Under the Hood

Chances Of A Repeat Suicide Attempt Drop With New Therapy Plus Regular Therapist Letters

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A personalized three-week-long course of therapy followed by regular letters from a therapist can help people who have attempted suicide attempt avoid future attempts for up to two years. Sean Loyless, CC BY 2.0

Despite our growing willingness to address the issue of suicide and some minor victories, there’s been overall little headway made in reducing the number of deaths from it.

For instance, among adults aged 35 to 64, the annual, age-adjusted suicide rate has actually substantially increased since the turn of the millennium, from 13.7 deaths per 100,000 people in 1999 to 17.6 deaths in 2010, a 28 percent greater incidence. Similarly, there’s been no major advances in creating a widely adoptable psychiatric intervention that aims to prevent suicide for those especially at risk — namely people already hospitalized for a suicide attempt. A new study published Tuesday in PLOS Medicine, however, may provide us with the first glimpses of such a breakthrough.

A "Patient-Centered, Collaborative Approach"

The study authors recruited 120 patients who were admitted to the emergency department of the Bern University General Hospital in Switzerland following their suicide attempt, voluntarily enrolling them into one of two randomly assigned groups: those who received treatment as usual (TAU), customized to fit their unique needs; and those who additionally participated in the Attempted Suicide Short Intervention Program (ASSIP), a “novel brief therapy based on a patient-centered model of suicidal behavior, with an emphasis on” fostering a sense of collaboration between the therapist and patient.

While both groups were followed up with over the course of two years, the ASSIP group also received periodical and personalized letters from their therapist, intended to remind them of the coping strategies they devised together to prevent full-blown “suicidal crises.” By study’s end, the differences between the two groups were dramatic.

Though each group had one completed suicide, the ASSIP group only experienced five repeat suicide attempts compared to the 41 attempts experienced by the TAU group, an approximate 80 percent reduction in risk. The ASSIP group also collectively experienced 72 percent fewer days of hospitalization compared to the TAU group (29 vs. 101 days) following its original ED visit, and it was more likely to remain in contact with the researchers throughout the study (with a dropout rate of 7 percent vs. 22 percent).

“The study’s findings in a real-world clinical setting (a university hospital in the Swiss capital) are promising,” the researchers concluded. “They justify further testing in large clinical trials and diverse settings to answer conclusively whether and where ASSIP can reduce repeat suicide attempts, prevent deaths from suicide, and reduce health-care costs.”

Those given ASSIP took part in three (sometimes four) 60 to 90 minute-long weekly sessions. During the first, they were given a recorded narrative interview, allowing them to tell their personal stories on how they arrived at their decision to attempt suicide. During the second, both therapist and patient went over the recording, trying to zero in on the “automatic thoughts, emotions, physiological changes, and contingent behavior” that spurned their attempt; they also received an educational handout. On the last, the two devised a “list of long-term goals, individual warning signs, and safety strategies,” that was later copied onto a credit-card sized folded leaflet they could carry in their wallet at all times, along with a “crisis card” detailing the telephone numbers of people they could call whenever they felt suicidal impulses. The subsequent letters, personally signed by the ASSIP therapist and sprinkled with references to their sessions, were mailed out every three months during the first year and every six months in the second.

Importantly — and expectedly — there were no significant group differences in how suicidal participants felt by the end of the study, nor in their level of depression (though both factors did decrease over time), the ASSIP group was simply better equipped to handle their crises when they came up, validating the researchers’ hypothesis that “ASSIP’s patient-centered, collaborative approach to suicidal behavior promotes therapeutic alliance and maximizes treatment engagement.”

Other studies of similarly collaborative approaches have yielded their own large reductions in suicide attempts, but the researchers noted theirs is the first to combine “psychological interventions with subsequent ongoing contact through letters,” an approach that may have “not only provided a feeling of connectedness with the ASSIP therapist, but also may have acted as reminders of patients’ increased suicide risk and may have increased awareness of problems that could trigger future suicidal crises.” They added that the fact ASSIP is both brief and can be easily taught to other therapists via an structured manual offers a potential advantage over other treatment methods, such as cognitive behavioral therapy.

Of course, every study has its limitations. For one, the researchers deliberately excluded people suffering from psychotic disorder or severe cognitive impairment, meaning we can’t generalize the findings to these populations. Additionally, while ASSIP may indeed be effective in preventing suicide attempts, those at risk first have to be willing to try it out — 25 percent of the original 291 people asked to participate refused, with some denying they had any suicidal ideation and/or refusing any treatment.

Additionally, while the study is obviously encouraging, it’s only the beginning of a long process. The researchers noted that none of the randomized controlled treatment studies referenced by them have yet to be replicated by others, a step pivotal to both validating and encouraging the use of methods like ASSIP elsewhere.

“Large pragmatic trials will be needed to conclusively establish the efficacy of ASSIP and to replicate our findings in other clinical settings,” they wrote.

The need for pragmatism shouldn’t negate anyone’s excitement over these results, though. According to research cited by the authors, one in every 25 people who are sent to the hospital for self harm will eventually complete a suicide attempt by five years time, and the completed suicide risk is 40 to more than 100 percent higher for those who have already attempted it at least once before when compared to the general population, with the risk increasing for every subsequent attempt (in the current study, 50 percent had a history of prior attempts).

Conversely, reducing the number of attempts made annually in the United States (1.3 million, according to a 2014 report) by even 25 percent would in turn save around 1,000 lives every year.

That’s a goal well worth fighting for.

Source: Gysin-Maillart A, Schwab S,  Soravia L, et al. A Novel Brief Therapy for Patients Who Attempt Suicide: A 24-months Follow-Up Randomized Controlled Study of the Attempted Suicide Short Intervention Program (ASSIP). PLOS Medicine. 2016.

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