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August 11, 2005

Talk Therapy For Suicide Prevention

A new study in the Journal of American Medicine shows that short-term cognitive-behavioral therapy intervention can significantly reduce suicide risk and depression severity in a population of high-risk subjects who have previous histories of attempted suicides.

People with bipolar disorder have a significantly increased risk of suicide as compared to the general population - meta-analysis studies estimate that about 1/3 of all people with bipolar disorder will attempt suicide at least once, and 10-15% will succeed in taking their own life (Source: TAC Briefing Paper on Suicide). People with Bipolar II have been reported to have higher risk of suicide attempts than bipolar I, perhaps because of the higher burden of depression that is often associated with that subtype.

Given this increased risk, the findings of this study offer hope that we can reduce suicide attempts among people with bipolar disorder with short-term, relatively easy psychosocial interventions.

The study included 120 subjects who had been medically or psychiatrically evaluated following a suicide attempt. 77% had a major depressive disorder and 68% had a substance use disorder. These types of subjects represented a particularly high-risk and treatment-resistant population, and are often excluded from studies of suicide prevention techniques because they tend to confound results.

"These are the kinds of people who wouldn't qualify for 90 percent of the treatment trials out there" said Dr. Steven Hollon, a psychology professor at Vanderbilt University (not associated with the study). "But if you don't ever include them, you don't know what works for them. No guts, no glory." (Source: NY Times Article, Aug 9 2005).

The subjects were randomly assigned to one of two treatment groups. The "usual care" group received clinician care, case-manager follow-up, and referrals to community treatment facilities. The cognitive therapy intervention group received usual care plus 10 sessions of cognitive-behavioral therapy. The sessions were designed specifically for suicide prevention.

"The central feature of this psychotherapy was the identification of proximal thoughts, images, and core beliefs that were activated prior to the suicide attempt. Cognitive and behavioral strategies were applied to address the identified thoughts and beliefs and participants were helped to develop adaptive ways of coping with stressors. Specific vulnerability factors that were addressed included hopelessness, poor problem solving, impaired impulse control, treatment noncompliance, and social isolation. A relapse prevention task was conducted near the end of therapy." (Source: JAMA, Volume 294(5), 3 Aug 2005).

The results from the cognitive-behavioral group were encouraging: 13 out of 60 subjects in that treatment group (24%) tried another suicide attempt during the intervention and follow-up period, as compared to 23 subjects (41.6%) in the "usual care" group. Using statistical calculations, the authors estimated that the probability of staying re-attempt free for the cognitive-therapy group during an 18 month period was about .76, as compared to a calculated probability of .56 for the other group over the same time period.

Moreover, the cognitive-therapy group had significantly reduced depression and hopelessness severity as compared to the usual-care group.

The authors concluded: "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% less likely to attempt suicide during the follow-up period than participants in the usual care group."

It might be interesting for future studies to examine whether such psychosocial interventions, when used as adjunct therapy to lithium treatment, can even further reduce the risk of suicide. Both lithium and clozapine (an atypical antipsychotic sometimes used to treat acute mania) have been shown in studies to reduce risk of suicide. Further studies might also show whether this type of cognitive-behavioral therapy is as effective in a population of bipolar subjects with high-risk of suicide. The present study did not include anyone diagnosed with bipolar disorder, although 77% of the subjects had major depression.

However, we can surmise from the results of the current study that, especially for people who are lithium- or otherwise treatment-resistant, short-term psychosocial intervention may be an imporant treatment to control depressive tendencies and suicide attempts.

See more resources for preventing suicide in people with bipolar disorder

Study Abstract: Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial.
JAMA. 2005 Aug 3;294(5):563-70.

Original Source Article: Talk Therapy Succeeds in Reducing Suicide Risk. New York Times (http://www.nytimes.com), Aug 9 2005.

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