Adults who had attempted suicide reduced their risk of a repeat attempt by participating in a cognitive therapy program, compared to adults who received the usual care, according to a study in the August 3 issue of JAMA, a theme issue on violence and human rights.
In 2002, suicide was the fourth leading cause of death for adults between the ages of 18 and 65 years with approximately 25,000 suicides for this age group in the United States, according to background information in the article. Attempted suicide is one of the strongest risk factors for completed suicide in adults. Previous studies have indicated that individuals who attempted suicide were about 40 times more likely to commit suicide than those who had not attempted suicide. Evidence for treatments that effectively prevent repetition of suicide attempts has been limited.
Gregory K. Brown, Ph.D., of the University of Pennsylvania, Philadelphia, and colleagues conducted a randomized controlled trial to determine whether a brief psychosocial intervention could reduce the rate of repeat suicide attempts over an 18-month interval. The study included 120 adults who attempted suicide and were evaluated at a hospital emergency department within 48 hours of the attempt. Sixty participants were randomized to receive 10 sessions of cognitive therapy and 60 to receive enhanced usual care with tracking and referral services.
The central feature of cognitive therapy was the identification of thoughts, images, and core beliefs that were activated prior to the suicide attempt. Strategies were applied to address the identified thoughts and beliefs and participants were helped to develop adaptive ways of coping with stressors. Usual care included outpatient therapy and medication.
From baseline to the 18-month assessment, 13 participants (24.1 percent) in the cognitive therapy group and 23 participants (41.6 percent) in the usual care group made at least one subsequent suicide attempt.
"The results of this randomized controlled trial indicated that a relatively brief cognitive therapy intervention was effective in preventing suicide attempts for adults who recently attempted suicide. Specifically, participants in the cognitive therapy group were approximately 50 percent less likely to attempt suicide during the follow-up period than participants in the usual care group," the authors write.
The researchers also found that the severity of depression by one measurement was significantly lower for the cognitive therapy group than for the usual care group at the 6-month, 12-month, and 18-month assessments. The cognitive therapy group also had significantly less hopelessness than the usual care group at six months.
"An important goal of the National Strategy for Suicide Prevention is to improve community linkages with primary care and mental health/substance abuse health systems for translating evidence-based treatments into community-based settings. The short-term feature of cognitive therapy would make it particularly applicable for the treatment of suicide attempters at community mental health centers, which typically provide relatively short-term therapy. Additional studies are warranted to examine the feasibility, effectiveness, and cost-effectiveness of this intervention in community-based mental health and substance use treatment settings," the authors conclude.
(JAMA. 2005; 294:563–570. Available pre-embargo to the media at www.jamamedia.org.)
Editor's Note: This research was supported by grants from the National Institute of Mental Health and the CDC.
Editorial: Mental Illness and Violent Death – Major Issues for Public Health
In an accompanying editorial, Thomas B. Cole, M.D., M.P.H., and Richard M. Glass, M.D., of JAMA, Chicago, comment on the studies in this week's JAMA on suicide and violence.
"Identifying persons at risk of violence to themselves or others and offering or compelling them to receive mental health treatment services is warranted. Barriers to delivery of these services may be financial, such as lack of access to health care; structural, such as the lack of mental heath programs and practitioners; or personal, such as concerns about confidentiality or discrimination. Another barrier is scientific – lack of randomized controlled trials of therapeutic interventions for suicide and interpersonal violence prevention to guide clinical and systems management."
"Other strategies for violence prevention address the lethality of weapons or social, pharmacological, and other situational factors that may lower the threshold for violent ideation to progress to violent action. Although these factors are late in the causal pathway from mental illness to violence, they are no less important for the prevention of violent death. A severely anxious, depressed, impulsive, or hopeless person whose violent actions are interrupted before he or she harms himself or herself or someone else would be considered a good outcome from the perspective of violence prevention. But without effective psychiatric treatment, such a person will still be in distress and is likely to remain at risk for violence. From this public health perspective, society should devote adequate resources to developing and evaluating psychiatric treatments and lowering barriers to their delivery," they conclude.
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