Cognitive therapy can halve suicide risk

Gregory K. Brown (left) and Judd Hollander say their study offers hope that repe

People who survive one attempted suicide are likely to try again. Until recently scant research existed to suggest ways to prevent this destructive cycle. A Penn study recently published in the Journal of the American Medical Association offers hope, with evidence that a short course of cognitive therapy can reduce the risk of a repeat attempt within 18 months by 50 percent.

According to Gregory K. Brown, a research associate professor of clinical psychology in the Department of Psychiatry and a member of the research team, few good clinical trials have been conducted with suicide attempters. “It’s not convenient,” he says. “It takes a lot of work to keep them in a study, and people are afraid of being sued.” The National Institute of Mental Health funded their study along with the National Institutes For Health and the Center for Disease Control and Prevention.

Brown and his team—which included Judd Hollander, a professor in the School of Medicine’s Department of Emergency Medicine—recruited participants for the study in the emergency department at HUP.

One of the big challenges for clinical researchers, especially in the psychiatric world, is finding patients who qualify for a study. “Normally,” says Hollander, “you’d wait for patients to have a psychiatric referral. The problem is, these patients are suicidal so they don’t often follow through.” The key, he says, is to enroll them while they’re still in the hospital.

“The emergency department is a funny place,” Hollander continues. “People who are there are there with an acute problem and that’s when they’re more likely to want intervention, rather than a month later.” Hollander and his staff developed a system where, once a patient was stable medically and willing to speak, a research assistant would approach them in their room, explain the study and ask for permission to refer them to the psychiatric department who would then meet with the patient.

Most of the 120 participants were repeat attempters, many were already taking antidepressants and a large portion had multiple problems, such as drug addiction, schizophrenia, bipolar disorder or homelessness. “We tried to take all comers,” says Brown, to make the group as large and diverse as possible.

Half the group was randomly assigned to 10 weeks of cognitive therapy and half to standard counseling services. Very quickly, Brown says, they ran into a problem: “We’d schedule patients and they wouldn’t show.” To keep the participants engaged, case managers were hired to track them and remind them of appointments—even searching homeless databases and prison registries when necessary.

The therapy was tightly focused. Replaying the events that led up to the attempt frame by frame, says Brown, the therapist and patient would identify the emotional trigger—such as a job or relationship setback—and the sequence of increasingly hopeless thoughts that followed. “It might go like this,” says Brown, “from ‘I can’t handle this,’ to ‘I need to escape,’ to drug use, to shame, to ‘I always screw up,’ to ‘My life is hopeless’ to suicide.” The therapy, he says, targeted specific self-defeating thoughts and taught skills that would head them off or help the patient respond in a different, more positive, way.

After 10 sessions, the patients got to practice their newfound skills, going through a potential scenario and coming up with coping strategies. Those who flunked the test received additional therapy sessions.

After 18 months, 13 of those who received cognitive therapy attempted suicide again, compared with 24 of those who got standard treatment. (None of the attempts were successful.)
Brown says the results are tremendously heartening. “There really hasn’t been much research done to show that suicide prevention was even possible,” he says. “This gives hope to providers and to the public.”

Now, Brown and his team are doing a follow-up study, training counselors in community health centers and addiction treatment centers to carry out the therapy. That’s the real test, says Brown, “and we’ve found that we can train them very well.”

Hollander is optimistic, too. “What’s nice is the magnitude of the effect we saw in the study suggests that even if doesn’t work as well when it’s taken out of the ideal environment, it may still work well enough to effect a significant portion of patients.”

Originally published on September 8, 2005