Suicidal behaviour: identifying the best preventive interventions

Reducing short term suicide risk after hospitalization: A randomized controlled trial of the Collaborative Assessment and Management of Suicidality

BACKGROUND

This study compared the "next day appointment" (NDA) use of the Collaborative Assessment and Management of Suicidality (CAMS) to treatment as usual (TAU) for individuals discharged from the hospital following a suicide-related crisis. We hypothesized that CAMS would significantly reduce suicidal thoughts and behaviors as well as improve psychological distress, quality of life/overall functioning, treatment retention and patient satisfaction.

METHODS

Participants were 150 individuals who had at least one lifetime actual, aborted, or interrupted attempt and were admitted following a suicide-related crisis. There were 75 participants in the experimental condition who received adherent CAMS and 75 participants who received TAU. Suicidal thoughts and behaviors, psychological distress, and quality of life/overall functioning were assessed at baseline and at 1, 3, 6, and 12 months post-baseline. Treatment retention and patient satisfaction were assessed at post-treatment.

RESULTS

Participants in both conditions improved from baseline to 12 months but CAMS was not superior to TAU for the primary outcomes. A small but significant improvement was found in probability of suicidal ideation at 3 months favoring TAU and amount of suicidal ideation at 12 months favoring CAMS. CAMS participants experienced less psychological distress at 12 months compared to baseline.

LIMITATIONS

The study was limited by only one research clinic, lower than expected recruitment, and imbalance of suicidal ideation at baseline.

CONCLUSIONS

All participants improved but CAMS was not more effective than TAU. The NDA clinic was feasible and acceptable to clients and staff in both conditions and future research should investigate its potential benefit.

Suicide mortality after a nonfatal suicide attempt: A systematic review and meta-analysis

INTRODUCTION

Deliberate self-harm and suicide attempts share common risk factors but are associated with different epidemiological features. While the rate of suicide after deliberate self-harm has been evaluated in meta-analyses, the specific rate of death by suicide after a previous suicide attempt has never been assessed. The aim of our study was to estimate the incidence of death by suicide after a nonfatal suicide attempt.

METHOD

We developed and followed a standard meta-analysis protocol (systematic review registration-PROSPERO 2021: CRD42021221111). Randomized controlled trials and cohort studies published between 1970 and 2020 focusing on the rate of suicide after suicide attempt were identified in PubMed, PsycInfo and Scopus and qualitatively described. The rates of deaths by suicide at 1, 5 and 10 years after a nonfatal suicide attempt were pooled in a meta-analysis using a random-effects model. Subgroup analysis and meta-regressions were also performed.

RESULTS

Our meta-analysis is based on 41 studies. The suicide rate after a nonfatal suicide attempt was 2.8% (2.2-3.5) at 1 year, 5.6% (3.9-7.9) at 5 years and 7.4% (5.2-10.4) at 10 years. Estimates of the suicide rate vary widely depending on the psychiatric diagnosis, the method used for the suicide attempt, the type of study and the age group considered.

CONCLUSION

The evidence of a high rate of suicide deaths in the year following nonfatal suicide attempts should prompt prevention systems to be particularly vigilant during this period.

[Social pain at the core of suicidal behavior]

BACKGROUND

Intolerable pain is often reported in suicide notes. Moreover, the frequency of life events preceding a suicidal act is high, especially interpersonal difficulties. Such adversity is the source of psychological or social pain.

METHODS

We propose a narrative review to discuss the role of pain in the suicidal process while having a focus on social ties.

RESULTS

Using Ecological Momentary Assessment in suicide attempters it has been shown that being alone increased suicidal ideation while being with close others significantly reduced this risk. At a neuroanatomical level, suicidal vulnerability is associated with dysfunctional insula activation during social exclusion, a region involved in social and physical pain processing. Social pain elicited by social exclusion or devaluation shares common neurobiological patterns with physical pain. It is also an exemplar of psychological pain. Despite the complexity of its definition, higher psychological pain levels are associated with suicidal ideation and acts. Finally, intense physical pain or chronic pain are strong risk factors of suicidal ideation and act. Interestingly, suicide notes often report the existence of an intolerable pain. Presence of psychological pain and difficulties in communication predict the lethality and seriousness of suicide attempts. Moreover, presence of psychological pain is associated with more impulsive choices in suicidal patients, suggesting that a suicidal act is a means to escape intolerable suffering despite negative long-term consequences (i.e. death). Analgesics are usually used to get relief from pain but are also frequently involved in suicidal overdoses. It has been shown that opioid analgesics are associated with an increased risk of suicide. Higher consumption of opioid analgesics has been shown in suicidal patients in comparison to patients with history of depression but no suicidal act and healthy controls whereas non-suicidal patients were those reporting higher presence of pain in comparison to healthy controls. It may suggest that opioids are being used by suicidal patients to get relief from psychological/social pain rather than from physical pain. Involvement of opioidergic system in suicidal process opens new therapeutic strategies. Recently, the time-limited, short-term use of very low dosages of sublingual buprenorphine (vs. placebo) was associated with decreased suicidal ideation and mental pain in severely suicidal patients without substance abuse. In a randomized controlled trial comparing a 7-week acceptance and commitment therapy (ACT) versus relaxation group, as adjunct to treatment as usual for adult outpatients suffering from a current suicidal behavior disorder, ACT has shown its effectiveness in reducing suicidal ideation and psychological pain. Evidence indicates that maintaining contact either via letter, postcard or telephone with at-risk adults following discharge from care services after a suicide attempt can reduce reattempt risk. Based on these results, a preventive program of recontact for suicide attempters, VIGILANS, has been developed in France in usual care.

CONCLUSION

The approach of the suicidal issue by the angle of pain and social disconnection offers new advances to improve clinical assessment, to identify new biological pathways involved in suicidal risk, and to propose innovative therapeutic and preventive actions.

Cognitive Reappraisal Intervention for Suicide Prevention (CRISP) for Middle-Aged and Older Adults Hospitalized for Suicidality

Middle-aged and older adults constitute a high suicide-risk group. Among adults aged 50 years old and older, suicide rates increased and suicide deaths almost doubled during the period from 2000 to 2015. Suicide rates are elevated for patients hospitalized for suicidality (i.e., active suicidal ideation or suicide attempt) and the 3 months post-hospitalization is the time of the highest suicide risk. Psychosocial interventions for middle-aged and older adults hospitalized for suicidality are sparse. In this article, we present the main aspects, stages, techniques and a clinical case study of Cognitive Reappraisal Intervention for Suicide Prevention (CRISP), a psychosocial intervention targeting cognitive reappraisal to reduce suicide risk in middle-aged and older adults who have been recently hospitalized for suicidal ideation or a suicide attempt. CRISP is based on the theory that hospitalization for suicidality is preceded by an emotional crisis ("perfect storm"); this emotional crisis is related to personalized (patient- and situation-specific) triggers; and identifying these personalized triggers and the associated negative emotions and providing strategies for an adaptive response to these triggers and negative emotions will reduce suicidal ideation and improve suicide prevention. CRISP therapists identify these triggers of negative emotions and use cognitive reappraisal techniques to reduce these negative emotions. The cognitive reappraisal techniques have been selected from different psychosocial interventions and the affective neuroscience literature and have been simplified for use with middle-aged and older adults. CRISP may fill a treatment need for the post-discharge high-risk period for middle-aged and older adults hospitalized for suicidality.

A Novel Brief Therapy for Patients Who Attempt Suicide: A 24-months Follow-Up Randomized Controlled Study of the Attempted Suicide Short Intervention Program (ASSIP)

BACKGROUND

Attempted suicide is the main risk factor for suicide and repeated suicide attempts. However, the evidence for follow-up treatments reducing suicidal behavior in these patients is limited. The objective of the present study was to evaluate the efficacy of the Attempted Suicide Short Intervention Program (ASSIP) in reducing suicidal behavior. ASSIP is a novel brief therapy based on a patient-centered model of suicidal behavior, with an emphasis on early therapeutic alliance.

METHODS AND FINDINGS

Patients who had recently attempted suicide were randomly allocated to treatment as usual (n = 60) or treatment as usual plus ASSIP (n = 60). ASSIP participants received three therapy sessions followed by regular contact through personalized letters over 24 months. Participants considered to be at high risk of suicide were included, 63% were diagnosed with an affective disorder, and 50% had a history of prior suicide attempts. Clinical exclusion criteria were habitual self-harm, serious cognitive impairment, and psychotic disorder. Study participants completed a set of psychosocial and clinical questionnaires every 6 months over a 24-month follow-up period. The study represents a real-world clinical setting at an outpatient clinic of a university hospital of psychiatry. The primary outcome measure was repeat suicide attempts during the 24-month follow-up period. Secondary outcome measures were suicidal ideation, depression, and health-care utilization. Furthermore, effects of prior suicide attempts, depression at baseline, diagnosis, and therapeutic alliance on outcome were investigated. During the 24-month follow-up period, five repeat suicide attempts were recorded in the ASSIP group and 41 attempts in the control group. The rates of participants reattempting suicide at least once were 8.3% (n = 5) and 26.7% (n = 16). ASSIP was associated with an approximately 80% reduced risk of participants making at least one repeat suicide attempt (Wald χ21 = 13.1, 95% CI 12.4-13.7, p < 0.001). ASSIP participants spent 72% fewer days in the hospital during follow-up (ASSIP: 29 d; control group: 105 d; W = 94.5, p = 0.038). Higher scores of patient-rated therapeutic alliance in the ASSIP group were associated with a lower rate of repeat suicide attempts. Prior suicide attempts, depression, and a diagnosis of personality disorder at baseline did not significantly affect outcome. Participants with a diagnosis of borderline personality disorder (n = 20) had more previous suicide attempts and a higher number of reattempts. Key study limitations were missing data and dropout rates. Although both were generally low, they increased during follow-up. At 24 months, the group difference in dropout rate was significant: ASSIP, 7% (n = 4); control, 22% (n = 13). A further limitation is that we do not have detailed information of the co-active follow-up treatment apart from participant self-reports every 6 months on the setting and the duration of the co-active treatment.

CONCLUSIONS

ASSIP, a manual-based brief therapy for patients who have recently attempted suicide, administered in addition to the usual clinical treatment, was efficacious in reducing suicidal behavior in a real-world clinical setting. ASSIP fulfills the need for an easy-to-administer low-cost intervention. Large pragmatic trials will be needed to conclusively establish the efficacy of ASSIP and replicate our findings in other clinical settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02505373.