Brief Cognitive-Behavioral Therapy for Suicidal Inpatients

Brief Cognitive Behavioral Therapy for Suicidal Inpatients: A Randomized Clinical Trial

Importance

Suicide risk is elevated after discharge from inpatient level of care. Empirically supported inpatient suicide prevention treatments are needed.

Objective

To determine whether adding an inpatient version of brief cognitive behavioral therapy for suicide prevention to treatment as usual reduces postdischarge suicide attempts, suicidal ideation, and psychiatric readmissions and to determine whether substance use disorder moderates treatment effects.

Design, Setting, and Participants

This randomized clinical trial compared treatment as usual (n = 106) to treatment as usual plus brief cognitive behavioral therapy for inpatients (n = 94) at a private psychiatric hospital in Connecticut. Follow-up assessments were completed monthly for 6 months postdischarge. Participants were enrolled from January 2020 through February 2023. Inpatients admitted following a suicidal crisis (past-week suicide attempt or ideation with plan on admission and attempt within previous 2 years) were included. Medical records of consecutive admissions (n = 4137) were screened, 213 were study eligible and randomized, and 200 were analyzed. A total of 114 participants (57.0%) completed 6-month follow-up assessments. Data from medical records were also obtained through 6-month follow-up.

Intervention

Up to 4 individual sessions of brief cognitive behavioral therapy for suicide prevention designed for inpatients.

Main Outcomes and Measures

Suicide attempts and readmissions were assessed via blind interviews and medical record review. Suicidal ideation was assessed via self-report.

Results

The mean (SD) age among 200 analyzed participants was 32.8 (12.6) years; 117 participants were female and 83 were male. Brief cognitive behavioral therapy-inpatient reduced the occurrence of suicide attempt over 6 months postdischarge by 60% (odds ratio, 0.40; 95% CI, 0.20-0.80; number needed to treat, 7) in the entire patient group, and the rate of psychiatric readmissions by 71% (rate ratio, 0.29; 95% CI, 0.09-0.90) in those without a substance use disorder. The effect of treatment condition on suicidal ideation was less clear, although post hoc analyses indicated less severe suicidal ideation following brief cognitive behavioral therapy-inpatient vs treatment as usual at 1 and 2 months postdischarge.

Conclusions and Relevance

Brief cognitive behavioral therapy-inpatient reduced 6-month postdischarge suicide reattempts and rate of readmissions when added to treatment as usual. Substance use disorder moderated the treatment's effect on readmission rates. Treatment effects on suicidal ideation were less clear. Implementation research is needed to facilitate dissemination. Additional research is also needed to optimize outcomes for individuals with substance use disorders.

Trial Registration

ClinicalTrials.gov Identifier: NCT04168645.

A Systematic Review of the Use, Acceptability, Perceived Effectiveness and Effectiveness of Self-Help Toolkits

Self-harming behaviours can include cutting the skin, ligaturing and taking overdoses. These actions can result in infection, blood loss, or even death. A young person's risk of dying by suicide increases if they engage in self-harm. Self-help empowers people to utilise different coping strategies and implement life changes without reliance on a clinical intervention, "helping people to help themselves". Self-help toolkits contain a variety of items that are selected by the person to help them manage the urge to self-harm. The items included sensory objects, distractions, prompts to seek help and creative prompts such as colouring books and pens and personal items that trigger positive memories. AMED, EMBASE, APA Psycinfo and MEDLINE were searched with no language restriction or date restriction. Of the 368 studies screened, 13 met the inclusion criteria. The studies were mainly small scale or case studies pertaining to the use of self-help toolkits or similar. They described the need for a flexible and/or individualised approach to self-help toolkits. Abstracts and studies were screened separately by two members of the research team for inclusion. Qualitative data was analysed using Grounded Theory. Nine themes were identified: Creativity, Hope, Social contact/help seeking, calming/relaxing, sensory items, reflection, distractions, therapeutic prompts and emotional release. Self-efficacy and self-awareness were the two main mechanisms identified. Self-help toolkits were found to be acceptable and helpful, but the limited evidence base means their efficacy for reducing self-harm episodes has not been established.

Borderline Personality Traits Do Not Moderate the Relationship Between Depression, Beliefs, and Suicidal Thoughts and Behaviors

Adults with clinically significant borderline personality disorder traits (BPTs) are at high risk of experiencing suicidal thoughts and behaviors (STBs). STBs among those with BPTs have been associated with suicidal beliefs (e.g., that one is unlovable or that distress is intolerable). However, the extent to which suicidal beliefs uniquely mediate the relationship between emotional distress and STBs among individuals with BPTs is not known. Individuals admitted to an inpatient unit (N = 198) with recent STBs completed assessments of BPTs, depression, suicidal beliefs, suicidal ideation, and suicide attempt history. Moderated mediation models were used to explore whether suicidal beliefs mediated the relationship between depression and STBs conditional on BPTs. Suicidal patients with versus without BPTs reported stronger suicidal beliefs and more severe STBs (i.e., suicidal ideation, lifetime attempts). Exploratory moderated mediation analysis demonstrated that suicidal beliefs mediated the relationship between depression and suicidal ideation as well as suicide attempts. The mediation effect of suicidal beliefs on the depression-ideation and depression-attempt relationship was not significantly moderated by BPTs. This study was cross-sectional and therefore the estimated mediation models must be considered exploratory. Longitudinal research will be needed to assess the potential causal mediation of suicidal beliefs on the relationship between depression and STBs. The results of this study suggest that suicidal beliefs may play a significant role in the relationship between depression and STBs for inpatients with a history of suicidality regardless of BPTs. This suggests suicidal beliefs may be an important treatment target for adults with a history of STBs.

Exploring suicide ideation in university students: sleep quality, social media, self-esteem, and barriers to seeking psychological help

The purpose of the current study is to analyze how variations in suicidal ideation scores can relate to sleep quality, social media consumption, self-esteem, and perceived barriers to seeking psychological help in a sample of university students in Honduras. A quantitative cross-sectional design was used. Self-reported data was collected from a non-random sample of 910 university students in Honduras; their average age was 24.03 years (SD=6.05). Most respondents were women (67%) with men accounting for 33% of the sample. Measurements included item 9 of the Patient Health Questionnaire-9, the Single-Item Sleep Quality Scale, Rosenberg's Self-Esteem Scale, Barriers to Seeking Psychological Help Scale for College Students, and a self-reported questionnaire on social media. In response to the query, "Over the past two weeks, how frequently have you experienced thoughts that you would be better off dead or of hurting yourself?" 54% (n=495) of participants indicated "not at all" 18% (n=168) reported "several days" 14% (n=129) responded "more than half of the days" and 13% (n=118) stated "nearly every day". The results from the ordinal logistic regression model indicate that sleep quality and self-esteem serve as protective factors associated with decreased suicide ideation. At the same time, a higher number of social media platforms used per week and perceived barriers to seeking psychological help increase suicide ideation. Altogether, these variables explained 19% of the variance in suicidal ideation scores. Suicidal ideation is highly prevalent among the sampled university students.

Uncovering the role of substance use in suicide attempts using a mixed-methods approach

INTRODUCTION

Substance use is an established risk factor for suicide attempt. Clarifying the role of substance use in suicide attempts may identify modifiable treatment targets. This study used mixed methods to associate substance use with suicide attempt history and identify pathways through which substance use contributes to attempts.

METHODS

Study 1 included 213 adult inpatients (n = 127 with substance use disorder [SUD]), who completed assessments of suicide attempt history as well as demographic and clinical suicide risk factors. Study 2 was a narrative analysis of suicide attempt stories described by 20 inpatients diagnosed with SUD.

RESULTS

In Study 1, patients with co-occurring alcohol and drug use disorders reported more actual lifetime suicide attempts than did those without SUD. In addition, alcohol and drug use disorders were independently associated with lifetime suicide attempts after controlling for demographic and clinical confounders. In Study 2, substance use played a role in all suicide attempts through at least one pathway before, during, or after a triggering stressor, or as suicide attempt method.

CONCLUSIONS

Substances play a role in suicide attempt baseline risk, acute risk and as means. It is important to target chronic and acute substance use in suicide prevention treatment plans.

Negative Urgency, (Lack of) Premeditation, and Sensation Seeking: Indirect Relationships with Suicidal Ideation through Thwarted Interpersonal Needs

OBJECTIVE

Differences in how impulsivity is conceptualized, along with a myopic focus on impulsivity's relationship with historical suicidal behaviors, have resulted in limited implications made from prior research regarding impulsivity and suicidal thoughts and behaviors. The current study investigated the indirect effect facets of impulsivity may have on suicidal ideation, specifically, through thwarted interpersonal needs.

METHODS

Participants were N = 424 undergraduate students who completed a cross-sectional survey. Participants completed the Urgency, Premeditation, Perseverance, Sensation Seeking, Impulsive Behavior Scale (UPPS), the Adult Suicide Ideation Questionnaire (ASIQ), and the Interpersonal Needs Questionnaire (INQ). Parallel mediation models were run to examine the relation between facets of impulsivity, perceived burdensomeness, thwarted belongingness, and suicidal ideation.

RESULTS

Thwarted belonginess and perceived burdensomeness significantly accounted for the variance in the relation between negative urgency and suicidal ideation. Neither thwarted belongingness nor perceived burdensomeness significantly explained variance in the relation between (lack of) premeditation and suicidal ideation. Conversely, perceived burdensomeness and thwarted belonginess significantly explained the inverse relation between sensation seeking and suicidal ideation (i.e., greater sensation seeking was related to lower perceived burdensomeness and thwarted belongingness and in turn lower suicidal ideation).

CONCLUSION

Negative urgency, in particular, is related to suicidal ideation through thwarted interpersonal needs. Future research should continue to differentiate between various types of impulsivity and its relationship with both suicidal ideation and behaviors utilizing both cross-sectional and ambulatory assessments of these constructs.HIGHLIGHTSNegative urgency is related to suicidal ideation.Negative urgency is related to thwarted interpersonal needs.Thwarted interpersonal needs partially explain the relation between negative urgency and suicidal ideation.

Brief and Ultra-Brief Suicide-Specific Interventions

The rising rates of suicide warrant effective treatments that can quickly help stabilize suicidal individuals and prevent future suicidal crises from occurring. Across the past few decades, there has been a rise in the development of ultra-brief (1-4 sessions) and brief suicide-specific interventions (6-12 sessions) to meet this need. This article reviews several prominent ultra-brief and brief interventions, including the Teachable Moment Brief Intervention, Attempted Suicide Short Intervention Program, Safety Planning Intervention, Crisis Response Planning, Cognitive Therapy for Suicide Prevention, Brief Cognitive-Behavioral Therapy for Suicide Prevention, Collaborative Assessment and Management of Suicidality, and the Coping Long-Term With Active Suicide Program. A brief review of each interventions' evidence base is also provided. Current challenges and directions for future research in testing the efficacy and effectiveness of suicide prevention initiatives are discussed.

Age Progression in the Treatment of Suicidal Patients

Suicide is a very distressing but preventable phenomenon; it is also the most profound and serious outcome for patients and healthcare professionals. Suicidal ideations and hopelessness are a high-risk predictor for suicide attempts and death by suicide. The proper therapeutic management of suicidal patients continues to be an important challenge to all practicing clinicians. This article provides a review of age progression and specific information on the value and use of hypnotically mediated age progression as a therapeutic tool in the effective clinical management of patients with suicidal thoughts and behaviors. Case examples are provided to illustrate the use of age progression in clinical practice. The literature that explores a future-oriented strategy in the treatment of suicidal patients is reviewed. Moreover, information on a method of enhancing a future oriented strategy with hypnotically mediated age progression interventions is provided. The goal is to improve therapeutic results and reducing the risk of suicide attempts and death by suicide.

An Ecological Momentary Intervention Study of Emotional Responses to Smartphone-Prompted CBT Skills Practice and the Relationship to Clinical Outcomes

The practice of therapeutic skills outside of sessions in which they are learned is one presumed key component of cognitive behavioral therapy (CBT). Yet, our understanding of how skills practice relates to clinical outcomes remains limited. Here, we explored patients' emotional responses to CBT skills practice in a pilot study pairing smartphone-app-delivered skills reminders and guided practice (ecological momentary intervention [EMI]) using ecological momentary assessment (EMA). Participants (n = 25) were adults recently hospitalized for a suicide attempt or severe suicidal thinking. They received brief inpatient CBT (1 to 3 sessions covering core CBT skills from the Unified Protocol), followed by 1 month of EMI and EMA after discharge. On average, participants reported modest reductions in negative affect after skills use (i.e., immediate responses; median time elapsed = 4.30 minutes). Additionally, participants tended to report less negative affect when the timepoint preceding the current assessment included EMI skills practice, rather than EMA alone (i.e., delayed responses; median time elapsed between prompts = 2.17 hours). Immediate effects were unrelated to longer-term clinical outcomes, whereas greater delayed effects were associated with lower symptom severity at follow-up. Future studies should further examine how CBT skills use in daily life may alleviate symptoms.