Treating suicidal service members
The research base for effective treatments for suicidal behaviors is limited relative to our knowledge base for treating other psychiatric and behavioral disorders; very few studies explicitly investigate suicidal behaviors as a primary outcome variable, which limits our ability to understand treatment effects. There are a large number of uncontrolled studies of treatments for suicidal individuals, including case studies and single-sample longitudinal follow-up studies, but these types of studies cannot provide causal information about treatment effectiveness.
Furthermore, treatment studies for other associated psychiatric conditions (eg, depression, psychosis) might report suicidal behaviors as a secondary or tertiary outcome. However, the methods used to measure or define suicide-related constructs in these studies are often inconsistent and/or unreliable, making it difficult to accurately understand treatment effects across studies. Of the many treatments that have been tested, the clearest and most consistent empirical support has been found for certain cognitive-behavioral treatments, which generally reduce the likelihood of subsequent suicide attempts by about 50% for up to 2 years posttreatment.19-21
Tragically, the greatest barrier for effectively treating suicidal service members arises from the limited implementation of empirically supported treatments by mental health clinicians across disciplines. Interventions with limited, inferior, or no empirical support and that are based instead on personal experience rather than scientific evidence are often used.22-24 Those service members who do choose to access specialty mental health care are therefore unlikely to receive the treatments that have been shown to best reduce psychological suffering and the likelihood for future suicidal behaviors. Effective treatments share several critical elements13:
• Such treatments are based on clearly articulated, easily understood, scientifically supported theoretical models that integrate cognitive, emotional, behavioral, and physical phenomena
• These treatments view suicidal behaviors as a problem of emotional regulation and problem solving—not as a symptom of psychiatric illness—and therefore target suicide risk independent of diagnosis
• Effective treatments ensure that providers are trained to a predetermined minimal competence and supervised throughout treatment to minimize deviation from the treatment protocol
• These treatments provide clear guidelines for how to address patient nonadherence and/or loss of motivation
• They identify “what is wrong” with the patient and teach the patient “what to do about it” and “how to do it” with in-session practice and skills development
• They emphasize the suicidal patient’s self-reliance, self-control, and personal responsibility for choices and behaviors and respect the patient’s capacity to take his or her own life
• They teach patients how to identify personal emergencies, how to resolve them, and how to appropriately access support when needed
To date, no suicide treatment studies have been published using military samples, although 2 randomized clinical trials of cognitive-behavioral treatments (1 for outpatient clinics and 1 for inpatient units) are currently under way in military settings. Both treatments are adaptations of the same empirically supported cognitive-behavioral treatment, and are therefore based on the 7 elements described above.21,25
1. Department of Defense Task Force on the Prevention of Suicide by Members of the Armed Forces. The Challenge and the Promise: Strengthening the Force, Preventing Suicide, and Saving Lives. Washington, DC: US Dept of Defense; 2010.
2. Department of the Army. Army Health Promotion, Risk Reduction, Suicide Prevention Report 2010. Washington, DC: US Dept of the Army; 2010.
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19. Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder [published correction appears in Arch Gen Psychiatry. 2007;64:1401]. Arch Gen Psychiatry. 2006;63:757-766.
20. Linehan MM, Armstrong HE, Suarez A, et al. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry. 1991;48:1060-1064.
21. Brown GK, Ten Have T, Henriques GR, et al. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA. 2005;294:563-570.
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24. Groopman J. How Doctors Think. Boston: Houghton Mifflin; 2007.
25. Wenzel A, Brown GK, Beck AT. Cognitive Therapy With Suicidal Patients: Scientific and Clinical Applications. Washington, DC: American Psychological Association; 2008.