Happy New Year! And, what a year it has been for the field of suicidology! Two of the largest randomized controlled trials were published with findings so
robust that each study required its own press release and was featured on the
NIMH website homepage. Knowing how busy our readership is, I thought I
would use my last presidential column to briefly highlight these tremendous
advances in the field of clinical emergencies and crises. In our line of work, it is
critically important for all of us to be mindful of these accomplishments while
not losing sight of the necessary next steps to advance our clinical-research.
Cognitive Therapy (CT)
Greg Brown and colleagues (2005) reported that recent suicide attempters
(N=120) treated with CT were 50 percent less likely to try to kill themselves
again within 18 months than those who received enhanced usual care with
tracking and referral services. The majority of the sample was ethnic minority
females in their mid-thirties. The majority of their prior suicide attempts were
comprised of drug overdose. Moreover, 77% of the sample met diagnostic criteria
for major depression and 68% had a substance use disorder.
Those in the cognitive therapy group (who were also encouraged to receive
usual care in the community and were tracked by study case managers by mail and phone throughout the 18 month follow-up period) were scheduled to receive 10 outpatient weekly or biweekly cognitive therapy sessions specifically focusing on preventing further suicidal behavior. Twenty-one percent of those receiving CT also received “usual care” psychotherapy outside of the study, while 27% of those in the usual care group received psychotherapy outside of the study. About half of the participants in both groups took psychotropic medications and about 15% received drug abuse treatment.
During the one and one-half year follow-up period, the groups did not differ significantly in suicidal thoughts. However, those receiving CT scored better on measures of depression severity and hopelessness. Most importantly, however, was the finding that only 24% of those participants in the CT group made repeat suicide attempts compared to 42% of the usual care group. The authors acknowledge that this is a difficult to engage population and that the case management services coupled with the short-term nature of CT may have contributed to the positive outcomes.
Dialectical Behavior Therapy (DBT)
Since 1991, DBT has consistently demonstrated greater efficacy in multiple randomized trials for the treatment of suicidal behavior and borderline personality disorder as compared to treatment as usual. To advance their research and the field, Linehan and colleagues (2006) developed an innovative control condition (i.e., community treatment by non-behavioral experts; TBE) to maximize internal validity by controlling for therapist sex, availability, expertise, allegiance, training and experience, consultation availability, and institutional prestige.
Participants were comprised of 101 clinically referred women with recent suicidal and self-injurious behaviors meeting DSM-IV criteria, matched to condition on age, suicide attempt history, negative prognostic indication, and number of lifetime intentional self-injuries and psychiatric hospitalizations. Subjects were randomized to either one year of DBT or 1 year of treatment by experts, each with a oneyear follow-up period.
Those receiving DBT were half as likely to make a suicide attempt, required less hospitalization for suicide ideation, and had lower risk across all suicide attempts and self-injurious acts combined, as compared to those receiving TBE. Moreover, subjects receiving DBT were less likely to drop out of treatment and had fewer psychiatric hospitalizations and psychiatric emergency department visits.
In sum, these findings replicated those from Linehan and colleagues’ (1991, 1993, 1999) prior studies of DBT and suggest that the effectiveness of DBT cannot reasonably be attributed to general factors associated with expert psychotherapy. DBT is consistently effective at reducing suicide attempts, psychiatric hospitalizations, and retaining subjects in outpatient psychotherapy.
Both Brown and colleagues (2005) and Linehan and colleagues (2006) deserve much applause from those of us in the field who know how difficult it is to conduct a randomized controlled trial, let alone with suicidal individuals!! Taking a “page” out of the Linehan playbook, Brown and colleagues may choose to consider using community-treatment-by-experts as the next comparison group when evaluating the effectiveness of CT. Linehan and colleagues are undertaking a components analysis study to evaluate which components of DBT are necessary to retain in order to achieve these outcomes and which, if any, components are not necessary to retain in the multimodal treatment package.
Wishing everyone in Section VII a very happy, healthy, and productive 2007.
Brown, G.K. Have, T.T., Henriques, G.R., Xie, S.X., Hollander, J.E., & Beck, A.T. (2005). Cognitive therapy for the prevention of suicide attempts. JAMA, 294, 563-570.
Linehan, M.M., Comtois, K.A., Murray, A.M., Brown, M.Z., Gallop, R.J., Heard, H.L., Korslund, K.E., Tutek, D.A., Reynolds, S.K., & Lindenboim, M. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs. therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63, 757-766.