Preliminary Results

1
Preliminary Results
2
Number of Patients Attempting Suicide during
Follow-up by Treatment Condition
One EC patient completed suicide
(n 60)
(n 60)
Includes all participants during the one to two
year follow-up
3
Survival Curves for Days until First Suicide
Attempt by Treatment Condition
1.0
14 of 60 (23) of CTEC patients
0.9
0.8
Cummulative survival
0.7
26 of 60 (43) of EC patients
Cummulative Survival
0.6
0.5
0.4
0
183
366
549
732
Days
4
Total Number of Subsequent Suicide Attempts by
Treatment Condition
(n 60)
(n 60)
Includes all participants during the one to two
year follow-up
5
Beck Depression Inventory by Treatment Condition
p .04
Follow-up Month
6
Beck Hopelessness Scale by Treatment Condition
p .04
Follow-up Month
7
(No Transcript)
8
The Cognitive Therapy Protocol
9
Cognitive Therapy for Suicide Attempters General
Description

• Brief (10 sessions) and flexible
• Active, directive, semi-structured, and problem
  focused
• Standard cognitive therapy practices (e.g.
  setting agenda, setting homework)
• Focus on problem of suicide behavior
• Identify and restructure thoughts/beliefs ?
  suicidal behavior
• Increase adaptive use of social supports and
  compliance with health care

10
CLINICAL TRIALS WITH SUICIDAL IDEATORS OR
ATTEMPTERS
RESULTS
TREATMENT
POPULATION
C.T. LESS HOPELESS
12 C.T. vs. IMIPRAMINE
DEPRESSED OUTPATIENTS
RUSH BECK, 1978 N 44
C.T. LESS SUICIDAL THAN PLACEBO
20-28 C.T. vs. DRUG THERAPY
DEPRESSED OUTPATIENTS
DERUBEIS HOLLON, 2001 N 60
LESS SUICIDE IDEATION
50 C.T.
SUICIDAL BORDERLINES
BROWN ET AL., 2001 N 27
HOPELESSNESS IDEATION ATTEMPTS
5 C.T. vs. T.A.U.
SUICIDE ATTEMPTERS
SALKOVSKIS ET AL., 1990 N 20
DEPRESSION RATE OF ATTEMPTS
UP TO 5 C.T. vs. T.A.U.
SUICIDE ATTEMPTERS
EVANS ET AL., 1998 MANUAL ASSISTED COGNITIVE
THERAPY N 34
11
Ongoing Management

• Directly inquire about suicidal thinking and
  behavior during visits
• Evaluate access to lethal methods
• Explain nature of depression and treatment to
  patient
• Focus on compliance with treatment
• Focus on alcohol or drug use

12
Structure of the Therapy Session

• Brief Update and Mood Check
• Assessment of Suicide/Homicide Risk
  (if indicated)
• Medication Check (if taking medication)
• Alcohol and Substance Abuse Check
  (if indicated)
• Bridge from Previous Session
• Set Session Agenda
• Discussion of Agenda Items
• Assign Homework
• Final Summary and Feedback

13
Early Sessions
Session 1 2 3 4 5 6 7 8 9 10

• Introduction of Cognitive Model
• Cognitive conceptualization of the suicide
  attempt
• Problem solving orientation
• Suicide as a (maladaptive) attempt to solve to
  ones problems
• Short-term beneficial vs. long-term detrimental
• Problem solving skills
• Developing reasons for living
• Problem and Goal List
• Transforming Hopelessness into Hope

14
Case Conceptualization
    Early Experiences Physically and sexually
abused by father Strict Baptist Upbringing/Taught
what good girls do and dont do Physically and
verbally abusive relationship with
Ex-Boyfriend Crack Addiction  Core Beliefs I am
unlovable and shameful Other people are only out
for themselves  Conditional Beliefs If other
people do not love me, then I am a nobody If I
dont protect myself, I will be taken advantage of
15
Middle Sessions
Session 1 2 3 4 5 6 7 8 9 10

• Changing maladaptive beliefs
• Addressing problem solving deficits
• Developing reasons for living
• Addressing impulsivity
• Increasing compliance with health care
  professionals
• Increasing Social Support

16
Session 1 2 3 4 5 6 7 8 9 10
Middle Sessions Specific Strategies

• Coping Cards
• Crisis plan and Steps for Reducing Suicidal
  Thoughts
• Construction of a Hope Box/Survivor Kit
• Activities in Choosing to Live (e.g., pros and
  cons of attempting/committing suicide)
• Social Support List
• Removal of Means to Harm

17
Middle Sessions Problem Solving
Session 1 2 3 4 5 6 7 8 9 10

• Identify and list problems
• Connect problems in living to suicidality
• Focus on functionality/adaptiveness of
  response(s)
• Generate alternatives and plans
• Weigh pros and cons of possible solutions
• Work out discrete tasks to achieve solution
• Review the consequences of the solution

18
Later Sessions
Session 1 2 3 4 5 6 7 8 9 10

• Relapse Prevention Task
• Anticipating Lapses
• Termination
• Review of Treatment
• Abandonment
• Ethical issues
• Extensions (if necessary)
• Booster Sessions (if necessary)

19
Relapse Prevention Task

• Explain rationale, describe exercise and obtain
  informed consent
• Three Steps
• Imagine chain of events, thoughts and feelings
  leading to attempt
• Imagine sequence of events again, but respond to
  maladaptive thoughts and images
• Imagine future scenario likely to trigger
  suicidal reaction
• Debrief patient

20
Sequence in Borderline Patient
NOBODY AT PARTY
IF IGNORED IM NOTHING
IM ALL ALONE
I WANT TO DIE
SERIOUS SUICIDE ATTEMPT
HAVE TO KILL MYSELF NOW
ITS OK
21
SEQUENCE TO USING AND ATTEMPTING

• - I CANT HANDLE THIS
• I HATE THE WAY PEOPLE TREAT ME
• - NO POINT IN KEEPING TRYING

• I NEED RELIEF OR ESCAPE
• SCREW IT ALL
• - I MIGHT AS WELL HAVE A SMOKE, ETC.

JOB OR INTERPERSONAL SETBACK

• CONSEQUENCES
• RUN OUT OF MONEY
• BLAME/REJECTION
• SHAME/GUILT

• IM A LOSER
• DIRTY ADDICT
• I HAVE NO CONTROL

DRUG USE

• NOTHING I CAN DO
• MY PROBLEMS ARE GETTING WORSE
• IT WILL BE THIS WAY FOREVER
• I JUST NEED TO END IT ALL

SUICIDAL
22
CONCEPTUALIZATION OF BORDERLINE PERSONALITY
DISORDER
DICHOTOMOUS REPRESEN-TATIONS
EXTREME INTER-PRETATION
INTENSE CRAVING IMPULSES
EXTREME AFFECT

• SUBSTANCE ABUSE
• VIOLENCE
• CLINGING
• DEMANDING
• SELF-MUTILATION
• SUICIDE

IDEALIZE OR DEMONIZE
AMBIVALENCE LOVE/HATE
23
Lack of Adaptive Strategies

• CONSIDERING OTHER EXPLANATIONS
• EX SUICIDAL WOMAN WHOSE PARTY FAILED
• ACCESS TO PAST POSITIVES
• EX FRIENDS ALWAYS ATTENTIVE IN THE PAST
• PERSPECTIVE RE DISTRESS CRAVINGS
• THESE PASS IN TIME
• ADAPTIVE PROBLEM-SOLVING WHEN SUICIDAL
• CAN CALL A FRIEND, GO FOR A WALK, ETC.
• LACK OF RECOGNITION OF OWN LATENT STRENGTHS
• TOLERATING DYSPHORIA
• CONTROLLING URGES
• SOLVING PERSONAL PROBLEMS

24
Negative Beliefs About Self-Control

• I CANT CONTROL MY IMPULSES.
• MY CRAVING IS SO STRONG I HAVE TO GIVE IN TO IT.
• THIS IS THE ONLY WAY I CAN RELIEVE MY TENSION,
  ANXIETY, SADNESS, ANGER, SHAME, OR GUILT.
• I SHOULD NOT HAVE TO CONTROL MYSELF.
• I HAVE THE RIGHT TO DO WHAT I WANT EVEN IF IT
  HURTS ME OR OTHER PEOPLE.
• IF OTHERS TREAT ME BADLY, I HAVE TO TEACH THEM A
  LESSON.
• IF I DONT ASSERT MYSELF, NOBODY WILL LISTEN TO
  ME.
• I DONT CARE ABOUT THE CONSEQUENCES

25
IMPULSIVITY

• ACTION ORIENTED
• EXTREME BELIEFS DEMAND EXTREME ACTION
• CRAVINGS, URGES SHOULDS, MUSTS, OUGHTS
• REASSURANCE
• DRUGS, FOOD
• REVENGE
• SELF-MUTILATION
• SUICIDE
• PERMISSION GIVING
• OK BECAUSE I NEED IT BADLY
• OK BECAUSE IM ENTITLED
• OK BECAUSE YOU DESERVE TO BE PUNISHED

26
F
C
H
B
D
A
G
E
I


A Patient engages in therapy, begins to trust
therapist. B Patient has relationship problems
with son. C Therapist goes out of state for 10
days. D Patient makes suicide attempt during
his absence. E Patient is pleased at therapist
return.
Invalid data point. Patient responds badly
to therapist inquiry about high BHS score. F
Disengagement from therapy discussed.
I feel abandoned. G Patient moves into
dream house. H Attracted to another man. I
am the worst person in the world. Patient
hospitalized. I Happy to see therapist after
discharge from hospital.
27
Multiple Suicide Attempters
Specific High Risk Subgroups
28
Multiple Suicide Attempters (MSAs) vs.
Single Suicide Attempters (SSAs)

• Appear to be a different diagnostic group. Higher
  levels on virtually all measures of
  psychopathology (depression, hopelessness, global
  functioning, substance use, borderline pathology,
  unemployment, etc.)
• Easily assessed
• Much greater risk for subsequent suicide attempt

29
Global Assessment of Functioning (GAF) in the
Past Year
p .016
30
Number of Lifetime Suicide Attempts and Lethality
of Index Attempt
ns
p .085
31
Survival Analysis Comparing BPD toNo BPD on Time
Until Subsequent Suicide Attempt
32
Summary of Findings

• 35 of 153 patients who presented to an urban
  emergency room following a suicide attempt met
  criteria for BPD.
• Suicide attempters with BPD exhibit greater
  depression and hopelessness, more social
  problem-solving difficulties, a greater number of
  previous suicide attempts and more suicidal
  ideation.
• A survival analysis showed that patients with BPD
  were at higher risk of re-attempting suicide than
  those without BPD.

33
Current Study Diagnostic Picture
65 Nonpsychotic (n 103)
35 Psychotic Disorder (n 55)
85 Major Depression (n 87)
67 Major Depression with Psychotic Features (n
37)
7 Bipolar I Disorder (n 7)
13 Bipolar I Disorder with Psychotic Features
(n 7)
1 Depressive Disorder NOS (n 1)
4 Depressive Disorder NOS plus Psychotic
Disorder NOS (n 2)
6 Bipolar II Disorder (n 6)
15 Schizoaffective (n 8)
2 Dysthymia (n 2)
34
Demographics
Older African Americans (Age gt 30) are much more
likely to be diagnosed with a Psychotic Disorder
35
Is the presence of psychosis associated with
increased suicidal ideation?
after attempt
t(156) 4.85, p lt .001
r 0.36 R2 0.13
36
Does psychosis predict suicidal ideation over and
above other symptomatology?
Multiple Regression Entered at Step 1
Depression, Hopelessness, Substance
Abuse/Dependence, Social Problem Solving Entered
at Step 2 Psychotic Disorder
37
Summary of Psychosis and Suicidality Findings

• Psychosis associated with suicidal ideation,
  intent possibly with lethality
• Psychosis predicted subsequent reattempt up to 2
  years later
• Relationship with ideation and intent remains
  even after partialing out depression,
  hopelessness, substance abuse, social problem
  solving
• Depression and Hopelessness appear to mediate
  relationship with ideation
• Hopelessness, Substance Abuse, and Social Problem
  Solving appear to mediate the relationship with
  intent

38
CONCLUSIONS

• A 10 COURSE OF CT HAS HAD A PROPHYLACTIC EFFECT
  ON REPEATED ATTEMPTS (DURING A 24 MONTH
  OBSERVATION PERIOD)
• A HISTORY OF MULTIPLE ATTEMPTS IS PREDICTIVE OF
  SUBSEQUENT ATTEMPTS. A SINGLE ATEMPT IS UNLIKELY
  TO LEAD TO A SUBSEQUENT ATTEMPT
• BPD, DRUG ABUSE (WITH OR WITHOUT ALCOHOL), AND
  PSYCHOTIC DEPRESSIVE DISORDER ARE PREDICTORS OR
  REATTEMPTS

39
LIMITATIONS OF STUDY

• PREVIOUS ATTEMPT DATA AND SOME OF REATTEMPT DATA
  ARE BASED ON VERBAL REPORTS
• EVALUATORS WERE NOT BLIND TO TREATMENT CONDITIONS
• ENRICHED CARE COMPONENT IS ATYPICAL OF TREATMENT
  AS USUAL
• THERAPY BY TRAINED THERAPISTS LIMITS
  GENERALIZABILITY

40
QUALITATIVE ANALYSIS OF SUICIDE ATTEMPTERS

• BACKGROUND
• Diagnoses (Depression, etc.) Substance
  Use/Abuse Previous Attempts
• SEQUENCE
• Precipitating Situations (Rejection, etc.)
• Reaction Cognitive/Affective (Depressed, etc.)
• Behaviors Impulsive (e.g., Drug Use)
• Interpersonal
• Reaction Cognitive/Affective (Hopeless)
• Behavior Suicide Attempt

41
BELIEFS ABOUT CONTROL QUESTIONNAIRE FOR SUICIDE
ATTEMPTERS
42
Percentage of Suicide Attempters Subsequently
Hospitalized at Six Months from Baseline
CT EC
EC
43
Total Number of Days Spent in the Hospital at
Six Months from Baseline
CT EC
EC