Collaborative assessment and management of suicidality in an inpatient setting: results of a pilot study

Facilitators and barriers to implementation of suicide prevention interventions: Scoping review

We know that suicide is preventable, yet hundreds of thousands of people still die due to suicide every year. Many interventions were proven to be effective, and dozens of others showed promising results. However, translating these interventions into new settings brings several challenges. One of the crucial obstacles to success is not anticipating possible barriers to implementation nor enhancing possible benefits of factors facilitating the implementation. While we witnessed great support for suicide prevention activities globally in the past years, implementation barriers and facilitating factors are yet to be comprehensively mapped to help implementation activities worldwide. This scoping review maps current knowledge on facilitators and barriers to the implementation of suicide prevention interventions while using the Consolidated Framework for Implementation Research (CFIR) for classification. We included 64 studies. Barriers and facilitators were most commonly identified in the outer setting CFIR domain, namely in the sub-domain of patient needs and resources, which refers to the way in which these needs and resources are reflected by the reviewed interventions. The second most saturated CFIR domain for facilitators was intervention characteristics, where relative advantage, adaptability and cost of intervention sub-domains were equally represented. These sub-domains refer mostly to how the intervention is perceived by key stakeholders, to what extent it can be tailored to the implementation context and how much it costs. While intervention characteristics domain was the second most common also for barriers, the complexity sub-domain referring to high perceived difficulty of implementation was the most frequently represented. With reference to the results, we recommend adapting interventions to the needs of the target groups. Furthermore, carefully selecting the intervention to suit the target context concerning their adaptability, costs and complexity is vital for a successful implementation. Further implications for practice and research are discussed.

The Collaborative Assessment and Management of Suicidality compared to enhanced treatment as usual for inpatients who are suicidal: A randomized controlled trial

Background

Although use of inpatient crisis hospital intervention for suicide risk is common, the evidence for inpatient treatments that reduce suicidal thoughts and behaviors is remarkably limited. To address this need, this novel feasibility pilot randomized controlled trial compared the use of the Collaborative Assessment and Management of Suicidality (CAMS) to enhanced treatment as usual (E-TAU) within a standard acute inpatient mental health care setting.

Objectives

We hypothesized that CAMS would be more effective than E-TAU in reducing suicidal thoughts and behaviors. As secondary outcomes we also investigated depressive symptoms, general symptom burden, reasons for living, and quality of the therapeutic relationship.

Methods

All patients were admitted due to acute suicidal thoughts or behaviors. They were randomly assigned to CAMS (n = 43) or E-TAU (n = 45) and assessed at four time points (admission, discharge, 1 month and 5 months after discharge). We used mixed-effects models, effect sizes, and reliable change analyses to compare improvements across and between treatment groups over time.

Results

Intent-to-treat analyses of 88 participants [mean age 32.1, SD = 13.5; n = 47 (53%) females] showed that both groups improved over time across all outcome measures with no significant between-group differences in terms of change in suicidal ideation, depression, reasons for living, and distress. However, CAMS showed larger effect sizes across all measures; for treatment completers CAMS patients showed significant improvement in suicidal ideation (p = 0.01) in comparison to control patients. CAMS patients rated the therapeutic relationship significantly better (p = 0.02) than E-TAU patients and were less likely to attempt suicide within 4 weeks after discharge (p = 0.05).

Conclusions

CAMS and E-TAU were both effective in reducing suicidal thoughts and symptom distress. Within this feasibility RCT the pattern of results was generally supportive of CAMS suggesting that inpatient use of CAMS is both feasible and promising. However, our preliminary results need further replication within well-powered multi-site randomized controlled trials.

Trial registration

DRKS-ID/ICTRP-ID: DRKS00013727. The trial was retrospectively registered in the German Clinical Trials Register, registration code/ DRKS-ID: DRKS00013727 on 12.01.2018 and also in the International Clinical Trials Registry Platform of the World Health Organization (identical registration code).

Inpatient suicide in psychiatric settings: Evaluation of current prevention measures

The risk of suicide in psychiatric hospitals is 50 times higher than in the general population, despite patient safety being a priority for any hospital. However, to date, due to the complexity of assessing suicide risk, there has been no consensus on the suicide prevention measures that should be in place in hospitals. The aim of this work is: To provide an overview of the progress that has been made in the field of inpatient suicide prevention in recent years; discuss the problems that remain; and suggest potential future developments. As new clinical dimensions (notably anhedonia, psychological pain and hopelessness) develop, they should become new therapeutic targets. Team training (like the Gatekeeper Training Program) and the latest advances in suicide risk assessment (such as the Collaborative Assessment and Management of Suicidality) should be implemented in psychiatric wards. Suicide prevention plans (e.g., ASSIP, SAFE-T, etc.) represent easy-to-administer, low-cost interventions. The Mental Health Environment of Care Checklist has been proven effective to reduce suicide risk at hospitals. Furthermore, the types of psychotherapy recommended to reduce suicide risk are cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT). There are several pharmacological treatments for suicide risk, such as lithium and clozapine, which have been shown to be effective in the long term, as well as ketamine and esketamine, which are more effective in the short term. Following some encouraging recent results, buprenorphine may also be proposed to patients with a suicide risk. Triple chronotherapy rapidly improves depressive symptoms over 9 weeks. Regarding brain stimulation techniques, rTMS has proven to be effective in alleviating multiple dimensions of suicidality.

Costs, benefits, and cost-benefit of Collaborative Assessment and Management of Suicidality versus enhanced treatment as usual

Suicide rates have been steadily increasing in both the U.S. general population and military, with significant psychological and economic consequences. The purpose of the current study was to examine the economic costs and cost-benefit of the suicide-focused Collaborative Assessment and Management of Suicidality (CAMS) intervention versus enhanced treatment as usual (ETAU) in an active duty military sample using data from a recent randomized controlled trial of CAMS versus ETAU. The full intent-to-treat sample included 148 participants (mean age 26.8 years ± 5.9 SD years, 80% male, 53% White). Using a micro-costing approach, the cost of each condition was calculated at the individual level from a healthcare system perspective. Benefits were estimated at the individual level as cost savings in past-year healthcare expenditures based on direct care reimbursement rates. Cost-benefit was examined in the form of cost-benefit ratios and net benefit. Total costs, benefits, cost-benefit ratios, and net benefit were calculated and analyzed using general linear mixed modeling on multiply imputed datasets. Results indicated that treatment costs did not differ significantly between conditions; however, CAMS was found to produce significantly greater benefit in the form of decreased healthcare expenditures at 6-month follow-up. CAMS also demonstrated significantly greater cost-benefit ratios (i.e., benefit per dollar spent on treatment) and net-benefit (i.e., total benefit less the cost of treatment) at 12-month follow-up. The current study suggests that beyond its clinical effectiveness, CAMS may also convey potential economic advantages over usual care for the treatment of suicidal active duty service members. Our findings demonstrate cost savings in the form of reduced healthcare expenditures, which theoretically represent resources that can be reallocated toward other healthcare system needs, and thus lend support toward the overall value of CAMS.

Working with Young People at Risk of Suicidal Behaviour and Self-Harm: A Qualitative Study of Australian General Practitioners' Perspectives

General Practitioners (GPs) play a crucial role in the identification and support of young people at risk of suicidal behaviour and self-harm; however, no studies have explored GPs' perspectives, approaches, challenges, and resource needs when working with this cohort in an Australian setting. This was a qualitative study where fifteen GPs (Mage = 45.25 years) from multiple clinics in Western Australia took part in semi-structured interviews, and data were analysed thematically. Seven main themes were identified: (1) working with young people has its unique challenges; (2) screening and assessment tools can help to manage uncertainty and discomfort; (3) going beyond tools-the dialogue and relationship are most important; (4) there are limits to what we can offer in the time available; (5) the service access and referral pathways lack clarity and coordination; (6) the provision of mental health support should not fall on GPs alone; and (7) more comprehensive training in suicide and self-harm is needed. The findings highlight a number of opportunities to enhance care and better assist GPs working with young people who present with suicidal behaviour and self-harm, including considerations for conducting assessments, targeted resources such as training, and system and service improvements.

A Randomized Controlled Trial of the Collaborative Assessment and Management of Suicidality (CAMS) Versus Treatment as Usual (TAU) for Suicidal College Students

This randomized controlled trial compared the Collaborative Assessment and Management of Suicidality (CAMS) and Treatment as Usual (TAU) for suicidal college students within a feasibility trial. Sixty-two suicidal college students were randomized to CAMS (n = 33) or TAU (n = 29). We hypothesized that those receiving CAMS would show more improvement in suicide-related measures, and effects would be moderated by borderline personality disorder (BPD), prior suicide attempts, and age. Both treatment groups showed improvements in all outcome variables; CAMS had a significantly higher impact on depression and suicidal ideation when measured weekly during care and was more likely than TAU to decrease hopelessness among students with fewer BPD features, no suicide attempt history, and older age. Conversely, TAU did better for students with BPD features and history of multiple suicide attempts.

The effectiveness of the Collaborative Assessment and Management of Suicidality (CAMS) compared to alternative treatment conditions: A meta-analysis

INTRODUCTION

This meta-analysis aimed to test the efficacy of the Collaborative Assessment and Management of Suicidality (CAMS) intervention against other commonly used interventions for the treatment of suicide ideation and other suicide-related variables.

METHOD

Database, expert, and root and branch searches identified nine empirical studies that directly compared CAMS to other active interventions. A random effects model was used to calculate the effect size differences between the interventions; additionally, moderators of the effect sizes were tested for suicidal ideation.

RESULTS

In comparison to alternative interventions, CAMS resulted in significantly lower suicidal ideation (d = 0.25) and general distress (d = 0.29), significantly higher treatment acceptability (d = 0.42), and significantly higher hope/lower hopelessness (d = 0.88). No significant differences for suicide attempts, self-harm, other suicide-related correlates, or cost effectiveness were observed. The effect size differences for suicidal ideation were consistent across study types and quality, timing of outcome measurement, and the age and ethnicity of participants; however, the effect sizes favoring CAMS were significantly smaller with active duty military/veteran samples and with male participants.

CONCLUSIONS

The existing research supports CAMS as a Well Supported intervention for suicidal ideation per Center of Disease Control and Prevention criteria. Limitations and future directions are discussed.

Collaborative Assessment and Management of Suicidality for Teens: A Promising Frontline Intervention for Addressing Adolescent Suicidality

This pilot open trial examined the feasibility, acceptability, and preliminary outcomes of the Collaborative Assessment and Management of Suicidality for teens (CAMS-4Teens) who presented to outpatient care with suicidal thoughts and behaviors. Participants were 22 adolescents (13-17; 59% identified as female) with clinical elevations (≥7) on the Suicidal Behaviors Questionnaire-Revised (SBQ-R). Primary outcomes were feasibility and acceptability. We also explored outcomes of suicidal thoughts and behaviors, as well as mixed effects modeling for weekly assessments of the Suicide Status Form (SSF) Core Assessment constructs. Our main implementation outcomes suggest that the intervention is acceptable, appropriate, and feasible to deliver. Clinicians were adherent to the model with high ratings of adherence. In addition, preliminary evaluation of suicidal thoughts and behaviors found a large effect size for reduction in suicidal thoughts. Benchmarking to other adolescent suicide specific interventions and the Collaborative Assessment of Management of Suicidality with adult populations provide promise that suicidal adolescent responses may be on par with established interventions. Findings from the study are preliminary in nature and intended to inform if CAMS with adolescents is a promising approach to engage and treat patient-defined "drivers" of suicide. The results suggest that a future investigation with power to detect significant change over another active intervention is warranted.

[Collaborative Assessment and Management of Suicidality: An Effective Brief Intervention for the Treatment of Suicidal Patients]

Das "Collaborative Assessment and Management of Suicidality" (CAMS) ist einer von mehreren Interventionsansätzen zur Behandlung von suizidalen Patienten und Patientinnen und wurde weltweit seit 3 Jahrzehnten untersucht und weiterentwickelt. Das CAMS ist auf die Etablierung einer tragenden therapeutischen Beziehung auf Augenhöhe zu einer suizidalen Person ausgerichtet. Der Patient wird aktiv an der Einschätzung seines Suizidrisikos beteiligt und zum "Mitverfasser" seines eigenen suizidspezifischen Behandlungsplans. Das konkrete therapeutische Vorgehen wird durch ein vielseitig anwendbares Instrument, die sogenannte Suizidstatusform (SSF), strukturiert und geleitet. Das CAMS kann von verschiedenen therapeutischen Berufsgruppen sowie bei Patienten und Patientinnen mit unterschiedlichen Diagnosen angewandt werden. Die Wirksamkeit im Hinblick auf eine Verringerung von Suizidgedanken, der allgemeinen psychischen Belastung und Depressivität sowie auf eine Zunahme von Hoffnung und Zuversicht ist mittlerweile empirisch gut belegt.The "Collaborative Assessment and Management of Suicidality" (CAMS) is an intervention approach for the treatment of suicidal patients that has been studied and developed for three decades around the world. CAMS is focused on establishing a continuing therapeutic relationship at eye level with a suicidal person. The patient is actively involved in assessing his or her suicide risk and becomes the "co-author" of his or her own suicide-specific treatment plan. The specific therapeutic procedure is structured and guided by a versatile instrument called the Suicide Status Form (SSF). CAMS can be applied by different therapeutic professional groups to patients with different diagnoses. Its effectiveness in reducing suicidal ideation, general psychological distress and depressiveness, and increasing hope and confidence is now empirically well established.

Clinicians' Experience of Collaboration in the Treatment of Suicidal Clients Within the Collaborative Assessment and Management of Suicidality Framework

INTRODUCTION

There is little known about the clinicians' experience of collaboration using the Collaborative Assessment and Management of Suicide (CAMS) framework. This study aimed to give voice to the clinician experience.

METHOD

A qualitative design utilised semi-structured interviews with ten psychologists who worked in a Suicide Assessment and Treatment Service (SATS) in Ireland which utilises the CAMS framework.

RESULTS

An Interpretative Phenomenological Analysis (IPA) approach revealed several important findings. The superordinate themes included 'Finding Safety', 'Regulation of the Self', 'Connecting', and 'Systemic Challenges'.

DISCUSSION

The CAMS framework plays an important role in providing a safe base for the clinician (in terms of understanding suicidality, in addition to the structures of the framework). It provides a mechanism in which to process difficult emotions, and a way of communicating a formulation of suicide to the treating team. Importantly, the CAMS emerged as facilitating a collaborative, therapeutic way of working.

The Psychological Pathway to Suicide Attempts: A Strategy of Control Without Awareness

Objectives

This paper aims to identify potential areas for refinement in existing theoretical models of suicide, and introduce a new integrative theoretical framework for understanding suicide, that could inform such refinements.

Methods

Literature on existing theoretical models of suicide and how they contribute to understanding psychological processes involved in suicide was evaluated in a narrative review. This involved identifying psychological processes associated with suicide. Current understanding of these processes is discussed, and suggestions for integration of the existing literature are offered.

Results

Existing approaches to understanding suicide have advanced the current knowledge of suicide in various ways. They have guided valuable research in the following areas: motivations for suicide and the psychological distress which influences suicide attempts; ambivalence about suicide; suicidal individuals’ focus of attention; and ways in which individuals who contemplate suicide differ from individuals who attempt suicide. We outline a new theoretical framework as a means to integrating all of these concepts into the three principles of control, conflict, and awareness. Within this framework, suicide is regarded as occurring due to a long standing conflict between an individual’s personal goals, culminating in an episode of acute loss of control. The new framework posits that the individual then strives to regain control through the means of suicide because of a narrowed awareness of consequences of their actions on other valued goals. This psychological mechanism of limited awareness is posited to be the common pathway by which individuals make a suicide attempt, regardless of which risk factors are present.

Conclusion

This article introduces a theoretical framework that generates several hypotheses for future research, and focuses on psychological processes occurring during immediate crisis. One of the key hypotheses resulting from our predictions on how individuals progress from contemplating to attempting suicide will be tested in an ongoing program of research: Individuals who attempt suicide have a significantly reduced awareness of consequences of suicide, which would negatively impact on their important life goals, values, principles, or ideals, compared to individuals who contemplate suicide. Therapy guided by the new framework may be more flexible, immediate, and client-focused than other therapies for suicidal individuals.

Collaborative Assessment and Management of Suicidality (CAMS) compared to enhanced treatment as usual (E-TAU) for suicidal patients in an inpatient setting: study protocol for a randomized controlled trial

BACKGROUND

The Collaborative Assessment and Management of Suicidality (CAMS) is a therapeutic framework that has been shown to reduce suicidal ideation and overall symptom distress. CAMS has not been previously evaluated in a standard acute inpatient mental health care setting with only short treatment times for suicidal patients. In this randomized controlled trial (RCT) we are investigating whether CAMS is more effective than Enhanced-Treatment as Usual (E-TAU) in reducing suicidal thoughts as primary outcome variable. We are also investigating depressive symptoms, general symptom relief, and the quality of the therapeutic alliance as secondary outcomes.

METHODS/DESIGN

This RCT is designed as a single-center, two-armed, parallel group observer-blinded clinical effectiveness investigation. We are recruiting and randomizing 60 participants with different diagnoses, who are admitted as inpatients because of acute suicidal thoughts or behaviors into the Clinic for Psychiatry and Psychotherapy, Ev. Hospital Bethel in Bielefeld, Germany. The duration of treatment will vary depending on patients' needs and clinical assessments ranging between 10 and 40 days. Patients are assessed four times, at admission, discharge, 1 month, and 5 months post-discharge. The primary outcome measure is the Beck Scale for Suicide Ideation. Other outcome measures are administered as assessment timepoints including severity of psychiatric symptoms, depression, reasons for living, and therapeutic relationship.

DISCUSSION

This effectiveness study is being conducted on an acute ward in a psychiatric clinic where patients have multiple problems and diagnoses. Treatment is somewhat limited, and therapists have a large caseloads. The results of this study can thus be generalizable to a typical inpatient psychiatric hospital settings.

TRIAL REGISTRATION

This clinical trial has been retrospectively registered with the German Clinical Trials Register; registration code/ DRKS-ID: DRKS00013727 (on January 12, 2018). In addition, the study was also registered with the International Clinical Trials Registry Platform of the World Health Organization (identical registration code). Registry Name: "Evaluation von CAMS versus TAU bei suizidalen Patienten - Ein stationärer RCT".

A novel engagement of suicidality in the emergency department: Virtual Collaborative Assessment and Management of Suicidality

OBJECTIVE

A novel avatar system (Virtual Collaborative Assessment and Management of Suicidality System; V-CAMS) for suicidal patients and medical personnel in emergency departments (EDs) was developed and evaluated. V-CAMS facilitates the delivery of CAMS and other evidence-based interventions to reduce unnecessary hospitalization, readmissions, and suicide following an ED visit.

METHOD

Using iterative user-centered design with 24 suicidal patients, an avatar prototype, "Dr. Dave" (based on Dr. Jobes) was created, along with other patient-facing tools; provider-facing tools, including a clinical decision support tool were also designed and tested to aid discharge disposition.

RESULTS

Feasibility tests supported proof of concept. Suicidal patients affirmed the system's overall merit, positive Perception of Care, and acceptability; medical providers (n = 21) viewed the system as an efficient, effective, and safe method of improving care for suicidal ED patients and reducing unnecessary hospitalization.

CONCLUSIONS

Technology tools including a patient-facing avatar and e-caring contacts, along with provider-facing tools may offer a powerful method of facilitating best-practice suicide prevention interventions and point-of-care tools for suicidal patients seeking ED services and their medical providers. Future directions include full development of V-CAMS and integration into a health electronic medical record and a rigorous randomized controlled trial to study its effectiveness.

Psychotherapy for Mixed Depression and Mixed Mania

Treatment guidelines for mixed states of depression or (hypo)mania focus almost exclusively on psychopharmacologic intervention without tapping into the benefits of psychotherapy. The authors highlight the complex clinical picture and illness course of mixed states, and discuss the benefit of taking a patient-centered approach to treatment incorporating techniques from a variety of evidence-based psychotherapies. A careful assessment of suicide risk as well as interventions designed specifically for anxiety are also recommended.

Perceived Coercion During Admission Into Psychiatric Hospitalization Increases Risk of Suicide Attempts After Discharge

OBJECTIVE

There is an elevated risk for suicide in the year following psychiatric hospitalization. The present study examined whether perceived coercion during admission into psychiatric hospitalization increases risk for postdischarge suicide attempts.

METHODS

Participants were 905 psychiatric inpatients from the MacArthur Violence Risk Assessment Study that were assessed every 10 weeks during the year following discharge. Perceived coercion during admission was assessed while hospitalized, and suicide attempts were assessed following discharge. Analyses adjusted for nonrandom assignment of groups via propensity score weighting and for established correlates of postdischarge suicidal behavior.

RESULTS

Of 905 participants, 67% endorsed perception of coercion into psychiatric hospitalization, and 168 (19%) made a postdischarge suicide attempt. Patients who perceived coercion during hospitalization admission were more likely to make a suicide attempt after discharge than those who did not, even after adjusting for established covariates (OR = 1.29, |z| = 2.87, p = .004, 95% CI = 1.08, 1.54). There was no interaction between recent self-harm or suicidal ideation at time of admission and perceived coercion on postdischarge suicide attempts.

CONCLUSIONS

Patients' perception of the context in which they were hospitalized is associated with a small but significant increase in their likelihood of postdischarge suicide attempts.

Using EMDR therapy with patients in an acute mental health crisis

BACKGROUND

Death by suicide continues to be a global public health concern with little research demonstrating the effectiveness of treatment options. This exploratory study exams the efficacy of Eye Movement Desensitisation and Reprocessing (EMDR) Therapy delivered to patients experiencing an acute mental health crisis to explore if by treating their background trauma, improvements could be seen in their general psychopathology and if there was a resulting decrease in their desire for suicide.

METHODS

A practice-based service development project was conducted within a mental health hospital. A non-randomised, exploratory pre-test post-test design was utilised. Participants were identified from adult patients currently receiving care from either an inpatient mental health ward or the Crisis Resolution and Home Treatment Team (CRHTT). Those who had reported experiencing at least one event that they considered to be traumatic were offered EMDR Therapy. Notes from the electronic database were analysed to assess contact with services 12 months prior to treatment and following treatment.

RESULTS

72 patients were offered treatment in the study with 57 completing treatment. Patients made significant improvements across all the psychometrics, including a reduction in suicidal ideation. The majority needed less than 10 sessions and needed no onward referral for further psychological therapy. Cost savings were realised by retracting referrals for further therapy and in early discharge from CRHTT and acute wards, and by preventing admissions. Contact with services post treatment also reduced.

CONCLUSIONS

EMDR Therapy can be an effective treatment for patients experiencing a mental health crisis who have a trauma picture, resulting in significant improvements in their mental well-being and substantial cost savings for the National Health Service (NHS).

Patient safety in inpatient mental health settings: a systematic review

OBJECTIVES

Patients in inpatient mental health settings face similar risks (eg, medication errors) to those in other areas of healthcare. In addition, some unsafe behaviours associated with serious mental health problems (eg, self-harm), and the measures taken to address these (eg, restraint), may result in further risks to patient safety. The objective of this review is to identify and synthesise the literature on patient safety within inpatient mental health settings using robust systematic methodology.

DESIGN

Systematic review and meta-synthesis. Embase, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium, MEDLINE, PsycINFO and Web of Science were systematically searched from 1999 to 2019. Search terms were related to 'mental health', 'patient safety', 'inpatient setting' and 'research'. Study quality was assessed using the Hawker checklist. Data were extracted and grouped based on study focus and outcome. Safety incidents were meta-analysed where possible using a random-effects model.

RESULTS

Of the 57 637 article titles and abstracts, 364 met inclusion criteria. Included publications came from 31 countries and included data from over 150 000 participants. Study quality varied and statistical heterogeneity was high. Ten research categories were identified: interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorised leave, clinical decision making, falls and infection prevention and control.

CONCLUSIONS

Patient safety in inpatient mental health settings is under-researched in comparison to other non-mental health inpatient settings. Findings demonstrate that inpatient mental health settings pose unique challenges for patient safety, which require investment in research, policy development, and translation into clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42016034057.

A systematic review of efficacy of Collaborative Assessment and Management of Suicidality (CAMS) in managing suicide risk and deliberate self-harm in adult populations

OBJECTIVE

Evaluate the efficacy of Collaborative Assessment and Management of Suicidality (CAMS) in managing suicide risk and deliberate self-harm in adults.

METHODS

Ten databases were searched for publications referring to CAMS or the Suicide Status Form. Results were evaluated by two reviewers.

RESULTS

Limited evidence that CAMS is effective in reducing suicide risk and deliberate self-harm in adult populations.

CONCLUSIONS

Although CAMS appears to show promise in managing suicidal patients across a range of measures, further evidence is needed to clarify its efficacy in managing suicide risk and deliberate self-harm.

Community-based aftercare following an emergency department presentation for attempted suicide or high risk for suicide: study protocol for a non-randomised controlled trial

BACKGROUND

Suicide is a major public health issue worldwide. Those who have made a recent suicide attempt are at high risk for dying by suicide in the future, particularly during the period immediately following departure from a hospital emergency department. As such the transition from hospital-based care to the community is an important area of focus in the attempt to reduce suicide rates. There is a need for evaluation studies to test the effectiveness of interventions directed to this stage (termed 'aftercare' interventions).

METHODS

A controlled non-randomised two group (intervention vs treatment-as-usual control) design, using an intention-to-treat model, will evaluate the effectiveness of a suicide prevention aftercare intervention providing follow-up after presentations to a hospital emergency department as a result of a suicide attempt or high risk for suicide. The intervention is a community-based service, utilising two meetings with a mental health clinician and follow-up contacts by peer workers via a combination of face-to-face and telephone for four weeks, with the option of extension to 12 weeks. Seventy-five participants of the intervention service will be recruited to the study and compared to 1265 treatment-as-usual controls. The primary hypotheses are that over 12 months, those who participate in the aftercare follow-up intervention are less likely than controls to present to a hospital emergency department for a repeat suicide attempt or because of high risk for suicide, will have fewer re-presentations during this period and will have lower all-cause mortality. As a secondary aim, the impact of the intervention on suicide risk factors for those who participate in the service will be evaluated using pre- and post-intervention repeated measures of depression, anxiety, stress, hopelessness, belongingness, burdensomeness, and psychological distress. Enrolments into the study commenced on 1 November 2017 and are anticipated to cease in November 2019.

DISCUSSION

The study aims to contribute to the understanding of effective interventions for individuals who have presented to a hospital emergency department as a result of a suicide attempt or at high risk for suicide and provide evidence in relation to interventions that incorporate peer-workers.

TRIAL REGISTRATION

ACTRN12618001701213 . Registered on 16 October 2018. Retrospectively registered.

Machine learning discovery of longitudinal patterns of depression and suicidal ideation

Background and aim

Depression is often accompanied by thoughts of self-harm, which are a strong predictor of subsequent suicide attempt and suicide death. Few empirical data are available regarding the temporal correlation between depression symptoms and suicidal ideation. We investigated the anecdotal concern that suicidal ideation may increase during a period of depression improvement.

Data

Longitudinal Patient Health Questionnaire (PHQ)-9 is a questionnaire of 9 multiple-choice questions to assess the frequency of depressive symptoms within the previous two weeks. We analyzed a chronic depression treatment population’s electronic health record (EHR) data, containing 610 patients’ longitudinal PHQ-9 scores (62% age 45 and older; 68% female) within 40 weeks.

Methods

The irregular and sparse EHR data were transformed into continuous trajectories using Gaussian process regression. We first estimated the correlations between the symptoms (total score of the first 8 questions; PHQ-8) and suicide ideation (9th question score; Item 9) using the cross-correlation function. We then used an artificial neural network (ANN) to discover subtypes of depression patterns from the fitted depression trajectories. In addition, we conducted a separate analysis using the unfitted raw PHQ scores to examine PHQ-8’s and Item 9’s pattern changes.

Results

Results showed that the majority of patients’ PHQ-8 and Item 9 scores displayed strong temporal correlations. We found five patterns in the PHQ-8 and the Item 9 trajectories. We also found 8% - 13% of the patients have experienced an increase in suicidal ideation during the improvement of their PHQ-8. Using a trajectory-based method for subtype pattern detection in depression progression, we provided a better understanding of temporal correlations between depression symptoms over time.

Managing suicidality within specialized care: A randomized controlled trial

BACKGROUND

Suicide prevention is a core task in mental health services. Our objective was to determine whether Collaborative Assessment and Management of Suicidality (CAMS) reduced suicidal thoughts and behaviors and mental health distress more effectively than treatment as usual (TAU) in a heterogeneous patient population within specialized mental health care services.

METHODS

In this observer-blinded pragmatic randomized controlled trial participants who scored 13 or above on Beck's Scale for Suicide Ideation-Current (BSSI-C) were included from seven in- and outpatient units. Primary outcome was suicidal ideation (BSSI-C). Secondary outcomes were mental health distress measured by the Outcome Questionnaire-45, and suicidal behaviors measured by the Suicide Attempt Self-Injury Count. Patients were assessed at baseline and after 6 and 12 months.

RESULTS

The final intent-to-treat analyses included 78 participants (mean age 35.9 years, SD = 14.5, 41 females). The majority were depressed (65%), had a secondary diagnosis (73%) and 32% suffered from borderline personality disorder or borderline traits. After 6 months, CAMS participants reported lower levels of suicidal ideation compared to TAU (β = -4.29, 95% CI = -8.32 to -0.27, p = .036). Larger changes in mental health distress were observed for CAMS participants after 6 months (β = -11.87, 95% CI = -22.99 to -0.76, p = .036) and 12 months (β = -13.70, 95% CI = -24.88 to -2.51, p = .017).

LIMITATIONS

The modest sample size rendered the trial unable to detect small between-group differences.

CONCLUSIONS

CAMS reduced suicidal ideation and mental health distress more efficiently than TAU in a heterogeneous patient population within specialized care.

Effectiveness of Psychotherapy on Suicidal Risk: A Systematic Review of Observational Studies

Background: Suicidal behavior is a major public health concern worldwide, and the interest in the development of novel and more efficient treatment strategies and therapies to reduce suicidal risk is increasing. Some recent studies have summarized the results of randomized clinical trials (RCTs) assessing the efficacy of psychotherapeutic tools designed to treat patients at suicidal risk. However, observational studies, which reflect real-world effectiveness and may use original approaches, have not been reviewed. Method: The aim of this study is to systematically review the available scientific evidence issued from observational studies on the clinical effectiveness of psychotherapeutic tools designed to treat patients at suicide risk. We have thus performed a systematic search of PubMed and Web of Science databases. Results: Out of 1578 papers, 40 original observational studies fulfilled our selection criteria. The most used psychotherapeutic treatments were dialectical behavioral therapy (DBT, 27.5%) and cognitive behavioral therapy (CBT, 15.0%) in patients with a diagnosis of borderline personality disorder (32.5%) and depression (15.0%). Despite the between-study heterogeneity, interventions lead to a reduction in suicidal outcomes, i.e., suicidal ideation (55.0%) and suicide attempts (37.5%). The content and reporting quality varied considerably between the studies. Conclusion: DBT and CBT are the most widely used psychotherapeutic interventions and show promising results in existing observational studies. Some of the included studies provide innovative approaches. Group therapies and internet-based therapies, which are cost-effective methods, are promising treatments and would need further study.

The psychometric properties of the Collaborative Assessment and Management of Suicidality rating scale

OBJECTIVE

The CAMS Rating Scale (CRS) is an adherence measure for the Collaborative Assessment and Management of Suicidality (CAMS), a suicide-specific clinical intervention. This study examined the ability of the CRS to assess adherence to CAMS.

METHODS

Video-recorded therapy sessions of clinicians delivering either CAMS or Enhanced Care-As-Usual (E-CAU) were rated with the CRS. These ratings (N = 98) were used to evaluate criterion validity, internal consistency, and factor structure.

RESULTS

Criterion validity and factor analyses did not support the organization of the CRS into its current subscales. Furthermore, the identified factor model and item-level statistics revealed weak CRS items. Finally, internal consistency was higher among CAMS clinicians than among clinicians delivering E-CAU.

CONCLUSION

These results establish the CRS as a measure that can effectively assess the adherence to CAMS in its current form. Potential revisions to future iterations of the CRS are discussed.

Word count as an indicator of suicide risk in an inpatient setting

The current study replicates a previously used methodology with a suicidal inpatient sample regarding word counts generated by participants writing about suicidal constructs. Word counts (i.e., the number of written words) on the Suicide Status Form from initial sessions with suicidal inpatients were compared to self-rated suicide risk scores as well as to continuous and repeated measures of hopelessness and suicide ideation assessed over the course of inpatient care. Results showed that higher word counts were associated with initially higher suicide ideation scores that steadily declined over the course of treatment. Lower word counts were associated with lower initial hopelessness scores that increased during treatment before ultimately decreasing. In addition, word count was not found to be a significant predictor of self-rated suicide risk. Clinical implications of these data and future directions are discussed.

Understanding Therapists' Work With Suicidal Patients: An Examination of Qualitative Data

The collaborative assessment and management of suicidality (CAMS) serves as a framework for maintaining a collaborative relationship between the therapist and patient. This study used an original coding manual to examine responses to open-ended questions to better understand the ways in which therapists use CAMS collaboratively as well as their reasons for adhering (or not adhering) to certain aspects of the framework. Results suggest differences in treatment application based on therapist characteristics including amount of experience, intensity of training received, and experience of a patient suicide attempt. Implications of this research include informing therapists interested in using the CAMS framework about the specific ways in which implementation can be made collaborative. Further, this research helps to shed light on how experiencing a client's death by suicide can impact therapists' future work with suicidal clients.

The relationship between therapeutic alliance and patient's suicidal thoughts, self-harming behaviours and suicide attempts: A systematic review

BACKGROUND

Suicidality is a common concern for people with mental health problems. The interpersonal nature of suicidality suggests that therapeutic alliance may be important when working clinically with suicidal patients. This paper is a systematic review of studies investigating the association between alliance and treatment outcome relating to suicidal ideation and behaviours.

METHODS

Systematic searches of PsychINFO, MEDLINE, AMED, EMBASE, Web of Science and CINAHL were completed using words that captured the concepts of alliance and suicidality. Eligible studies: involved participants aged 18-years-old or over; used a validated measure of therapeutic alliance; and reported associations between alliance and suicidality. Abstracts, qualitative studies and articles not written in English were excluded.

RESULTS

Twelve studies were included. Findings indicated that alliance is associated with suicidality. Alliance was related to suicidality in eleven of the papers. Self-harming behaviours had the strongest association with patient-rated alliance. Suicide attempts had the weakest association, possibly due to the infrequency of suicide attempts in the studies reviewed.

LIMITATIONS

The twelve studies were heterogeneous in terms of the measure of alliance used, method of assessing suicidality, clinical setting and professional-type. This variability limited the degree to which findings could be synthesised.

CONCLUSION

Therapists, care-coordinators and mental health teams should recognise the importance of building a strong therapeutic alliance with suicidal patients. Researchers should use consistent methods of measuring alliance and assessing suicidality in future studies. Clinicians and researchers should note that suicidal thoughts, self-harm and suicide attempts may be related to alliance in different ways and therefore should be assessed as separate constructs.

Recognizing and addressing unique vulnerabilities of suicidal patients: Suicide research at The Menninger Clinic

Suicide risk is an inescapable presence in the treatment of people with psychiatric disorders, a fact that applies especially in inpatient psychiatric settings. This article summarizes a several-year research initiative at The Menninger Clinic aimed at better understanding psychological contributors to suicidality and developing more effective clinical interventions. Two areas of research are described, an outcomes arm focused on assessing the feasibility and effectiveness of a suicide-specific intervention (The Collaborative Assessment and Management of Suicidality) and an exploratory arm whose objective is to learn about psychological vulnerabilities that distinguish suicidal from nonsuicidal patients, with an eye toward developing interventions that address such vulnerabilities. The author concludes that, combined with other developments in the field, this body of work strongly supports the view that suicidal patients should be treated with interventions that specifically target vulnerabilities that seem to set the stage for suicidal episodes.

A controlled comparison trial of the Collaborative Assessment and Management of Suicidality (CAMS) in an inpatient setting: Outcomes at discharge and six-month follow-up

This controlled comparison trial evaluated a suicide-specific intervention, the Collaborative Assessment and Management of Suicidality (CAMS), in an extended-stay psychiatric inpatient setting. Multiple outcomes were examined for 104 patients, half of whom received individual therapy from therapists trained in CAMS. The comparison group was selected from a larger pool through Propensity Score Matching to ensure comparability on age, sex, treatment program, number of prior suicide attempts, and severity of suicidal ideation. Results showed that a) all patients improved significantly across a wide range of measures, including depression, suicidal ideation, functional disability, and well-being; b) these gains were durable over a 6-month post-discharge period; and c) patients treated by a CAMS-trained individual therapist improved significantly more from admission to discharge across all measures. Differences between CAMS and non-CAMS patients were no longer statistically significant at 6-month follow-up, although statistical power was compromised due to attrition. Although replication studies are needed, these findings suggest that interventions specifically tailored for suicidal patients may have advantages compared to usual, intensive inpatient treatment, perhaps by addressing psychological vulnerabilities specific to the population. The lack of significant differences at follow-up suggest that post-treatment contact may be needed to maintain advantages associated with this and similar interventions.

Utility of an integrated electronic suicide alert system in a psychiatric hospital

Management of suicide-related behaviors in a hospital is challenging. This article (1) describes integration of an electronic suicide risk notification system to improve assessment of psychiatric inpatients, (2) details the manner in which these alerts complement standard of care, and (3) provides support of using aggregate data to inform administrative decision-making. Complementing routine clinical care and under the supervision of an assessment coordinator, adult inpatients at a specialty psychiatric hospital complete a computerized battery of outcome assessments throughout the course of their hospitalization. A critical-item response notification system for suicide-related behaviors was implemented within the larger, assessment architecture, sending an alert e-mail to unit staff if patients endorsed suicidal ideation on any 1 of 6 critical items. Analysis of aggregate data over a 19-month period reveal a linear trend of increasing rate of suicide alerts from October 2012 to April 2013 (Phase A) with a stabilization at the heightened level from July 2013 to April 2014 (Phase B), R = 0.697, P = .007. Findings suggest that more nuanced training in the management of suicide-related behavior may be necessary and that traditional approaches to staffing may need to accommodate patient acuity. The communication innovation of this system is in line with the Joint Commission's emphasis on designing and implementing patient-centered systems that enhance quality of care, including improved safety.

Collaborative Assessment and Management of Suicidality (CAMS) compared to treatment as usual (TAU) for suicidal patients: study protocol for a randomized controlled trial

Background

Collaborative Assessment and Management of Suicidality (CAMS) is a therapeutic framework that appears promising to reduce suicidal ideation and suicidal cognition. CAMS has not previously been evaluated in a standard specialized mental health care setting for patients with suicidal problems in general. In this pragmatic randomized controlled trial (RCT) we will investigate if CAMS is more effective than treatment as usual (TAU) in reducing suicidal thoughts and behaviors. Effects will also be investigated on mental health and symptom relief in general and upon readmissions to inpatient units.

Methods/design

The study is a multicenter, observer-blinded, superiority, two-armed RCT which will include patients from four clinical departments at Vestre Viken Hospital Trust, Norway. We aim to include 100 patients with moderate to strong suicidal problems, as defined by a score of 13 or more on Beck’s Scale for Suicide Ideation - Current. Patients are included regardless of diagnosis. Randomization will be performed using a stratified four-block procedure with treatment unit as the stratification variable. The duration of treatment will vary depending on patients’ needs and clinical assessments. Patients are interviewed by research staff at four checkpoints: baseline, 2 weeks, 6 months, and 12 months. Central outcome measures are the Beck Scale for Suicide Ideation - Current, Outcome Questionnaire – 45, and Suicide Attempt Self-Injury Count.

Discussion

This pragmatic trial is effectuated within the Public Health Care System in Norway, where patients have multiple problems and diagnoses and therapists have a high work load. Results from this trial are highly generalizable to a typical everyday clinical setting, and one should expect similar results if CAMS is implemented in the future as a standard component in specialized mental health care systems.

Trial registration

Open Science Framework: DOI 10.17605/OSF.IO/JHRM2. Registered 5 July 2015. ClinicalTrials.gov: NCT02685943. Registered on 8 February 2016.

Acute Suicidal Affective Disturbance (ASAD): A confirmatory factor analysis with 1442 psychiatric inpatients

Acute Suicidal Affective Disturbance (ASAD) is a newly proposed diagnostic entity that characterizes rapid onset suicidal intent. This study aims to confirm the factor structure of ASAD among psychiatric inpatients, and to determine the clinical utility of ASAD in predicting suicide attempt status. Overall, 1442 psychiatric inpatients completed a battery of self-report questionnaires assessing symptoms theorized to comprise the ASAD construct. Utilizing these data, a confirmatory factor analysis with a one-factor solution was performed. Regression analyses were employed to determine if the ASAD construct predicted past suicide attempts, and analyses of variance (ANOVAs) were employed to determine if ASAD symptoms differed by the presence and number of past suicide attempts. The one-factor solution indicated good fit: χ(2)(77) = 309.1, p < 0.001, Tucker-Lewis Index (TLI) = 0.96, comparative fit index (CFI) = 0.97, root-mean-square error of approximation (RMSEA) = 0.05. Controlling for depressive disorders and current symptoms, the ASAD construct significantly predicted the presence of a past suicide attempt. Moreover, ASAD differentiated in the expected directions between individuals with a history of multiple suicide attempts, individuals with a single suicide attempt, and individuals with no history of a suicide attempt. Acute Suicidal Affective Disturbance (ASAD) appears to be a unified construct that predicts suicidal behavior and is distinct from an already-defined mood disorder.

EFFECTIVENESS OF DIALECTICAL BEHAVIOR THERAPY VERSUS COLLABORATIVE ASSESSMENT AND MANAGEMENT OF SUICIDALITY TREATMENT FOR REDUCTION OF SELF-HARM IN ADULTS WITH BORDERLINE PERSONALITY TRAITS AND DISORDER-A RANDOMIZED OBSERVER-BLINDED CLINICAL TRIAL

BACKGROUND

Many psychological treatments have shown effect on reducing self-harm in adults with borderline personality disorder. There is a need of brief psychotherapeutical treatment alternative for suicide prevention in specialized outpatient clinics.

METHODS/DESIGN

The DiaS trial was designed as a pragmatic single-center, two-armed, parallel-group observer-blinded, randomized clinical superiority trial. The participants had at least two criteria from the borderline personality disorder diagnosis and a recent suicide attempt (within a month). The participants were offered 16 weeks of dialectical behavior therapy (DBT) versus up to 16 weeks of collaborative assessment and management of suicidality (CAMS) treatment. The primary composite outcome was the number of participants with a new self-harm (nonsuicidal self-injury [NSSI] or suicide attempt) at week 28 from baseline. Other exploratory outcomes were: severity of borderline symptoms, depressive symptoms, hopelessness, suicide ideation, and self-esteem.

RESULTS

At 28 weeks, the number of participants with new self-harm in the DBT group was 21 of 57 (36.8%) versus 12 of 51 (23.5%) in the CAMS treatment (OR: 1.90; 95% CI: 0.80-4.40; P = .14). When assessing the effect of DBT versus CAMS treatment on the individual components of the primary outcome, we observed no significant differences in the number of NSSI (OR: 1.60; 95% CI: 0.70-3.90; P = .31) or number of attempted suicides (OR: 2.24; 95% CI: 0.80-7.50; P = .12).

CONCLUSION

In adults with borderline personality traits and disorder and a recent suicide attempt, DBT does not seem superior compared with CAMS for reduction of number of self-harm or suicide attempts. However, further randomized clinical trials may be needed.

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.

Suicide, Suicide Attempts, and Suicidal Ideation

Suicidal behavior is a leading cause of death and disability worldwide. Fortunately, recent developments in suicide theory and research promise to meaningfully advance knowledge and prevention. One key development is the ideation-to-action framework, which stipulates that (a) the development of suicidal ideation and (b) the progression from ideation to suicide attempts are distinct phenomena with distinct explanations and predictors. A second key development is a growing body of research distinguishing factors that predict ideation from those that predict suicide attempts. For example, it is becoming clear that depression, hopelessness, most mental disorders, and even impulsivity predict ideation, but these factors struggle to distinguish those who have attempted suicide from those who have only considered suicide. Means restriction is also emerging as a highly effective way to block progression from ideation to attempt. A third key development is the proliferation of theories of suicide that are positioned within the ideation-to-action framework. These include the interpersonal theory, the integrated motivational-volitional model, and the three-step theory. These perspectives can and should inform the next generation of suicide research and prevention.

Impact of a Suicide-Specific Intervention within Inpatient Psychiatric Care: The Collaborative Assessment and Management of Suicidality

A growing body of literature indicates that suicidal patients differ from other psychiatric patients with respect to specific psychological vulnerabilities and that suicide-specific interventions may offer benefits beyond conventional care. This naturalistic controlled-comparison trial (n = 52) examined outcomes of intensive psychiatric hospital treatment (mean length of stay 58.8 days), comparing suicidal patients who received individual therapy from clinicians utilizing the Collaborative Assessment and Management of Suicidality (CAMS) to patients whose individual therapists did not utilize CAMS. Propensity score matching was used to control for potential confounds, including age, sex, treatment unit, and severity of depression and suicidality. Results showed that both groups improved significantly over the course of hospitalization; however, the group receiving CAMS showed significantly greater improvement on measures specific to suicidal ideation and suicidal cognition. Results are discussed in terms of the potential advantages of treating suicide risk with a suicide-specific intervention to make inpatient psychiatric treatment more effective in reducing risk for future suicidal crises.

Helping callers to the National Suicide Prevention Lifeline who are at imminent risk of suicide: the importance of active engagement, active rescue, and collaboration between crisis and emergency services

In 2012, the SAMHSA-funded National Suicide Prevention Lifeline (Lifeline) completed implementation of the first national Policy for Helping Callers at Imminent Risk of Suicide across its network of crisis centers. The policy sought to: (1) provide a clear definition of imminent risk; (2) reflect the state of evidence, field experience, and promising practices related to reducing imminent risk through hotline interventions; and (3) provide a uniform policy and approach that could be applied across crisis center settings. The resulting policy established three essential principles: active engagement, active rescue, and collaboration between crisis and emergency services. A sample of the research and rationale that underpinned the development of this policy is provided here. In addition, policy implementation, challenges and successes, and implications for interventions to help Lifeline callers at imminent risk of suicide are detailed.

Suicide-specific Safety in the Inpatient Psychiatric Unit

In total, 75% of suicides reported to the Joint Commission as sentinel events since 1995, have occurred in psychiatric settings. Ensuring patient safety is one of the primary tasks of inpatient psychiatric units. A review of inpatient suicide-specific safety components, inclusive of incidence and risk; guidelines for evidence-based care; environmental safety; suicide risk assessment; milieu observation and monitoring; psychotherapeutic interventions; and documentation is provided. The Veterans Health Administration (VA) has been recognized as an exemplar system in suicide prevention. A VA inpatient psychiatric unit is used to illustrate the operationalization of a culture of suicide-specific safety. We conclude by describing preliminary unit outcomes and acknowledging limitations of suicide-specific inpatient care and gaps in the current inpatient practices and research on psychotherapeutic interventions, observation, and monitoring.

Implementation of online suicide-specific training for VA providers

OBJECTIVE

Due to the gap in suicide-specific intervention training for mental health students and professionals, e-learning is one solution to improving provider skills in the Veterans Affairs (VA) health system. This study focused on the development and evaluation of an equivalent e-learning alternative to the Collaborative Assessment and Management of Suicidality (CAMS) in-person training approach at a Veteran Health Affairs medical center.

METHODS

The study used a multicenter, randomized, cluster, and three group design. the development of e-CAMS was an iterative process and included pilot testing. Eligible and consenting mental health providers, who completed a CAMS pre-survey, were randomized. Provider satisfaction was assessed using the standard VA evaluation of training consisting of 20 items. Two post training focus groups, divided by learning conditions, were conducted to assess practice adoption using a protocol focused on experiences with training and delivery of CAMS.

RESULTS

A total of 215 providers in five sites were randomized to three conditions: 69 to e-learning, 70 to in-person, 76 to the control. The providers were primarily female, Caucasian, midlife providers. Based on frequency scores of satisfaction items, both learning groups rated the trainings positively. In focus groups representing divided by learning conditions, participants described positive reactions to CAMS training and similar individual and institutional barriers to full implementation of CAMS.

CONCLUSIONS

This is the first evaluation study of a suicide-specific e-learning training within the VA. The e-CAMS appears equivalent to the in-person CAMS in terms of provider satisfaction with training and practice adoption, consistent with other comparisons of training deliveries across specialty areas. Additional evaluation of provider confidence and adoption and patient outcomes is in progress. The e-CAMS has the potential to provide ongoing training for VA and military mental health providers and serve as a tutorial for psychiatrists in preparation for specialty boards.

The DiaS trial: dialectical behavior therapy versus collaborative assessment and management of suicidality on self-harm in patients with a recent suicide attempt and borderline personality disorder traits - study protocol for a randomized controlled trial

Background

In Denmark 8,000 to 10,000 people will attempt suicide each year. The Centre of Excellence in Suicide Prevention in the Capital Region of Denmark is treating patients with suicidal behavior, and a recent survey has shown that 30% of the patients are suffering from borderline personality disorder. The majority of patients (70% to 75%) with borderline personality disorder have a history of deliberate self-harm and 10% have a lifetime risk to die by suicide. The DiaS trial is comparing dialectical behavior therapy with collaborative assessment and management of suicidality-informed supportive psychotherapy, for the risk of repetition of deliberate self-harm in patients with a recent suicide attempt and personality traits within the spectrum of borderline personality disorder. Both treatments have previously shown effects in this group of patients on suicide ideation and self-harm compared with treatment as usual.

Methods/Design

The trial is designed as a single-center, two-armed, parallel-group observer-blinded randomized clinical superiority trial. We will recruit 160 participants with a recent suicide attempt and at least two traits of the borderline personality disorder from the Centre of Excellence in Suicide Prevention, Capital Region of Denmark. Randomization will be performed though a centralized and computer-generated approach that conceals the randomization sequence. The interventions that are offered are a modified version of a dialectical behavior therapy program lasting 16 weeks versus collaborative assessment and management of suicidality-informed supportive psychotherapy, where the duration treatment will vary in accordance with established methods up to 16 weeks. The primary outcome measure is the ratio of deliberate self-harming acts including suicide attempts measured at week 28. Other exploratory outcomes are included such as severity of symptoms, suicide intention and ideation, depression, hopelessness, self-esteem, impulsivity, anger, and duration of respective treatments.

Trial registration

Clinical Trial.gov: NCT01512602.

Using the suicide index score to predict treatment outcomes among psychiatric inpatients

For many suicidal people, the desire to die is moderated by a competing desire to live. This study aimed to demonstrate the ability of a wish-to-live versus wish-to-die index score to measure ambivalence and trichotomize suicidal inpatients into distinct stratified risk groups. Analyses revealed that index scores calculated for patients at treatment start significantly discriminated among the groups at index and uniquely predicted suicidal ideation, hopelessness, and depression scores across treatment. On average, patients with wish-to-live and wish-to-die orientations resolved suicidal ideation by discharge. Changes in suicidal ideation among ambivalently oriented patients were more variable. Clinical and research implications are discussed.

Suicide risk assessment and formulation: an update

There continues to be a lack of clarity on how to assess individual cases for suicidal risk. Though a surfeit of information regarding patient risk factors for suicide is available, clinicians and mental health professionals face difficulties in integrating and applying this information to individuals, in order to come up with an assessment report that is at once comprehensive, operational and easily communicable. This article outlines the basic steps involved in risk assessment with a focus on applying and integrating them. Illustrative questions and examples are used to aid understanding where appropriate. The three major domains emphasized across all contemporary models of risk assessment are specific suicidal thoughts, risk factors and protective factors. Evidence based warning signs associated with near term risk of suicide are reviewed and various approaches proposed for risk formulation are discussed with the aim of providing usable and practical information regarding assessment and formulation of suicide risk. The importance of following a structured, systematic approach is highlighted.

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.