August 3, 2005
Cognitive Therapy Reduces Repeat Suicide Attempts by 50 Percent
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 Center 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 outpatient 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 behaviors 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."
"We were surprised by the amount of energy and resources it takes to reach out to individuals who attempt suicide," noted Brown. "This population lacks a positive attitude toward the mental health system and often fails to show up for scheduled appointments. However, the combination of cognitive therapy plus case management services was effective in preventing suicide attempts." He suggests that cognitive therapy's short-term nature makes it a good fit for treatment of suicide attempters at community mental health centers.
"Suicide and suicide attempts are serous public health problems that devastate individuals, families and communities," added Dr. Ileana Aria, Director, CDC's National Center for Injury Prevention and Control. "This research provides valuable insight for those treating people at risk, so that they can learn adaptive ways to handle stress and resolve their problems and thereby reduce the likelihood they will resort to suicidal behavior as a solution."
Also participating in the study were: Drs. Thomas Ten Have, Sharon Xie, and Judd Hollander, University of Pennsylvania, and Dr. Gregg Henriques, James Madison University.
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