Game, there was a higher likelihood of rejecting offers in the low stakes condition in all acutely suicidal groups compared with healthy controls. Stake size, offer, education, and gender of the proposer were significantly associated with rejection rates. Acutely suicidal patients may be more vulnerable to adverse interpersonal interactions. Further characterization of social behavior may provide targets for secondary and tertiary prevention for high-risk individuals.

'Don't push me aside, Doctor': Suicide attempters talk about their support needs, service delivery and suicide prevention in South Africa

Few studies have explored the expressed support needs of suicide attempters in developing countries. Data, collected via in-depth interviews with suicide attempters admitted to a South African hospital, were analysed using thematic content analysis. Participants explicitly asked for integrated psycho-social services at a primary health care level and say they require assistance with alleviating psychiatric symptoms, establishing connectedness, interpersonal conflict and solving socio-economic problems. Findings highlight the importance for suicide prevention of (1) considering interpersonal and contextual socio-economic factors in addition to the psychiatric causes of suicidal behaviour; and (2) multilevel strategies, intersectoral collaboration and integrated person-centred primary health care.

Perceived problem-solving deficits and suicidal ideation: Evidence for the explanatory roles of thwarted belongingness and perceived burdensomeness in five samples

Perceived social problem-solving deficits are associated with suicide risk; however, little research has examined the mechanisms underlying this relationship. The interpersonal theory of suicide proposes 2 mechanisms in the pathogenesis of suicidal desire: intractable feelings of thwarted belongingness (TB) and perceived burdensomeness (PB). This study tested whether TB and PB serve as explanatory links in the relationship between perceived social problem-solving (SPS) deficits and suicidal thoughts and behaviors cross-sectionally and longitudinally. The specificity of TB and PB was evaluated by testing depression as a rival mediator. Self-report measures of perceived SPS deficits, TB, PB, suicidal ideation, and depression were administered in 5 adult samples: 336 and 105 undergraduates from 2 universities, 53 homeless individuals, 222 primary care patients, and 329 military members. Bias-corrected bootstrap mediation and meta-analyses were conducted to examine the magnitude of the direct and indirect effects, and the proposed mediation paths were tested using zero-inflated negative binomial regressions. Cross-sectionally, TB and PB were significant parallel mediators of the relationship between perceived SPS deficits and ideation, beyond depression. Longitudinally and beyond depression, in 1 study, both TB and PB emerged as significant explanatory factors, and in the other, only PB was a significant mediator. Findings supported the specificity of TB and PB: Depression and SPS deficits were not significant mediators. The relationship between perceived SPS deficits and ideation was explained by interpersonal theory variables, particularly PB. Findings support a novel application of the interpersonal theory, and bolster a growing compendium of literature implicating perceived SPS deficits in suicide risk. (PsycINFO Database Record

A Cognitive Distortions and Deficits Model of Suicide Ideation

Although cognitive distortions and deficits are known risk factors for the development and escalation of suicide ideation and behaviour, no empirical work has examined how these variables interact to predict suicide ideation. The current study proposes an integrative model of cognitive distortions (hopelessness and negative evaluations of self and future) and deficits (problem solving deficits, problem solving avoidance, and cognitive rigidity). To test the integrity of this model, a sample of 397 undergraduate students completed measures of deficits, distortions, and current suicide ideation. A structural equation model demonstrated excellent fit, and findings indicated that only distortions have a direct effect on suicidal thinking, whereas cognitive deficits may exert their effects on suicide ideation via their reciprocal relation with distortions. Findings underscore the importance of both cognitive distortions and deficits for understanding suicidality, which may have implications for preventative efforts and treatment.

Cognitive Behavioural Suicide Prevention for Male Prisoners: Case examples

Suicide is a serious public health problem but a problem that is preventable. This complex and challenging problem is particularly prevalent amongst prisoners; associated with a five-fold increase in risk compared to the general community. Being in prison can lead people to experience fear, distrust, lack of control, isolation, and shame, which is often experienced as overwhelming and intolerable with some choosing suicide as a way to escape. Few effective psychological interventions exist to prevent suicide although cognitive behaviour therapies appear to offer some promise. Offering cognitive behaviour suicide prevention (CBSP) therapy to high risk prisoners may help to reduce the likelihood of preventable self-inflicted deaths. In this paper we present three cases drawn from a randomised controlled trial designed to investigate the feasibility of CBSP for male prisoners. Implications of the current findings for future research and clinical practice are considered.

Linking insomnia and suicide ideation in college females: The role of socio-cognitive variables and depressive symptoms in suicide risk

BACKGROUND

Although insomnia symptoms are associated with risk of suicide ideation, the means by which insomnia influences ideation, as well as the role depression plays in these relationships, require further study. In this study, we examined whether certain socio-cognitive variables (fatigue, social problem-solving, and hopelessness) in conjunction with depression explained this relationship among female college students.

METHODS

483 female students completed measures assessing insomnia and depressive symptoms, fatigue, social problem-solving ability, hopelessness, and suicide ideation.

RESULTS

Path analyses indicated that socio-cognitive variables partially explained the insomnia-ideation relationship above the influence of depressive symptoms. Higher depressive symptoms exacerbated relationships between social problem-solving and hopelessness, heightening ideation risk.

CONCLUSIONS

Our findings expand knowledge of intermediate socio-cognitive variables that may contribute to the insomnia-ideation relationship, and indicate that clinically-severe depressive symptoms compound the contribution of negative self and future appraisals to thoughts of suicide. Suicidal females with insomnia and depressive symptoms may benefit from interventions targeting problem-solving skills and improving sleep.

Psychosocial interventions for self-harm in adults

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury) is common, often repeated, and associated with suicide. This is an update of a broader Cochrane review first published in 1998, previously updated in 1999, and now split into three separate reviews. This review focuses on psychosocial interventions in adults who engage in self-harm.

OBJECTIVES

To assess the effects of specific psychosocial treatments versus treatment as usual, enhanced usual care or other forms of psychological therapy, in adults following SH.

SEARCH METHODS

The Cochrane Depression, Anxiety and Neurosis Group (CCDAN) trials coordinator searched the CCDAN Clinical Trials Register (to 29 April 2015). This register includes relevant randomised controlled trials (RCTs) from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date).

SELECTION CRITERIA

We included RCTs comparing psychosocial treatments with treatment as usual (TAU), enhanced usual care (EUC) or alternative treatments in adults with a recent (within six months) episode of SH resulting in presentation to clinical services.

DATA COLLECTION AND ANALYSIS

We used Cochrane's standard methodological procedures.

MAIN RESULTS

We included 55 trials, with a total of 17,699 participants. Eighteen trials investigated cognitive-behavioural-based psychotherapy (CBT-based psychotherapy; comprising cognitive-behavioural, problem-solving therapy or both). Nine investigated interventions for multiple repetition of SH/probable personality disorder, comprising emotion-regulation group-based psychotherapy, mentalisation, and dialectical behaviour therapy (DBT). Four investigated case management, and 11 examined remote contact interventions (postcards, emergency cards, telephone contact). Most other interventions were evaluated in only single small trials of moderate to very low quality.There was a significant treatment effect for CBT-based psychotherapy compared to TAU at final follow-up in terms of fewer participants repeating SH (odds ratio (OR) 0.70, 95% confidence interval (CI) 0.55 to 0.88; number of studies k = 17; N = 2665; GRADE: low quality evidence), but with no reduction in frequency of SH (mean difference (MD) -0.21, 95% CI -0.68 to 0.26; k = 6; N = 594; GRADE: low quality).For interventions typically delivered to individuals with a history of multiple episodes of SH/probable personality disorder, group-based emotion-regulation psychotherapy and mentalisation were associated with significantly reduced repetition when compared to TAU: group-based emotion-regulation psychotherapy (OR 0.34, 95% CI 0.13 to 0.88; k = 2; N = 83; GRADE: low quality), mentalisation (OR 0.35, 95% CI 0.17 to 0.73; k = 1; N = 134; GRADE: moderate quality). Compared with TAU, dialectical behaviour therapy (DBT) showed a significant reduction in frequency of SH at final follow-up (MD -18.82, 95% CI -36.68 to -0.95; k = 3; N = 292; GRADE: low quality) but not in the proportion of individuals repeating SH (OR 0.57, 95% CI 0.21 to 1.59, k = 3; N = 247; GRADE: low quality). Compared with an alternative form of psychological therapy, DBT-oriented therapy was also associated with a significant treatment effect for repetition of SH at final follow-up (OR 0.05, 95% CI 0.00 to 0.49; k = 1; N = 24; GRADE: low quality). However, neither DBT vs 'treatment by expert' (OR 1.18, 95% CI 0.35 to 3.95; k = 1; N = 97; GRADE: very low quality) nor prolonged exposure DBT vs standard exposure DBT (OR 0.67, 95% CI 0.08 to 5.68; k = 1; N =18; GRADE: low quality) were associated with a significant reduction in repetition of SH.Case management was not associated with a significant reduction in repetition of SH at post intervention compared to either TAU or enhanced usual care (OR 0.78, 95% CI 0.47 to 1.30; k = 4; N = 1608; GRADE: moderate quality). Continuity of care by the same therapist vs a different therapist was also not associated with a significant treatment effect for repetition (OR 0.28, 95% CI 0.07 to 1.10; k = 1; N = 136; GRADE: very low quality). None of the following remote contact interventions were associated with fewer participants repeating SH compared with TAU: adherence enhancement (OR 0.57, 95% CI 0.32 to 1.02; k = 1; N = 391; GRADE: low quality), mixed multimodal interventions (comprising psychological therapy and remote contact-based interventions) (OR 0.98, 95% CI 0.68 to 1.43; k = 1 study; N = 684; GRADE: low quality), including a culturally adapted form of this intervention (OR 0.83, 95% CI 0.44 to 1.55; k = 1; N = 167; GRADE: low quality), postcards (OR 0.87, 95% CI 0.62 to 1.23; k = 4; N = 3277; GRADE: very low quality), emergency cards (OR 0.82, 95% CI 0.31 to 2.14; k = 2; N = 1039; GRADE: low quality), general practitioner's letter (OR 1.15, 95% CI 0.93 to 1.44; k = 1; N = 1932; GRADE: moderate quality), telephone contact (OR 0.74, 95% CI 0.42 to 1.32; k = 3; N = 840; GRADE: very low quality), and mobile telephone-based psychological therapy (OR not estimable due to zero cell counts; GRADE: low quality).None of the following mixed interventions were associated with reduced repetition of SH compared to either alternative forms of psychological therapy: interpersonal problem-solving skills training, behaviour therapy, home-based problem-solving therapy, long-term psychotherapy; or to TAU: provision of information and support, treatment for alcohol misuse, intensive inpatient and community treatment, general hospital admission, or intensive outpatient treatment.We had only limited evidence on whether the intervention had different effects in men and women. Data on adverse effects, other than planned outcomes relating to suicidal behaviour, were not reported.

AUTHORS' CONCLUSIONS

CBT-based psychological therapy can result in fewer individuals repeating SH; however, the quality of this evidence, assessed using GRADE criteria, ranged between moderate and low. Dialectical behaviour therapy for people with multiple episodes of SH/probable personality disorder may lead to a reduction in frequency of SH, but this finding is based on low quality evidence. Case management and remote contact interventions did not appear to have any benefits in terms of reducing repetition of SH. Other therapeutic approaches were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to these interventions is inconclusive.

Successful Treatment of Suicidal Risk

BACKGROUND

In this article we focused on analyzing surveyed patient-generated responses based on two outcome questions derived from a suicide-specific framework called the Collaborative Assessment and Management of Suicidality (CAMS): Q1 - "Were there any aspects of your treatment that were particularly helpful to you? If so, please describe these. Be as specific as possible." Q2 - "What have you learned from your clinical care that could help you if you became suicidal in the future?"

AIMS

To develop a reliable coding system based on formerly suicidal patients' responses to two open-ended prompts and examine most frequently identified themes.

METHOD

The present study utilized a consensual qualitative research process to examine responses of clinically resolved suicidal patients, based on the CAMS resolution criteria (i.e., three consecutive CAMS sessions reporting the effective management of suicidal risk), to two Suicide Status Form (SSF) outcome questions (n = 49 for Q1, and n = 52 for Q2).

RESULTS

Reliable coding systems were developed and used to determine major themes of successful patient responses.

CONCLUSION

The results of this study provide insight into patients' experiences of a successful treatment for suicidal risk with larger implications for suicide-specific treatments in general.

Perspectives of Suicidal Veterans on Safety Planning

Abstract. Aims: Individual interviews were conducted and analyzed to learn about the engagement of suicidal veterans in safety planning. Method: Twenty suicidal veterans who had recently constructed safety plans were recruited at two VA hospitals. In semistructured interviews, they discussed how they felt about constructing and using the plan and suggested changes in plan content and format that might increase engagement. Results: The veterans’ experiences varied widely, from reviewing plans often and noting symptom improvement to not using them at all and doubting that they would think of doing so when deeply depressed. Conclusion: The veterans suggested ways to enrich safety planning encounters and identified barriers to plan use. Their ideas were specific and practical. Safety planning was most meaningful and helpful to them when they experienced the clinician as a partner in exploring their concerns (e.g., fear of discussing and attending to warning signs) and collaborating with them to devise solutions.

Factor structure and item level psychometrics of the Social Problem Solving Inventory-Revised: Short Form in traumatic brain injury

Social problem-solving deficits characterise individuals with traumatic brain injury (TBI), and poor social problem solving interferes with daily functioning and productive lifestyles. Therefore, it is of vital importance to use the appropriate instrument to identify deficits in social problem solving for individuals with TBI. This study investigates factor structure and item-level psychometrics of the Social Problem Solving Inventory-Revised: Short Form (SPSI-R:S), for adults with moderate and severe TBI. Secondary analysis of 90 adults with moderate and severe TBI who completed the SPSI-R:S was performed. An exploratory factor analysis (EFA), principal components analysis (PCA) and Rasch analysis examined the factor structure and item-level psychometrics of the SPSI-R:S. The EFA showed three dominant factors, with positively worded items represented as the most definite factor. The other two factors are negative problem-solving orientation and skills; and negative problem-solving emotion. Rasch analyses confirmed the three factors are each unidimensional constructs. It was concluded that the total score interpretability of the SPSI-R:S may be challenging due to the multidimensional structure of the total measure. Instead, we propose using three separate SPSI-R:S subscores to measure social problem solving for the TBI population.

Interventions to prevent repeat suicidal behavior in patients admitted to an emergency department for a suicide attempt: a meta-analysis

BACKGROUND

A huge number of patients with self-harm and suicide attempt visit emergency departments (EDs). We systematically reviewed studies and examined the effect of interventions to prevent repeat suicidal behavior in patients admitted to EDs for a suicidal attempt.

METHOD

We searched the databases of MEDLINE, PsychoINFO, CINAHL, and EMBASE through August 2013. Eligible studies were randomized controlled trials assessing the effects on repeat suicidal behavior of interventions initiated in suicidal patients admitted to EDs. Interventions in each trial were classified into groups by consensus. Meta-analyses were performed to determine pooled relative risks (RRs) and 95% confidence intervals (CIs) of repetition of suicide attempt for interventions in each group.

RESULTS

Out of 5390 retrieved articles, 24 trials were included and classified into four groups (11 trials in the Active contact and follow-up, nine in the Psychotherapy, one in the Pharmacotherapy, and three in the Miscellaneous). Active contact and follow-up type interventions were effective in preventing a repeat suicide within 12 months (n=5319; pooled RR=0.83; 95% CI: 0.71 to 0.97). However, the effect at 24 months was not confirmed (n=925; pooled RR=0.98; 95% CI: 0.76-1.22). The effects of the other interventions on preventing a repetition of suicidal behavior remain unclear.

LIMITATION

Caution is needed regarding the heterogeneity of the effects.

CONCLUSION

Interventions of active contact and follow-up are recommended to reduce the risk of a repeat suicide attempt at 12 months in patients admitted to EDs with a suicide attempt. However, the long-term effect was not confirmed.

Effects of cognitive behavioral therapy for insomnia on suicidal ideation in veterans

OBJECTIVE

To examine the effects of cognitive behavioral therapy for insomnia (CBT-I) on suicidal ideation among Veterans with insomnia.

DESIGN

Longitudinal data collected in the course of an uncontrolled evaluation of a large-scale CBT-I training program.

SETTING

Outpatient and residential treatment facilities.

PARTICIPANTS

Four hundred five Veterans presenting for treatment of insomnia.

INTERVENTIONS

Cognitive behavioral therapy for insomnia (CBT-I).

MEASUREMENT AND RESULTS

At baseline, 32% of patients, compared with 21% at final assessment, endorsed some level of suicidal ideation [χ(2)(df = 1) = 125; P < 0.001]. After adjusting for demographic variables and baseline insomnia severity, each 7-point decrease in Insomnia Severity Index (ISI) score achieved during CBT-I treatment was associated with a 65% (OR = 0.35; 95% CI = 0.24 to 0.52) reduction in odds of suicidal ideation. The effect of change in insomnia severity on change in depression severity was also significant. After controlling for change in depression severity and other variables in the model, the effect of change in insomnia severity on change in suicidal ideation remained significant.

CONCLUSION

This evaluation of the largest dissemination of CBT-I in the United States found a clinically meaningful reduction in suicidal ideation among Veterans receiving CBT-I. The mechanisms by which effective treatment of insomnia with CBT-I reduces suicide risk are unknown and warrant investigation. The current results may have significant public health implications for preventing suicide among Veterans.

Constructing the Suicide Risk Index (SRI): does it work in predicting suicidal behavior in young adults mediated by proximal factors?

Suicide is a key concern among young adults. The aim of the study was to (1) construct a suicide risk index (SRI) based on demographic, situational, and behavioral factors known to be linked to suicidal behavior and (2) investigate whether the association between the SRI and suicidal behavior was mediated by proximal processes (personal factors, coping strategies, and emotional states). Participants consisted of 7,558 individuals aged 17-25 years (M = 20.35, SD = 1.91). Nearly 22% (n = 1,542) reported self-harm and 7% (n = 499) had attempted suicide. Mediation analysis revealed both a direct effect (ß = .299, 95% CI = [.281, .317], p < .001), and a mediated effect (ß = .204, 95% CI = [.186, .222], p < .001), between the risk index and suicidal behavior. The strongest mediators were levels of self-esteem, depression, and avoidant coping. Interventions to increase self-esteem, reduce depression, and encourage adaptive coping strategies may prevent suicidal behavior in young people.

Does cognitive behavioural therapy have a role in improving problem solving and coping in adolescents with suicidal ideation?

Problem-solving and coping skills deficits have been shown in adolescents who experience suicide-related behaviours, including suicidal ideation. Little evidence exists about effective interventions for this population. We undertook a pilot study of an Internet-based CBT programme that included problem-solving skills training to investigate its impact on skills deficits. The study employed a pre-test/post-test design. Outcomes of interest were negative problem orientation, emotion- and task-focused coping, and adolescents’ perception of helpfulness of the intervention. Participants, recruited via the school wellbeing team, were assessed at baseline, at weekly intervention sessions and immediately post-intervention. Twenty-one adolescents completed the intervention. Over the course of the intervention, negative problem-solving orientation improved and students relied less on emotion-focused coping strategies. Because there was no control group, we cannot be certain that the changes seen between baseline and post-intervention can be attributed to the intervention. Adolescents rated the problem-solving and cognitive restructuring modules as particularly helpful. Interventions that include enhancement of problem-solving skills, as well as cognitive restructuring to address adolescents’ appraisal of problems and their ability to solve them appear promising for adolescents with suicidal ideation. Further investigation is warranted.

Post-Admission Cognitive Therapy (PACT) for the Prevention of Suicide in Military Personnel With Histories of Trauma

To date, no inpatient evidence-based psychotherapeutic interventions have been developed for suicidal individuals with psychological trauma. Therefore, we have adapted, refined, implemented, and pilot-tested an inpatient-based cognitive behavioral therapy protocol, named Post-Admission Cognitive Therapy (PACT), for the prevention of suicide. This article briefly describes the theoretical and research underpinnings for PACT, components of the treatment protocol, and clinical challenges. A case study of a traumatized military service member hospitalized following a suicide attempt is presented. Baseline and follow-up assessment data show general improvements in suicide ideation, depression, hopelessness, and Post Traumatic Stress Disorder symptomatology over time. While the data for the presented case appears promising, the efficacy of PACT remains unknown and is currently under investigation in a randomized controlled trial. Recommendations for clinicians and students who deliver care to suicidal psychiatric inpatients are provided.

Relations between hopelessness, depressive symptoms and suicidality: mediation by reasons for living

OBJECTIVE

The present study examined whether reasons for living (RFL) would partially account for the associations between traditional risk factors (depressive symptoms, hopelessness) and suicidal ideation and attempts.

METHOD

Data were collected from 1,075 undergraduate college students who completed a battery of online assessments.

RESULTS

Results from a series of simultaneous mediational models indicated that the relations between risk factors and current suicidal ideation were partially mediated by total RFL (and Coping Beliefs and Self-Evaluation subscales). Further, total RFL (and the Coping Beliefs subscale) fully mediated the relation between hopelessness and past-year suicide attempt, and partially mediated the depressive symptoms-suicide attempt relation.

CONCLUSIONS

This study demonstrates the importance of assessing for the presence of these suicide risk and protective factors. Implications for the improved identification and treatment of young adults at risk for suicide are discussed.

Suicide Among Soldiers: A Review of Psychosocial Risk and Protective Factors

Suicide is difficult to predict and prevent and remains a leading cause of death worldwide. Although soldiers historically have had a suicide rate well below that of the general population, the suicide rate among members of the U.S. Army has increased markedly over the past several years and now exceeds that of the general population. This paper reviews psychosocial factors known to be associated with the increased risk of suicidal behavior in general and describes how some of these factors may be especially important in understanding suicide among soldiers. Moving forward, the prevention of suicide requires additional research aimed at: (a) better describing when, where, and among whom suicidal behavior occurs, (b) using exploratory studies to discover new risk and protective factors, (c) developing new methods of predicting suicidal behavior that synthesize information about modifiable risk and protective factors from multiple domains, and (d) understanding the mechanisms and pathways through which suicidal behavior develops. Although the scope and severity of this problem is daunting, the increasing attention and dedication to this issue by the Armed Forces, scientists, and society provide hope for our ability to better predict and prevent these tragic outcomes in the future.