Cognitive Therapy May Help Prevent Repeated Suicide Attempts
In 2002, suicide accounted for more than 25,000 deaths in the United States, making it the fourth-leading cause of death for adults aged 18 to 65 that year.
Thankfully, suicide attempts are much more common than completed suicides. Unfortunately, attempted suicide is one of the strongest risk factors for completed suicides. Studies indicate that a person who has attempted suicide is 40 times more likely to eventually commit suicide than a person who has never attempted it.
Individuals who have attempted suicide are clearly ideal candidates for some sort of intervention. But studies evaluating different types of interventions have been limited and far from conclusive.
In a study published in the August 3, 2005 Journal of the American Medical Association , researchers tested the effect of a brief intervention with cognitive therapy on individuals who had recently attempted suicide. They found that individuals who received cognitive therapy were significantly less likely to attempt another suicide within 18 months of the first attempt, compared to individuals who received enhanced usual care. Those who received cognitive therapy were also significantly less depressed during the follow-up, and reported significantly less hopelessness than the usual care group.
About the Study
The researchers enrolled 120 individuals who had attempted suicide and received a medical or psychiatric evaluation within 48 hours of the attempt. The patients’ ages ranged from 18 to 66, and 61% were women.
Sixty patients were randomly assigned to the cognitive therapy group, and 60 to the usual care group.
Cognitive therapy patients received at least ten outpatient sessions that were specifically designed to prevent repeated suicide attempts. The therapy focused on identifying thoughts, images, and core beliefs that triggered the initial suicide attempt. Cognitive and behavioral strategies were then applied to help participants develop ways to effectively cope with these triggers. The individuals were “tested” towards the end of therapy to determine how well they could respond to these triggers. If they were not able to respond appropriately, they were encouraged to continue with their cognitive therapy sessions.
Participants in both the cognitive therapy and enhanced usual care groups were contacted regularly by case managers who offered referrals to community mental health treatment, addiction treatment, and social services. When permission was given, they also contacted the study participants’ family, friends, clergy, probation officers, and mental health workers.
The researchers did not ask any of the study participants to discontinue any mental health or substance abuse treatment prior to beginning the study.
All participants reported their levels of ]]>depression]]> and hopelessness at six, 12, and 18 months. During this follow-up period, the researchers compared the number of repeated suicide and self-reported levels of depression and hopelessness in each group.
At the beginning of the study, 77% of participants had a major depressive disorder and 68% had a substance abuse disorder. The proportion of participants with these disorders did not vary significantly between the cognitive therapy and usual care groups.
During the 18-month study period, 13 participants in the cognitive therapy group (24.1%) made at least one suicide attempt, compared to 23 participants (41.6%) in the usual care group. This was a statistically significant difference.
The severity of participants’ depression was also significantly lower in the cognitive therapy group at the 6-, 12-, and 18-month marks, compared to usual care. In addition, the cognitive therapy group had significantly less hopelessness at six months, compared to usual care.
Although all participants had been allowed to continue with other therapies, there was no significant difference between the proportion of participants in the cognitive therapy and usual care groups receiving mental health or addiction treatment at any point in the study.
This study was designed to evaluate the effectiveness of a brief (10-session) cognitive therapy intervention. As such, it was limited by the ability of cognitive therapy participants to continue with their therapy for as long as necessary, if they were unprepared to ward off another suicide attempt at the completion of their ten sessions.
How Does This Affect You?
This study found that individuals who received cognitive therapy after a suicide attempt were significantly less likely to make another suicide attempt during the next 18 months than individuals who received usual care.
But there’s a bigger lesson here. Like cancer or heart failure, depression can be a terminal illness. Individuals who have attempted suicide are 40 times more likely to eventually succeed than those who have never attempted it. This means that these individuals are in desperate need for some type of effective intervention.
Whether this intervention should be cognitive therapy, another type of therapy, medication, substance abuse treatment, or something else entirely is still up for debate. Though this study makes a good case for cognitive therapy, much research still needs to be done to determine what kind of intervention will be most effective at preventing those who have attempted suicide from ever completing their mission.
National Institute of Mental Health
National Institutes of Health
Substance Abuse and Mental Health Services Administration
US Department of Health and Human Services
Brown GK et al. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA . 2005; 294:563-570.
Cole TB et al. Mental illness and violent death: major issues for public health. [Editorial.] JAMA . 2005; 294:623-624.
Last reviewed Aug 5, 2005 by ]]>Richard Glickman-Simon, MD]]>
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