Effectiveness of Suicide-Focused Psychosocial Interventions in Psychosis: A Systematic Review and Meta-Analysis

A cognitive-behavioral treatment for suicide prevention among adults with schizophrenia spectrum disorders in community mental health: Study protocol for a pilot feasibility and acceptability randomized clinical trial

BACKGROUND

Suicide is among the leading causes of death for adults with schizophrenia spectrum disorders (SSDs), and there is a paucity of evidence-based suicide prevention-focused interventions tailored for this vulnerable population. Cognitive-Behavioral Suicide Prevention for psychosis (CBSPp) is a promising intervention developed in the UK that required modifications for delivery in community mental health (CMH) settings in the United States of American. This pilot trial evaluates the feasibility, acceptability, and preliminary effectiveness of our modified CBSPp intervention in comparison to services as usual (SAU) within a CMH setting in a Midwestern state of the USA.

METHODS

This is a single-site randomized pilot trial with a planned enrollment of 60 adults meeting criteria for both SSD and SI/A. Eligible participants will be randomized 1:1 to either 10 sessions of CBSPp or SAU. Clinical and cognitive assessments will be conducted within a 4-waive design at baseline (prior to randomization and treatment) and approximately 1 month (mid-treatment), 3 months (post-treatment), and 5 months (follow-up) after baseline assessment. Qualitative interviews will also be conducted at post-treatment. The primary objective is to determine whether CBSPp is feasible and acceptable, involving examinations of recruitment rate, treatment engagement and adherence, retention and completion rates, and experiences in the CBSPp treatment and overall study. The secondary objective is to preliminarily evaluate whether modified CBSPp is associated with reductions in clinical (suicide ideation, suicide attempt, symptoms of psychosis, depression, and emergency/hospital service, hopelessness, defeat, and entrapment) and cognitive (information processing biases, appraisals, and schemas) outcomes in comparison to SAU from baseline to post-treatment assessment.

DISCUSSION

This randomized pilot trial will provide clinically relevant information about whether CBSPp can improve SI/A, depression, and psychosis among adults with SSDs. Testing this modified cognitive-behavioral suicide prevention-focused intervention has the potential for a large public health impact by increasing the intervention's utility and usability in CMH where many individuals with SSDs receive care, and ultimately working towards reductions in premature suicide death.

TRIAL REGISTRATION

ClinicalTrials.gov NCT#05345184. Registered on April 12, 2022.

A call to action: informing research and practice in suicide prevention among individuals with psychosis

Although it is well established that individuals living with psychosis are at increased risk for suicidal ideation, attempts, and death by suicide, several gaps in the literature need to be addressed to advance research and improve clinical practice. This Call-to-Action highlights three major gaps in our understanding of the intersection of psychosis and suicide as determined by expert consensus. The three gaps include research methods, suicide risk screening and assessment tools used with persons with psychosis, and psychosocial interventions and therapies. Specific action steps to address these gaps are outlined to inform research and practice, and thus, improve care and prognoses among persons with psychosis at risk for suicide.

An ecological momentary cognitive assessment study of over-attribution of threat and suicide risk factors in people with serious mental illness

INTRODUCTION

People with serious mental illness (SMI; schizophrenia, schizoaffective disorder, bipolar disorder) are at increased risk of suicidal ideation (SI). Over-attribution of social threat, or attributing threatening emotions to neutral faces, may contribute to social isolation through increased social avoidance and decreased social approach motivation. These factors are related to suicide, as well as perceived burdensomeness (PB) and thwarted belongingness (TB). This study examined how over-attribution of threat relates to PB, TB, and social motivations.

METHOD

N = 273 participants with SMI were assessed for current SI and behavior, and were stratified into SI (N = 130) vs. non-SI (N = 143) groups. Participants completed smartphone surveys (via ecological momentary assessments [EMA]) 3×/day for 10 days. They also completed the Mobile Ecological Test of Emotion Recognition (METER) 1×/day. Linear mixed models and multi-level mediation tested the relationships between over-attribution of threat, METER performance, PB/TB, and social motivations.

RESULTS

Participants with and without SI did not significantly differ in over-attribution of threat or METER performance. In separate models, there was a relationship of over-attribution of threat with increased PB (B = 1.00, SE = 0.21, t = 4.72, p < .001), reduced social approach motivation (B = -0.74, SE = 0.22, t = -3.33, p < .001), and increased social avoidance (B = 0.90, SE = 0.24, t = 3.70, p < .001), all significant when adjusting for facial affect recognition ability. A model examining social motivations as a mediator between over-attribution of threat and PB/TB was not significant.

CONCLUSION

These results suggest that over-attribution of threat relates to interpersonal constructs related to SI irrespective of facial affect abilities. This study may inform understanding of social cognitive processes related to suicide in SMI.

Clinical Trials Studying Suicide Risk Reduction: Who is Excluded From Participation

OBJECTIVE

The use of exclusion criteria in clinical trials can cause research participants to differ markedly from clinical populations, which negatively impacts generalizability of results. This study identifies and quantifies common and recurring exclusion criteria in clinical trials studying suicide risk reduction, and estimates their impact on eligibility among a clinical sample of adults in an emergency department with high suicide risk.

METHOD

Recent trials were identified by searching PubMed (terms suicide, efficacy, effectiveness, limited to clinical trials in prior 5 years). Common exclusion criteria were identified using Qualitative Content Analysis. A retrospective chart review examined a one-month sample of all adults receiving psychiatric evaluation in a large urban academic emergency department.

RESULTS

The search yielded 27 unique clinical trials studying suicide risk reduction as a primary or secondary outcome. After research fundamentals (e.g. informed consent, language fluency), the most common exclusion criteria involved psychosis (77.8%), cognitive problems (66.7%), and substance use (63.0%). In the clinical sample of adults with high suicide risk (N = 232), psychosis exclusions would exclude 53.0% of patients and substance use exclusions would exclude 67.2% of patients. Overall, 5.6% of emergency psychiatry patients would be eligible for clinical trials that use common exclusion criteria.

CONCLUSIONS

Recent clinical trials studying suicide risk reduction have low generalizability to emergency psychiatry patients with high suicide risk. Trials enrolling persons with psychosis and substance use in particular are needed to improve generalizability to this clinical population.

Systematic Review of the Link Between Social Cognition and Suicidal Ideation and Behavior in People With Serious Mental Illness

Background and Hypothesis

People with serious mental illness (SMI; psychotic and affective disorders with psychosis) are at an increased risk of suicide, yet there is limited research on the correlates of suicide in SMI. Social cognitive impairments are common among people with SMI and several studies have examined social cognition and suicidal ideation (SI) and behavior. This systematic review aims to evaluate the links between various domains of social cognition, SI, and suicidal behavior in SMI.

Study Design

Electronic databases (PubMed and PsycInfo) were searched through June 2023. Records obtained through this search (N = 618) were screened by 2 independent reviewers according to inclusion criteria. Relevant data were extracted, and study quality was assessed.

Study Results

Studies (N = 16) from 12 independent samples were included in the systematic review (N = 2631, sample sizes ranged from N = 20 to N = 593). Assessments of social cognition and SI and behavior varied widely between studies. Broadly, effects were mixed. Better emotion recognition of negative affect was linked to SI and a history of suicide attempts, though there is little consistent evidence for the relationship of emotion recognition and SI or behavior. On the other hand, better theory of mind ability was linked to SI and a history of suicide attempts. Furthermore, negative attributional bias was linked to current SI, but not a history of SI or attempt.

Conclusions

This review suggests mixed associations between social cognition, SI, and behavior in SMI. Future research should evaluate additional mediators and moderators of social cognition and suicide, employing prospective designs.

Suicide Safety Plan Self-knowledge in Serious Mental Illness: Psychiatric Symptom Correlates and Effects of Brief Intervention

Psychiatric symptoms experienced by people with serious mental illness (SMI; schizophrenia, bipolar and other psychotic disorders) may impact suicide safety planning. This study examined safety plan self-knowledge, or an individual's own knowledge and awareness of their safety plan, in a sample of people with SMI. Participants (N = 53) with SMI at elevated risk of suicide completed a 4-session intervention that included safety plans, with one intervention group that included mobile augmentation. Self-knowledge was assessed from previous safety plans at 4-, 12- and 24-weeks. Fewer warning signs generated was correlated with greater psychiatric symptoms (r = - .306, p = .026) and suicidal ideation (r = - .298, p = .030). Fewer coping strategies generated was correlated with greater suicidal ideation (r = .- 323, p = .018). Preliminarily, there was greater self-knowledge of warning signs over time among participants in the mobile intervention. These preliminary findings highlight the relationship of safety plan self-knowledge to symptoms and suggest that mobile augmentation of safety planning may be beneficial. Trial Registration: NCT03198364.

Heterogeneity in the Course of Suicidal Ideation and its Relation to Suicide Attempts in First-Episode Psychosis: A 5-Year Prospective Study

OBJECTIVES

Although the risk of suicide is high in first-episode psychosis (FEP), little is known about the course of suicidal ideation and its relation to suicide attempts. Therefore, we aimed to identify 5-year trajectories of suicidal ideation and associated factors in FEP and compare how suicide attempts were distributed across these identified trajectories.

METHOD

This 5-year prospective study assessed suicidal ideation, suicide attempts and potentially associated factors through research interviews, chart review and coroners' reports in 382 FEP patients [mean age = 23.53 (SD = 3.61)] admitted to 2 5-year early psychosis services in Montreal, Canada. Trajectories were identified using a semiparametric mixture model, and associated factors with multinomial logistic regression.

RESULTS

Three suicidal ideation trajectories were identified: low and decreasing (n = 325, 85.08%); early decline, then increasing (n = 30, 7.85%), and persistent suicidal ideation (n = 27, 7.07%). Suicidal ideation prior to admission (OR = 2.85, 95% CI, 1.23 to 6.63, P < 0.05) and cocaine use disorder (OR = 6.78, 95% CI, 1.08 to 42.75, P < 0.05) were associated with the early decline, then increasing suicidal ideation trajectory. Persons with prior suicide ideation (OR = 4.33, 95% CI, 1.66 to 11.29, P < 0.05) and attempts (OR = 8.18, 95% CI, 2.39 to 27.97, P < 0.001) and alcohol use disorder (OR = 3.63, 95% CI, 1.4 to 9.42, P < 0.05) were more likely to belong to the persistent suicidal ideation trajectory, and to attempt suicide during follow-up.

CONCLUSIONS

Our study highlights heterogeneity in the course of suicidal ideation over 5 years and the importance of ongoing assessment of suicidal risk in FEP patients, particularly for patients who persistently report suicidal ideation, as they are likelier to engage in suicide attempts. Patients with factors associated with increasing or persistent suicidal ideation trajectories should be targeted for suicide prevention interventions from the early phase of follow-up. Given the small number of persons in these trajectories and the wide CIs for some factors, larger studies are however needed to further characterize who belongs in each group.

Exploring the Relationship Between Suicidality and Persistent Negative Symptoms Following a First Episode of Psychosis

BACKGROUND AND HYPOTHESIS

Suicide is a leading cause of death in first-episode psychosis (FEP), with an elevated risk during the first year following illness onset. The association between negative symptoms and suicidality remains contentious. Some studies suggest that negative symptoms may be associated with lower suicidality, while others fail to find an association between the two. No previous studies have specifically investigated suicidality in Persistent Negative Symptoms (PNS) and its associated subgroups.

STUDY DESIGN

In a large cohort of FEP patients (n = 515) from an early intervention service, we investigated suicidality in those with PNS, secondary PNS (ie, sPNS; PNS with clinical-level positive, depressive, or extrapyramidal symptoms), and non-PNS (all other patients) over 24 months. Patients were categorized into PNS groups based on symptoms from month 6 to month 12, and suicidality was evaluated using the Brief Psychiatric Rating Scale (BPRS).

STUDY RESULTS

Covarying for age and sex, we found that sPNS had higher suicidality relative to PNS and non-PNS throughout the 24-month period, but PNS and non-PNS did not differ. These differences were maintained after adjusting for depressive symptoms.

CONCLUSION

We observed that PNS did not significantly differ from non-PNS. However, we identified sPNS as a group with elevated suicidality above and beyond depression, suggesting that sPNS would benefit from targeted intervention and that PNS categorization identifies a subgroup for whom negative symptoms are not associated with lower suicidality.

Impact of Treatment Initiation and Engagement on Deliberate Self-Harm Among Individuals With First-Episode Psychosis

OBJECTIVE

Individuals with psychosis are at increased risk for suicide, with the greatest risk being present during the first few months after diagnosis. The authors aimed to examine whether treatment initiation within 14 days of diagnosis and treatment engagement within 90 days of initiation reduce the risk for deliberate self-harm (DSH) among individuals with first-episode psychosis (FEP).

METHODS

A retrospective longitudinal cohort design was adopted by using Ohio Medicaid claims for 6,349 adolescents and young adults ages 15-24 years with FEP. Logistic regression was used to examine factors associated with treatment initiation and engagement. Cox proportional hazard models were used to estimate the impact of treatment initiation and engagement on DSH. Propensity score weighting was used to control for sociodemographic and clinical covariates.

RESULTS

Approximately 70% of the sample initiated treatment, 55% of whom engaged in treatment. Treatment initiation and engagement were associated with both demographic and clinical variables. Treatment initiation significantly reduced the hazard of DSH (average treatment effect in the entire population: hazard ratio [HR]=0.62, 95% CI=0.47-0.81; average treatment effect among those treated: HR=0.64, 95% CI=0.52-0.80). In contrast, treatment engagement was not significantly associated with DSH.

CONCLUSIONS

These results suggest that the initial treatment contact is essential for reducing DSH among adolescents and young adults with FEP. Additionally, the finding that treatment engagement did not reduce DSH suggests that standard clinical care may not be sufficient for reducing DSH in this population. These findings highlight the need for suicide-specific interventions for individuals with FEP.

Are all reasons for living made equally? Reasons for living and dysfunctional attitudes in psychotic disorders and bipolar I

OBJECTIVES

Persons with schizophrenia, schizoaffective, or bipolar I disorder are more likely to die by suicide compared to the general population. Dysfunctional attitudes have been shown to be significant predictors of cognitive vulnerability to depression, hopelessness, and poor problem-solving skills, which predict suicidal ideation. Dysfunctional attitudes are common in persons with schizophrenia spectrum disorders (SSDs) and bipolar I. The Reasons for Living Inventory (RFLI) examines distinct reasons for not dying by suicide. This study's objectives were to examine the relationship between the RFLI subscales and dysfunctional attitudes among persons with SSDs and bipolar I. We hypothesized significant positive correlations between two RFLI subscales (Fear of Suicide and Fear of Social Disapproval) and total score on the Dysfunctional Attitude Scale (DAS). We did not expect significant correlations between other subscales.

DESIGN AND METHODS

This correlational, cross-sectional study examined baseline scores on the RFLI and dysfunctional attitudes (DAS) among N = 102 outpatients with SSDs or bipolar I.

RESULTS

Significant positive correlations were observed between RFLI subscales Fear of Suicide and Fear of Social Disapproval and DAS total scores. No other significant relationships were observed.

CONCLUSIONS

Certain reasons for living (i.e. fear of suicide and social disapproval) may be associated with dysfunctional attitudes among persons with SSDs or bipolar I. These, in turn, may place these individuals at a greater risk for suicide by increasing their cognitive vulnerability. These findings may inform clinical treatment targets for persons with SSDs and bipolar I.

A cognitive-behavioral suicide prevention treatment for adults with schizophrenia spectrum disorders in community mental health: Preliminary findings of an open pilot study

Suicide is a leading cause of death among schizophrenia spectrum disorder populations. This open pilot study examined a modified cognitive-behavioral suicide prevention treatment for clients in community mental health. Providers (n=5) were trained to deliver the treatment and clients (n=5) received it in 10 individual therapy sessions. Clients experienced improvements in suicide ideation, depression, hopelessness, general symptoms of psychosis, entrapment, defeat, approaches to coping, psychological stress, impulsivity, and the number of treatment barriers from baseline to post-treatment. Qualitative findings reinforced quantitative results of client improvements and provided important suggestions to strengthen the intervention and its delivery in community mental health.

Depression, suicide intent, and plan among adults presenting in an emergency department after making a suicide attempt: Exploratory differences by psychosis symptom experience

Rates of suicide are significantly higher for individuals with schizophrenia spectrum disorders (SSDs) than those in the general population. With limited understandings of factors contributing to engaging in a suicide attempt among the psychosis population in the literature, the current study sought to preliminarily explore depression, suicide intent, and suicide plan among adults with and without psychosis symptom experiences who presented to an emergency department (ED) after making a suicide attempt. Electronic health record data were collected from the ED of an academic healthcare system in the Midwestern United States between 2011 and 2022. Patients included 1178 adults who arrived after making a suicide attempt. Trained research assistants conducted chart reviews and data were explored in SPSS28. A significantly smaller proportion of patients with psychosis had depressive symptoms and endorsed having suicide intent prior to their attempt in comparison to patients without psychosis. A smaller trending (p < .10) proportion of patients with psychosis endorsed having a suicide plan prior to their attempt than those with psychosis. Exploratory findings highlight the importance of EDs assessing for suicide risk beyond traditional approaches among patients with psychosis symptom experiences, including considerations for the potential of individuals not experiencing depression, suicide intent, or a suicide plan. Future research is particularly needed to examine psychosis symptomatology and the experience of distress as potential contributing factors to suicide behavior and death among patients with psychosis symptoms to better inform suicide risk assessment and intervention efforts.

Girl's and women's experiences of seeking mental health support for symptoms associated with psychosis. A narrative review

BACKGROUND

Women are more likely than men to experience symptoms associated with psychosis, such as voice hearing, and more likely to seek mental health support. However, little is known about the emotional experiences of girls and young women who seek help for symptoms of psychosis to inform gender sensitive services and access routes. The current review offers the first focused insights into barriers and facilitators relating to help seeking for girls and women experiencing symptoms of psychosis.

METHODS

OneSearch, PubMed, and PsychINFO databases were searched for suitable papers in relation to the research question between November 2021 and February 2022; 139 papers were found, of which eight met the inclusion criteria for review.

RESULTS

Across the eight papers reviewed, participants were aged 15- to 71-years-old. From the participant numbers available, data from a total of 54,907 participants from a range of demographic groups were included in the review. Results and findings sections from the eight papers were reviewed for themes, and four overarching themes emerged: (1) The emotional cost of seeking help, (2) voice hearing for girls and women, (3) side effects of treatment, and (4) facilitators to accessing support.

DISCUSSION

Engagement in talking therapies can be difficult when services minimize the experience of psychosis-related symptoms. Women may be more likely to have their symptom-related distress diagnosed as a mood disorder, rather than symptoms of psychosis being identified, preventing timely tailored intervention. Normalization, psychoeducation, social support, and validation were recommended as helpful interventions.

The significance of cognitive-behavioral therapy on suicide: An umbrella review

BACKGROUND

Suicide becomes a widespread public health concern. Cognitive-behavioral therapy (CBT) is used to correct negative thoughts and behaviors of patients at risk of suicide. The aim of this research is to summarize and evaluate the existing evidence to explore the impact of CBT on suicide.

METHOD

We conducted a systematic searched in PubMed, Web of Science, Cochrane database from the first available year to March 2021. The methodological quality was evaluated by AMSTAR-2 tool, and the evidence quality was evaluated by GRADE classification. We summarized all the comparative effects of CBT on suicide, and used forest plots to describe the impact of CBT on suicide related outcomes included suicidal ideation, suicide attempts. The random effects model was used to summarize data.

RESULTS

Nine systematic reviews and meta-analysis were included. Most of the systematic reviews and meta-analysis were of medium methodological and evidence quality. The impact of CBT on suicide outcomes could be divided into the following two categories: CBT reduced levels of suicidal ideation (SMD -0.28, 95 % CI -0.36 to -0.21), CBT relieved suicide attempts (RR 0.77, 95 % CI 0.69 to 0.87).

CONCLUSION

Based on the current evidence, CBT could relieve suicide, including suicide ideation, suicide attempts. CBT is scalable and cost-effective. It is helpful for health professionals to formulate personalized CBT programs, promote clinical and community applications and integrate them into comprehensive suicide interventions and prevention strategies.

Mental health provider perspectives of the COVID-19 pandemic impact on service delivery: a focus on challenges in remote engagement, suicide risk assessment, and treatment of psychosis

Background

The COVID-19 pandemic has been impacting the need, utilization, and delivery of mental health services with greater challenges being faced by clients and providers. With many clients facing reduced access to services and social isolation, a focus on suicide risk assessment and prevention is critical. Concern is particularly increased for clients with schizophrenia spectrum disorders given data show suicide rates are disproportionately high for those with psychosis in comparison to the general population. Provider perspectives of challenges in service delivery are needed to inform efforts to improve access, feasibility, and quality of mental health care throughout the evolving pandemic. This study explored mental health provider perspectives of client challenges in service utilization and provider challenges in service delivery, including remote engagement, suicide risk assessment, and treatment of psychosis.

Methods

Data were collected from social work mental health providers (n = 12) in United States community mental health setting. Providers consented to participate and responded to questions about service delivery experiences in late 2020 and in relation to COVID-19. Demographic and practice-related provider data were explored descriptively using SPSS and qualitative data using open coding and grounded theory methods in Dedoose.

Results

Among the 9 providers who engaged in remote service delivery, 7 (77.8%) experienced challenges in remote engagement with clients and 8 (88.9%) experienced challenges in treatment of psychosis. Among the 7 providers who engaged in remote suicide assessment, 4(57%) experienced challenges. Qualitative themes emerged including logistic (e.g., technology access and use), engagement (e.g., virtual rapport-building and limited remote services), and clinical (e.g., difficulty assessing suicide risk, internal stimuli, abnormal involuntary movement, and affect) challenges in service delivery.

Conclusions

Provider perspectives are essential to inform efforts to build resources and problem-solve challenges and barriers that both providers and clients face throughout various shifts in mental health service delivery. Findings emphasize the need to troubleshoot client access to technology, bolster support for providers to prevent burnout, and greater provider training to improve skills in remote engagement, assessment, and treatment, particularly in relation to psychosis and suicide prevention. Study implications are not only critical for the evolving COVID-19 pandemic, but also in preparation for ongoing shifts in service delivery as technology evolves.

Modifying a cognitive behavioral suicide prevention treatment for adults with schizophrenia spectrum disorders in community mental health

Suicide is among the leading causes of death for adults with schizophrenia spectrum disorders. Given a paucity of evidence-based interventions tailored for psychosis, we sought to modify a promising Cognitive-Behavioral Suicide Prevention for psychosis (CBSPp) treatment for adults in US community mental health (CMH) settings using community-based participatory research methods. This article presents our modification methodology, stakeholder data and scholarly expert input, and CBSPp adaptations prior to future intervention testing. Stakeholder data (n = 25) were collected from clients, providers, and peer advocates in a CMH setting in Michigan. Findings were subsequently presented to a panel of scholarly experts in the fields of suicide and psychosis research, intervention research, and implementation science for input. Emerging themes from stakeholders include logistic, perceptual, and clinical challenges in the process of introducing this treatment in a CMH setting. Consistent with literature, buy-in and support for the delivery of a new treatment emerged as important factors in modifying and implementing CBSPp. A final modification list is presented in this paper and collaborations among stakeholders, researchers, and scholarly experts are essential to navigate psychosocial treatment innovation barriers with an overall goal of improving access, feasibility, and quality of this suicide prevention treatment.

Clinical insight and cognitive functioning as mediators in the relationships between symptoms of psychosis, depression, and suicide ideation in first-episode psychosis

First-episode psychosis (FEP) is a particularly high-risk period for suicide. Literature suggests poor cognitive functioning may serve as a protective factor, while investigations of clinical insight reveal a complex relationship with suicide outcomes. This study examined the mediating role of cognition and clinical insight in the relationships between positive and negative symptoms, depression, and subsequent suicide ideation among individuals in FEP. Data were obtained from the Recovery After an Initial Schizophrenia Episode project. Participants (n = 404) included adolescents and adults in FEP between the ages of 15 and 40. Measurement utilized the Calgary Depression Rating Scale, Positive and Negative Syndrome Scale, and Brief Assessment of Cognition in Schizophrenia. Structural equation modeling was used to examine the mediation model. The likelihood of experiencing suicide ideation was significantly decreased when working memory was stronger (b = -0.034, SE = 0.02, OR = 0.967, p < .05), and significantly increased when clinical insight was stronger (b = 0.191, SE = 0.08, OR = 1.21, p < .01), positive symptoms were greater (b = 0.422, SE = 0.20, OR = 1.52, p < .05) and depressive symptoms were greater (b = 0.545, SE = 0.15, OR = 1.70, p < .001). Clinical insight and working memory functioned as mediators in the relationships between depression, positive symptoms, negative symptoms, and suicide ideation. Findings suggest it is essential that clinicians have awareness of insight being a risk factor for suicide ideation and balance therapeutic efforts to strengthen clinical insight and cognition in psychosocial treatments with suicide risk assessment and prevention methods.

Building on the past 50 years, not starting over: A balanced interpretation of meta-analyses, reviews, and commentaries on treatments for suicide and self-injury

Several recent meta-analyses on interventions for self-injurious thoughts and behaviors (SITBs) have been conducted. The primary finding of these meta-analyses is that the observed effects of interventions for SITBs are generally quite small and are far from where we need to be as a field. Although we agree with these general findings, we disagree, however, with many of the overly bleak conclusions drawn from these findings that emphasize creating new treatments while discounting the benefit of improving existing interventions and the decades of research that were involved in creating them. Accordingly, we offer three future directions with promise to build upon and improve our existing treatments, while we simultaneously work to develop new ones: (1) determine which intervention(s) are needed for which person and at which time, (2) conduct more research on intervention length before concluding that brief interventions are just as efficacious as longer ones, and (3) evaluate the potential of comprehensive models of suicide prevention as a more efficacious alternative to any one individual intervention.

Effectiveness of Cognitive Behavioural Therapy for Suicide in Schizophrenia: A Systematic Review

Background:

Suicide is probably one of the worst potential complications for people with schizophrenia. Even though the use of antipsychotic medication is essential in reducing suicidal behaviour, the use of psychological treatments seems to be in the same way necessary. Cognitive Behavioural Therapy (CBT) is an evidence-based form of psychotherapy that is constantly trying to synchronise with the latest recommendations from the research. The goal of the present work is to systematically review the scientific evidence from published studies testing the effectiveness of CBT designed to deal with suicide in patients with schizophrenia.

Methods:

We searched using multiple terms related to suicide prevention based on CBT in schizophrenia. Two databases (Medline and SCOPUS) were scrutinised for the electronic search and different reference lists from previous reviews were also hand checked.

Results:

We identified 5 randomised and controlled trials of CBT that included suicide-related cognitions or behaviours as a primary outcome measure. CBT focusing on suicidal cognitions and behaviours was found to be effective in reducing suicidal ideation. As the number of studies fulfilling the inclusion criteria is small and the assessment of outcomes is heterogeneous, we did not perform a meta-analysis and we present results in a narrative way.

Conclusion:

Research on CBT focused on suicide prevention in patients with schizophrenia is promising but current evidence is notoriously insufficient. Although those therapies seemed to be efficacious in the prevention of suicide, scarcity of randomised clinical trials specifically focusing on suicide is probably the most important issue to be faced. Given the current evidence, clinicians should be familiar with CBT techniques focusing on suicidal cognitions. However, suicide prevention and treatment in those with schizophrenia is complex, and many other factors such as possible earlier use of clozapine, optimizing adherence to medication, and other psychosocial aspects should be addressed. Combination of different strategies appears to be mandatory.

[Psychotherapy after a suicide attempt-current evidence and evaluation]

Suizidversuche gelten als einer der wichtigsten Risikofaktoren für Suizide. Vor diesem Hintergrund wurden in den letzten Jahren diverse Psychotherapieangebote für Personen nach einem Suizidversuch entwickelt und untersucht. Im Rahmen dieses Artikels wird der aktuelle Stand der Effektivitätsforschung zusammengefasst, es werden Beispiele für erfolgreiche suizidfokussierte Psychotherapieprogramme gegeben und der gegenwärtige Forschungs- und Wissensstand wird kritisch reflektiert. Die Ergebnisse von 2 aktuellen Cochrane-Reviews zur Psychotherapie nach selbstverletzendem Verhalten im Kindes‑, Jugend- und Erwachsenenalter sowie Befunde aus 14 weiteren Metaanalysen zur psychologischen Suizidprävention, die in den vergangenen 5 Jahren publiziert wurden, werden überblicksartig dargestellt.

Die kognitive Verhaltenstherapie (KVT) und die dialektisch-behaviorale Therapie (DBT) haben sich als effektiv erwiesen. Insgesamt sind die gemittelten Effektstärken jedoch von geringer Größe und diverse methodische Probleme verunmöglichen weitreichende Schlussfolgerungen. Grundsätzlich kommt der suizidspezifischen Psychotherapie in der individuumszentrierten Suizidprävention besondere Bedeutung zu; die empirische Fundierung und Dissemination entsprechender Programme sind jedoch noch unzureichend.

A systematic review of longitudinal studies of suicidal thoughts and behaviors in first-episode psychosis: course and associated factors

PURPOSES

To better assess and reduce suicidal risk in first-episode psychosis (FEP), we aimed to investigate the evolution of suicidal thoughts and behaviors (STBs) and associated factors in FEP.

METHOD

This systematic review (PROSPERO-CRD42020168050) meets PRISMA guidelines. PubMed, Medline, PsycINFO, Embase, EBM Reviews and references lists of relevant articles were searched (February 2020) to identify longitudinal studies, published in English or in French, that assessed the prevalence of STBs at entry to services and over follow-up, and examined factors associated with STBs among all persons with affective and non-affective FEP from a defined catchment area. Screening, data extraction and quality assessment using the adapted Newcastle Ottawa Scale were done independently by two reviewers. Results on prevalence and associated factors are presented by type of STB.

RESULTS

Of 3,177 references, 17 studies of 11 non-overlapping samples (n = 14,907) with varying lengths of follow-up (1-41.7 years) were included. The prevalence of STBs decreased over follow-up. Up to 21.6% made at least one suicide attempt, 27% had suicidal ideation, and 1-4.3% died by suicide during follow-up. Of 53 factors assessed across studies, only male sex, depressive symptoms, and STBs occurring early during follow-up were associated with subsequent STBs. Early intervention for psychosis decreased STBs in the first three years. Other factors were assessed in a single study, yielded conflicting results, or were not associated with STBs.

CONCLUSIONS

The high prevalence of STBs following onset of psychosis highlights the need for early detection and intervention and ongoing assessment of suicidal risk throughout follow-up, with attention to identified risk factors. The heterogeneity of the studies precluded a meta-analysis and several factors were each assessed by a single study. Additional well-designed longitudinal studies of STBs and associated factors are warranted.

Continuity of care and mortality in people with schizophrenia

BACKGROUND

People with schizophrenia have shortened lives. This excess mortality seems to be related to physical health conditions that may be amenable to better primary and secondary prevention. Better continuity of care may enhance such interventions as well as help prevent death by self-injury.

AIMS

We set out to examine the relationship between the continuity of care of patients with schizophrenia, their mortality and cause of death.

METHOD

Pseudoanonymised community data from 5551 people with schizophrenia presenting over 11 years were examined for changes in continuity of care using the numbers of community teams caring for them and the Modified Modified Continuity Index. These and demographic variables were related to death certifications of physical illness from the Office of National Statistics and mortal self-injury from clinical data. Data were analysed using generalised estimating equations.

RESULTS

We found no independent relationship between levels of continuity of care and overall mortality. However, lower levels of relationship continuity were significantly and independently related to death by self-injury.

CONCLUSIONS

We found no evidence that continuity of care is important in the prevention of physical causes of death in schizophrenia. However, there is evidence that declining relationship continuity of care has an independent effect on deaths as a result of self-injury. We suggest that there should be more attention focused on the improvement of continuity of care for these patients.

Psychosocial interventions for self-harm in adults

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Suicidal ideation in first-episode psychosis: Considerations for depression, positive symptoms, clinical insight, and cognition

BACKGROUND

Suicide is a leading cause of death for individuals with psychosis. Although factors influencing suicide risk have been studied in schizophrenia, far less is known about factors that protect against or trigger increased risk during early-stage and first episode of psychosis. This study examined whether depression, psychotic symptoms, clinical insight, and cognition were associated with suicide ideation among individuals with first-episode psychosis.

METHODS

Data were obtained from the Recovery After an Initial Schizophrenia Episode (RAISE) project. Participants (n = 404) included adults between ages 15 and 40 in a first episode of psychosis. Measurement included the Positive and Negative Syndrome Scale, Brief Assessment of Cognition in Schizophrenia, and Calgary Depression Scale for Schizophrenia. A logistic regression model evaluated clinical and cognitive variables as predictors of suicidal ideation.

RESULTS

Greater positive symptoms (OR = 1.085, p < .01) and depression (OR = 1.258, p < .001) were associated with increased likelihood of experiencing suicidal ideation during the RAISE project. Meanwhile, stronger working memory (OR = 0.922, p < .05) and impaired clinical insight (OR = 0.734, p < .05) were associated with a decreased likelihood of experiencing suicidal ideation.

CONCLUSION

The likelihood of experiencing suicidal ideation was significantly increased when positive and depressive symptoms were present, and significantly decreased when clinical insight was poorer and working memory stronger. These findings have important implications for the role of cognition and insight in risk for suicide ideation in early-stage psychosis, which may aid in improving the prediction of suicide behaviors and inform clinical decision-making over the course of the illness.