Donna M. Sudak, MD

In the past 30 years, a considerable body of research has been amassed regarding the use of psychotherapy to manage suicidal behavior. Much of this research included the premise that suicidal behavior must be dealt with as a problem separate from a primary diagnosis (eg, depression) and that techniques must be used to both manage the risk in the present and prevent recurrences in the future. Most clinicians are not aware that suicide risk should be addressed specifically and separately from the primary psychiatric diagnosis. Practical, evidence-based approaches have been developed that decrease the risk of present and future attempts. We aim to provide a brief synopsis of the research evidence, followed by several examples of strategies that such treatment employs.

Several systematic reviews have analyzed existing data on the effect of therapeutic interventions to reduce suicide risk. In 2008, Tarrier et al

 examined 28 randomized controlled trials (RCTs) involving adults and adolescents. The researchers concluded that cognitive behavioral therapy (CBT)-based interventions demonstrated effectiveness in reducing suicidal behavior. A subsequent systematic review by Mewton and Andrews

in 2016 limited its focus to RCTs examining the benefits of standard CBT in adults. Their conclusion agreed with the observation of Tarrier et al

: Treatment is more effective when directly targeting suicidal thoughts and behavior as opposed to when treatment is designed to address mental illness with the assumption that benefits will also impact suicidal behavior. Hence, the literature underscores the need for specific interventions targeting suicidal behavior.

The meta-analysis by Ougrin and colleagues

 in 2015 supported the effectiveness of therapeutic interventions including CBT, dialectical behavior therapy (DBT), and mentalization-based therapy in reducing self-harm in adolescents. The dearth of independently replicated studies impeded drawing firm conclusions on the comparative benefit of specific therapeutic strategies. Independent trials have looked at the effectiveness of DBT in adolescents who are at high risk for suicide. The RCT by Mehlum et al

 in 2014 and the recently published RCT by McCauley and colleagues

 suggest definite benefits of short-term DBT in adolescents with borderline personality traits who had engaged in prior self-harm and suicide attempts. The latter study also showed superiority of DBT with respect to treatment retention.

Engagement and retention of patients is a significant challenge in managing suicidal behavior. Often, such patients do not seek outpatient therapy and present for emergency care with suicidal crises. The emergency department (ED) must therefore be a key site for intervention. The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study by Miller and colleagues

 designed interventions for screening and provision of safety plans with follow-up phone calls to patients and significant others. Stanley et al

 discussed the benefits of such ED-based interventions in reducing suicidal risk. Their comparative cohort study showed that safety-planning interventions coupled with structured follow-up reduced the risk of suicidal behavior by 50% and achieved a twofold increase in the odds of treatment engagement over a 6-month period. The safety-planning intervention consisted of six specific strategies: identifying early warning signs, encouraging internal coping strategies, reaching out to family/friends, identifying other individuals who can provide support during suicidal crises, contacting mental health professionals, and lethal means planning. This large-scale study illustrates a feasible, pragmatic approach to suicidal behavior that does not demand extensive resources and can be easily delivered in an ED setting.

Cognitive behavioral therapy for suicide prevention is another short-term intervention designed to specifically address suicidal behavior that has significant effects in reducing future suicide attempts.

 It is composed of three phases: an initial phase promoting treatment engagement, an intermediate phase focused on cognitive and behavioral strategies targeting suicidal thoughts and mobilizing reasons to live, and a final phase that targets relapse prevention and consolidates the ability to effectively use strategies in the setting of future suicidal crises.

Each of the preceding studies have common psychotherapeutic strategies that may be employed by any clinician. All are rooted in the fundamental principle of the therapist as an empathic partner who forms a strong therapeutic alliance with patients and who acknowledges their suicidal thoughts and behaviors as a response to intolerable pain or acute subjective distress. The patient is enlisted as an active partner in the process of understanding personal risks for future suicide crises and developing remedies for such occurrences.

The following section describes four specific strategies common to these approaches, including lethal means reduction, safety planning, developing reasons for hope, and inspiring delay.

Lethal means reduction is the process of assessing whether patients have access to firearms or other lethal means to commit suicide and then working with them and their support network to restrict access to such means. It is one of the most important and most supported interventions to reduce suicide attempts. Collaborating with the patient by expressing genuine concern about his or her safety, explaining that reducing access will lower the risk of suicidal actions, and then negotiating with the patient and supportive others to make the environment safer is critical for success. In the event that the lethal means available is a firearm, one must assess for multiple firearms and then advocate for removal of all of them. Gunlocks, removal of ammunition, or gun safes are also possible ways to restrict access if the patient refuses to remove the gun(s) from the home.

Methodical inquiry about possible methods and what might limit the ability of the patient/family to remove them is the central task for the clinician. If the patient is hesitant, it helps to assess the pros and cons of restricted access, reminding the patient that this may be time-limited. As in all work with suicidal patients, the more collaboration that is possible with supportive others, the better.

Generally, suicidal behavior occurs as a reflexive response to certain triggers. It is common for patients who engage in such behavior to regard suicide as a means of solving problems that they view as insolvable. Such patients often have significant problem-solving deficits. When patients have no relief from relentless worry or concern about problems, and they think of suicide, the relief it may provide reinforces suicidal thinking and increases the risk for further action. Skill deficiencies that patients have-in problem solving, distress tolerance, emotion regulation, and conflict resolution-may increase their risk for future vulnerability to suicidal behavior.

A particularly good strategy is to plan alternatives that keep the patient safe until skills can be learned or other solutions put into place. Safety planning, as described by Stanley and colleagues,

 is an intervention with which the clinician actively and collaboratively determines with the patient a prioritized and personalized list of warning signs that a crisis is beginning to occur. The clinician then finds coping strategies and internal and external resources that the patient can use at this time. This plan is derived from a risk assessment and the narrative description of the patient’s crisis. It is designed to be over practiced (like a fire drill) so that the plan will be available for use during a suicide emergency. Making a safety plan begins with a chain analysis of the minute-by-minute thoughts, emotions, and behaviors that led to suicidal thoughts or an attempt and the subsequent consequences. The patient must understand that suicidal thoughts are transient and vary in intensity.

The plan provides time for these urges to decrease before permanent harm occurs. The patient is consulted as the expert on his or her own suicidal behavior: “What have you done on your own to decrease suicide urges?” and “How do you get your mind off of it?” If the patient cannot generate options, the clinician may provide suggestions. These may include distracting activities, alternative thoughts, or strategies to decrease painful emotions. After formulating a plan for distractions, the patient is asked to identify two groups of social contacts: a group with whom she or he may be distracted from the suicidal thoughts, and a group that can help with suicidal thoughts. Finally, emergency services are identified that the patient can access if a crisis is imminent.

At each step of the safety planning intervention, the patient is asked about the likelihood of using the intervention, the obstacles he or she anticipates to its use, and those obstacles solved. If the patient cannot solve obstacles or commit to the use of the plan, then more restrictive care is indicated. Once the plan is completed, the written plan is given to the patient and the patient is asked where it will be kept for review and use.

In later sessions, the therapist may provide training in skills that are absent and that increase the patient’s vulnerability to suicide and then mentally rehearse the deployment of those skills in a similar setting in the future. Patients must repeatedly practice new ways of thinking and behavior so that they have other solutions besides suicide available at times of future stress. Patients who develop better ways of coping in a crisis and repeatedly practice such skills (even in their imagination) have greater resilience during stressful circumstances and reduce their reliance on suicide as a solution.

A 45-year-old construction worker sustained a crush injury of his right arm 2 years ago. He has had four surgical procedures and extensive physical therapy, but has continued to experience intractable pain and has been unable to return to work. His family has struggled to make ends meet. He has used opiate pain medication since the accident but never exceeds what is recommended. He needs help with all of his activities of daily living, including dressing.

After his last surgery, he has been more despondent. He meets the full criteria for major depression. He has started to drink to fall asleep at night. His wife brought him to the ED after he told her that he thought she and the family would be better off without him.

After assessing him in the ED, the psychiatrist determines that there are no weapons in the home. The patient indicates that he had plans to overdose on his oxycodone when he got his monthly prescription this week. He and his wife agree that she will keep the pills locked at her place of work and give him access to only a day at a time. The psychiatrist then turns her attention to making a safety plan with her husband. They first discuss all the triggers that produce his intense thoughts of suicide. The patient is asked what would prevent him from using the plan. He says that if he were unable to contact a friend or his wife, he might have trouble. They review professional help that he can contact. He discusses his feeling that this makes him “weak” but eventually commits to doing so.

When asked for reasons to stay alive, the patient says, “My children.” The psychiatrist asks for more detail: “What is important to your children that you do together? What do you value about being with your children? What would you miss in your children’s lives if you died today?” As he describes more about their relationship, he becomes tearful, and the psychiatrist probes further about what he might miss in the future with his children were he to die. He is much more certain about using the safety plan reliably after this discussion.

Most CBT/DBT interventions approach suicidal patients with an eye toward managing hopelessness. A cornerstone of DBT is the idea that the patient must build a life worth living, even when the patient has many life problems and a wish to die. In CBT, a core premise is monitoring and managing hopelessness, because the presence of hopelessness is a significant risk factor for suicide even in the absence of depression.

Methods that improve hopelessness generally connect patients to core values and attachments to inspire the patient to tolerate current pain and stay alive. Making a list of reasons to live generally is a part of the safety plan. The psychiatrist must ask the patient to describe vividly the attachment the patient has to these reasons to strengthen resolve.

Another technique is to build a hope box. This is a tangible collection of items that remind the patient of reasons to stay alive. It may include photographs, inspirational scripture or quotes, poetry, letters, meaningful mementos, and reminders of things that the patient wants to do in the future. These items inspire more emotional connections to the commitment to stay alive. Such items can be actual or virtual (ie, in a phone app) so that the patient has easy access.

Generally, the impulse to suicide is momentary. If the patient can delay action on the impulse, it may be life-saving. Several strategies facilitate delay. First, the patient can be asked to reflect on the things that will be missed if they die, year by year. This brings to light the finality of death and the reality of what the patient will miss. Second, the patient can be asked to commit to “taking suicide off the table.” Many patients who are suicidal are beset with a significant number of psychosocial problems and experience relief when they think about dying as an escape. The patient needs time to begin to resolve these problems. Working with such patients is a challenge because it is impossible to discuss anything except suicide if that is a genuine possibility. Thus, it is often necessary to agree that the patient will commit to a delay to determine if things can improve enough to allow work on psychosocial problems to occur.

These are just a few examples of how it is possible to use psychotherapeutic interventions to more effectively manage the patient with suicidal thinking and behavior. Although these patients are challenging, there are some tools that we know make a difference.

Dr Sudak is Professor and Vice Chair for Education, Drexel University, Philadelphia, PA, and Dr Rajalakshmi is a Resident, Department of Psychiatry, Drexel University, Philadelphia, PA. 

The authors report no conflicts of interest concerning the subject matter of this article.

 Tarrier N, Taylor K, Gooding P. Cognitive-behavioral interventions to reduce suicide behavior: a systematic review and meta-analysis. 

 Mewton L, Andrews G. Cognitive behavioral therapy for suicidal behaviors: improving patient outcomes. 

 Ougrin D, Tranah T, Stahl D, et al. Therapeutic interventions for suicide attempts and self-harm in adolescents: systematic review and meta-analysis. 

 Mehlum L, TÃ¸rmoen AJ, Ramberg M, et al. Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial. 

 McCauley E, Berk MS, Asarnow JR, et al. Efficacy of dialectical behavior therapy for adolescents at high risk for suicide: a randomized clinical trial. 

 Miller IW, Camargo CA Jr, Arias SA, et al; ED-SAFE Investigators. Suicide prevention in an emergency department population: the ED-SAFE study. 

 Stanley B, Brown GK, Brenner LA, et al. Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. 

Cognitive Therapy for Suicidal Patients: Scientific and Clinical Applications

Articles

This article provides a brief synopsis of the research regarding the use of psychotherapy to manage suicidal behavior, followed by several examples of strategies that such treatment employs.

Reducing Suicide Risk: The Role of Psychotherapy

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Make the most of brief psychotherapeutic sessions with these practical tips.

6 Practical Strategies to Enhance Treatment Adherence

Treatment nonadherence in psychiatric patients contributes to increased suicide rates, illness exacerbation, hospitalization, and mortality. Nonadherence affects family relationships and society as a whole by both direct costs and loss of productivity. Most experienced clinicians do not need data to convince them of the widespread nature of this problem, but some recent work illustrates how pervasive it is.

Findings indicate nonadherence rates of 40% to 60% for antipsychotics, 30% to 97% for antidepressants, and 18% to 56% for mood stabilizers.

 examined the rate of medication nonadherence based on diagnosis. The rate of nonadherence was 28% to 52% for MDD, 20% to 50% for bipolar disorder, 20% to 72% for schizophrenia, and 57% for anxiety disorder. An inpatient cross-sectional study showed that the rate of nonadherence was 45.5% for bipolar disorder, 12.1% for schizophrenia/schizoaffective disorder, 18.2% for depression, and 24.2% in other disorders.

Patient outcomes may be improved by systematically targeting adherence in all patients who are given psychotropic medication; the 

 provides suggested strategies for promoting adherence. The following summarizes some of the recent work in cognitive behavioral therapy (CBT) that indicates it may be helpful in severe and persistent mental illnesses.

Adjunctive cognitive-behavioral therapies

CBT for bipolar disorder can enhance treatment adherence and improve overall treatment outcome. Cochran7 obtained significant improvement in adherence in outpatients with bipolar disorder by applying CBT strategies to enhance knowledge about treatment and to change attitudes toward treatment. Another CBT study in bipolar disorder showed decreased relapse rates with increased medication adherence.

 Randomly assigned patients with bipolar disorder and comorbid substance use disorders-a particularly difficult group to manage-received 12 weeks of low-intensity medication monitoring alone or in combination with CBT. The CBT group showed improved medication adherence on a compound measure derived from both patient self-report and blood levels of mood stabilizers.

In patients with schizophrenia, a number of studies have increased adherence to psychotropic medication by employing motivational interviewing and CBT. Gray and associates

 reported that CBT has significant effects not only on medication adherence but in improved attitudes of patients toward treatment. Cavezza and colleagues

 found significant effects of CBT interventions in psychotic illness on both medication adherence and improved psychiatric symptoms at 3-month follow-up.

All clinicians can employ principles of CBT in their work with patients. Even in brief medication management sessions, elements of CBT can be tailored to the needs of the patient to enhance outcomes.

John is a 22-year-old senior in college. He has been stable on medication for bipolar disorder since his last year in high school. He has a good treatment relationship with his psychiatrist, but in the past 6 months John has had more difficulty with keeping appointments and far more variability in lithium blood levels. He has a very busy class schedule; he is applying to graduate school and plays varsity basketball.

For many patients, taking medication can be a challenge. Patients more easily discuss difficulty with adherence when clinicians are transparent about how universal the problem is. Judicious use of self-disclosure may help to make it safe enough for the patient to tell you the truth. If you are comfortable, let the patient know about your own problems with adherence. Most people have found an antibiotic capsule or two in the bottle at the end of a course of treatment.

Cultivating a warm and empathic therapeutic alliance is critical to collaborating about concerns that could upend the plan to take medication. In addition, the plan must be modified when life circumstances change and present new obstacles. Travel, moving, or loss of family support can affect the patient’s typical reminders or motivation to stay on track.

A defining feature of most psychotherapeutic approaches is to individualize treatment based on a specific case formulation. Conceptualizing the patient’s difficulty with taking medication helps us to better manage complexity and tailor interventions accordingly. In a CBT model, we must understand what meaning the diagnosis, symptoms, and treatment have for the patient, in the form of thoughts and beliefs. If a patient thinks taking medication is a sign of weakness, for example, this thought will have a powerful effect on adherence.

Understanding the patient’s values and central concerns and linking these to the benefits of medication treatment is an excellent strategy to facilitate adherence. For example, if sleep is a problem, a good motivator for a patient to take nightly medication would be if it induces sleep. However, when sleep improves, the patient may be less likely to take medication as directed without using other prompts.

The formulation should identify aspects of the patient’s daily life that may interfere with the behavior of taking medication. Diagnostic characteristics of an illness such as hopelessness and memory problems can inherently produce problems. Trust issues, commonly seen in personality disorders, are another significant impediment. Stressors-whether from co-occurring medical problems, finances, or interpersonal relationships-will worsen adherence. Some patients have never cultivated or have significant impediments to routine; living in a shelter, for example, is hardly conducive to adherence.

As John’s stressors increase, his self-care becomes less of a priority and his routines are less predictable. His psychiatrist addresses the variation in his blood levels and normalizes the struggle with taking medication during times of stress and unpredictable schedules. The psychiatrist self-discloses that when traveling, she finds it difficult to remain on schedule with her blood pressure medication. This makes it easier for John to speak about the fact that remembering the pills just “feels like too much” and that the adverse effect of tremors is interfering with his free-throw shooting.

Very frequently our discussions with patients emphasize the adverse effects they are experiencing, particularly after symptomatic improvement. The practice of asking “Are you taking your medication?” followed by “How are the adverse effects?” will be less effective at obtaining accurate information-and will remind the patient that dry mouth, anorgasmia, and sedation are the result of taking medication. Emphasize the positive effects of the medication to counterbalance the adverse effects.

It is normal to forget much of what is said during a physician visit, so written information must accompany medication discussions. Teach patients to take notes and to write down questions between sessions to make them better partners. Genuine interest in the patient’s point of view enhances all aspects of the therapeutic alliance and, subsequently, adherence. Internet searches are commonly used for medication queries, not all of which produce positive results. Guide patients to reliable sites to help them be informed consumers. Bad information may be more harmful to adherence than no information at all!

Behavioral techniques are essential for forming habits, and taking medication regularly invariably involves habit change. Such techniques include self-monitoring (eg, charting medication taken each day) or reminder systems (eg, a pillbox, pairing medication doses with routine activities). Some less commonly used effective behavioral strategies include adding positive reinforcement (such as reading a favorite magazine) after several days of taking medication correctly.

Behavioral experiments can enhance the likelihood that patients will try a particular medication. For example, the patient may take a medication for the first time and spend the day in your waiting room when concerned about possible adverse effects of the drug.

Cognitive techniques are helpful when the patient’s thoughts about medication are a barrier to adherence. CBT interventions can be quite effective in developing alternative ideas about medication. A patient can use a decision matrix to list the pros and cons about a medication. This may be useful when the patient is unsure about pharmacotherapy. Evaluating negative thoughts about medications, psychiatric illnesses, or physicians may facilitate the willingness to take medication, or to take it more regularly.

Education, managing stigma and shame, and correcting misconceptions about health care providers may be subjected to behavioral experiments and evidence gathering. A basic CBT premise is not to tell the patient what to think, but to help the patient consider thoughts as testable hypotheses. For example, to help a patient develop more accurate ways of thinking about medications, ask him to consider what he would say if his child, spouse, or best friend required such medication. More global beliefs about the motives and trustworthiness of others may need special attention and efforts to build a trusting relationship with the patient over time. Empathic, validating comments, and open and direct communication about how difficult trust is may facilitate better adherence.

John and his psychiatrist discuss very specifically which days are most difficult for him regarding taking his medication. John has always used a pill box with the days of the week to help him stay on track. He noticed that Friday and Saturday were the most frequent days he missed taking the medication-John’s games were scheduled on these nights. The psychiatrist and John agree to a plan that aggressively targets his tremor, which results in improved adherence.

Dr. Sudak is Professor, Director of Psychotherapy Training, Senior Associate Training Director Department of Psychiatry, Drexel University, Philadelphia, PA; Dr. Ayub is Resident Physician, Department of Psychiatry, Drexel University.

 Zygmunt A, Olfson M, Boyer CA, Mechanic D. Interventions to improve medication adherence in schizophrenia. 

 Scott J, Pope M. Nonadherence with mood stabilizers: prevalence and predictors. 

 Pampallona S, Bollini P, Tibaldi G, et al. Patient adherence in the treatment of depression. 

 Patel MX, David AS. Medication adherence: predictive factors and enhancement strategies. 

 Julius RJ, Novitsky MA Jr, Dubin WR. Medication adherence: a review of the literature and implications for clinical practice. 

 Mert DG, Turgut NH, Kelleci M, Semiz M. Perspectives on reasons of medication nonadherence in psychiatric patients. 

 Cochran SD. Preventing medical noncompliance in the outpatient treatment of bipolar affective disorders. 

 Lam DH, McCrone P, Wright K, Kerr N. Cost-effectiveness of relapse-prevention cognitive therapy for bipolar disorder: 30-month study. 

 Schmitz JM, Averill P, Sayre S, et al. Cognitive behavioral treatment of bipolar disorder and substance abuse: a preliminary randomized study. 

 Gray R, Leese M, Bindman J, et al. Adherence therapy for people with schizophrenia: European multicentre randomised controlled trial. 

 Cavezza C, Aurora M, Ogloff JR. The effects of an adherence therapy approach in a secure forensic hospital: a randomised controlled trial. 

The authors outline a series of strategies that can help promote adherence to the therapeutic regimen.

Psychotherapeutic Strategies to Enhance Medication Adherence

What are the psychological and physiological effects of persistent loneliness? How prevalent in the US? What role can cognitive behavioral therapy play for persistently lonely people?

Dr Donna Sudak, a presenter at this year's American Psychiatric Association Annual Meeting, offers a brief overview of this underappreciated, but often overlooked, problem in this podcast. Dr Sudak is Professor of Psychiatry, and Senior Associate Training Director at Drexel University College of Medicine.

. 2005.
• Masi CM, Hawkley LC, Cacioppo JT. 

A Meta-analysis of interventions to reduce loneliness

Personality and Social Psychology Review.

Podcasts

What are the psychological and physiological effects of persistent loneliness? How prevalent in the US? What role can cognitive behavioral therapy play for persistently lonely people? In this podcast, an expert offers a brief overview of this underappreciated, but often overlooked, problem.

Author | Donna M. Sudak, MD

Articles

Reducing Suicide Risk: The Role of Psychotherapy

6 Practical Strategies to Enhance Treatment Adherence

Psychotherapeutic Strategies to Enhance Medication Adherence

Persistent Loneliness: A Relentless-and Prevalent-Problem