Recent suicide attempters treated with cognitive therapy were 50 percent less likely to try to kill themselves again within 18 months than those who did not receive the therapy, report researchers supported by the National Institutes of Health’s (NIH) National Institute of Mental Health (NIMH) and the Centre for Disease Control and Prevention (CDC). A targeted form of cognitive therapy designed to prevent suicide proved better at lifting depression and feelings of hopelessness than the usual care available in the community, according to Gregory Brown, Ph.D., Aaron Beck, M.D., University of Pennsylvania, and colleagues, who published their findings in the August 3, 2005 Journal of the American Medical Association (JAMA).
“Since even one previous attempt multiplies suicide risk by 38-40 times and suicide is the fourth leading cause of death for adults under 65, a proven way to prevent repeat attempts has important public health implications,” said NIMH Director Thomas Insel, M.D.
To achieve a large enough sample to reliably detect differences in the effectiveness of interventions, the researchers first screened hundreds of potential suicide attempters admitted to the emergency room of the Hospital of the University of Pennsylvania in Philadelphia, ultimately recruiting 120 patients into the study.
Averaging in their mid-thirties, 61 percent of the participants were female, 60 percent black, 35 percent white, and 5 percent Hispanic and other ethnicities. Most had attempted to kill themselves by drug overdosing (58 percent), with 17 percent by stabbing, 7 percent by jumping, and 4 percent by hanging, shooting or drowning. Seventy-seven percent had major depression and 68 percent a substance use disorder.
After a clinical evaluation, each participant was randomly assigned to one of two conditions: cognitive therapy or usual care — services available in the community. Cognitive therapy was developed by Beck in the 1970s and has been applied successfully in a wide variety of psychiatric disorders. Those in the cognitive group were scheduled to receive 10 outpatients weekly or biweekly cognitive therapy sessions specifically developed for preventing suicide attempts. The sessions helped patients find a more effective way of looking at their problems by learning new ways to handle negative thoughts and feelings of hopelessness. In a relapse-prevention task near the end of their therapy, they were asked to focus directly on the events, thoughts, feelings and behaviours that led to their previous suicide attempts and explain how they would respond in a more adaptive way. If they passed this task successfully, their cognitive therapy ended; if they were unsuccessful, additional sessions were provided.
Both groups were encouraged to receive usual care from clinicians in the community and were tracked by study case managers by mail and phone throughout the 18-month follow-up period. The case managers offered referrals to — but not payment for — local mental health and drug abuse treatment and social services.
About half of the participants in both groups took psychotropic medications and about 13 to 16 percent received drug abuse treatment. About 27 percent of those in the usual care group received psychotherapy outside of the study, compared to 21 percent of those also receiving cognitive therapy.
Over the year-and-a-half follow-up period, only 24 percent (13) of those in the cognitive therapy group made repeat suicide attempts, compared to 42 percent (23) of the usual care group. Although the groups did not differ significantly in suicidal thoughts, those who received cognitive therapy scored better on measures of depression severity and hopelessness, which the researchers suggest “may be more highly associated with a reduced risk of repeat suicide attempts.”
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