Cognitive Behavioral Therapy for Preventing Suicide Attempts

A Guide to Brief Treatments Across Clinical Settings

Craig J. Bryan, Craig J. Bryan

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781135088347
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Cognitive Behavioral Therapy for Preventing Suicide Attempts consolidates the accumulated knowledge and efforts of leading suicide researchers, and describes how a common, cognitive behavioral model of suicide has resulted in 50% or greater reductions in suicide attempts across clinical settings. Simple and straightforward descriptions of these techniques are provided, along with clear explanations of the interventions' rationale and scientific support. Critically, specific adaptations of these interventions designed to meet the demands and needs of diverse settings and populations are explained. The result is a practical, clinician-friendly, how-to guide that demonstrates how to effectively reduce the risk for suicide attempts in any setting.

Part I
Understanding Suicide

one
The Problem of Suicide

Michael D. Anestis and Lauren R. Khazem

UNIVERSITY OF SOUTHERN MISSISSIPPI

Suicide attempt (also referred to as suicidal self- directed violence [SDV], see Chapter 2)—defined as deliberate and self- directed behavior resulting in injury or the potential for injury to oneself in the presence of at least some intent to die, whether implicit or explicit (Crosby, Ortega, & Melanson, 2011)—is a trans-diagnostic and tragic outcome that impacts individuals across demographic categories and geographic boundaries. Although certain populations are at particularly high risk—a point we will highlight later in this chapter—it is worth initially noting the overall impact that suicide has on both a global and national level and, in doing so, establishing with utmost clarity why suicide represents such a pressing problem.

First and foremost, by definition, suicide represents the premature end of a life, which serves as a substantial loss on its own. Additionally, loved ones who survive an individual’s death by suicide are left to mourn and, due to natural responses and a variety of common misunderstandings regarding the nature and meaning of suicide attempts (e.g., Joiner, 2010), can experience outcomes ranging from normative grief to acute feelings of shame, stigma, and self- blame (e.g., Sveen & Walby, 2008). Indeed, Schneidman (1972) posited that the grief associated with the stigmatized death of a loved one (e.g., death by suicide) was distinctly different from that associated with deaths of loved ones through more socially accepted means (e.g., cancer). Similarly, individuals who have survived a nonlethal suicide attempt themselves are frequently met with stigma that could further interfere with recovery and future mental health–related outcomes (e.g., Batterham, Calear, & Christensen, 2013; Lester & Walker, 2006). In addition to the loss of life, death by suicide is associated with a substantial economic burden estimated to total approximately $34 billion per year in the United States, in addition to an estimated $8 billion per year in lost wages, lost productivity, and direct medical care for those who make suicide attempts (American Foundation for Suicide Prevention, 2013). As such, suicide attempts and, by extension, death by suicide, are problematic for reasons that extend beyond the act itself.

Although some interventions have been developed specifically to address suicide attempts (e.g., dialectical behavior therapy; Linehan & Heard, 1992), there remains a dearth of evidence- based approaches to prevent suicide attempts and limited implementation of those that exist (e.g., Jobes, 2012; Jobes & Berman, 1993; Jobes, Rudd, Overholser, & Joiner, 2008). As such, despite increased knowledge regarding risk factors for and correlates of suicide attempts (e.g., Bagge & Sher, 2008; Bostwick & Pankratz, 2000; Joiner, 2005; Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006), we remain somewhat ill equipped to stem the tide of death by suicide in a practical, cost- effective way. The purpose of summarizing the evidence underlying brief cognitive behavior therapy for suicidal individuals across a variety of settings is thus quite clear.

General Rates of Suicide and Suicide Attempts

Each year, approximately 1 million individuals die by suicide worldwide, translating to a rate of approximately 16 per 100,000 (World Health Organization, 2013). In 2010, the most recent year for which such data are currently available, 38,364 individuals died by suicide in the United States alone (50.5% by self- inflicted gunshot wounds), translating to an age- adjusted rate of approximately 12.08 per 100,000 (Centers for Disease Control and Prevention, 2013). This represents a stark increase relative to the early 2000s. In 2001, for instance, 30,622 individuals died by suicide (55.0% by self- inflicted gunshot wounds) in the United States, translating to an age- adjusted rate of 10.71 per 100,000 (CDC, 2013).

The overall increase in deaths by suicide within the United States has occurred among both males and females. In 2001, males represented 80.6% of US suicide deaths, with an age- adjusted rate of 18.17 per 100,000 (females died at a rate of 4.06 per 100,000). In 2010, males represented 78.9% of US suicide deaths, with an age- adjusted rate of 19.78 per 100,000 (females died at a rate of 4.99 per 100,000). Other demographic variables, however, reveal a substantial level of variability across groups over this time period.

Age is a particularly telling example of this phenomenon. In 2001, the rate for death by suicide was highest in older adults. Adults aged 75–79 died at a rate of 16.35 per 100,000, adults aged 80–84 died at a rate of 18.94 per 100,000, and adults aged 85 and older died at a rate of 17.83 per 100,000. These numbers declined by 2010, with adults aged 75–79 dying at a rate of 15.29 per 100,000, adults aged 80–84 dying at a rate of 16.24 per 100,000, and adults aged 85 and older dying at a rate of 17.62 per 100,000 (CDC, 2013). The trend for middle- aged adults, however, was quite different. In 2001, adults aged 45–49 died by suicide at a rate of 15.75 per 100,000, and adults aged 50–54 died by suicide at a rate of 14.35 per 100,000. In 2010, however, those numbers increased to 19.25 and 19.85 respectively (CDC, 2013). Given that middle- aged adults account for a substantially greater proportion of the population, this increase represents a potentially crucial explanation for the overall increase in deaths by suicide within the United States.

A substantial shift is also evident when examining the numbers by race. In 2001, the rates of death by suicide for Americans who self- identified as White, Black, American Indian/Alaskan Native, and Asian/Pacific Islander were 11.71, 5.45, 10.46, and 5.34 per 100,000, respectively (data were not reported for other racial groups; CDC, 2013). In 2010, however, whereas suicide rates remained relatively stable for those who identified as Black, American Indian/Alaskan Native, and Asian Pacific Islander (5.19, 10.87, and 6.19 per 100,000, respectively), the suicide rate for White Americans increased substantially (13.55 per 100,000). Given that White Americans represented 79.5% of the US population in 2010, the impact of this increase on the overall US suicide rate is clear.

Although obviously problematic, these numbers do not illustrate the entirety of the issue. Indeed, the impact of suicide attempts extends beyond death by suicide. In 2010, a total of 464,995 individuals (age- adjusted rate = 152.96 per 100,000) within the United States received treatment in an emergency room for all forms of self- directed violence, meaning that for every death by suicide (n = 38,364), there were 12.12 cases of suicidal and nonsuicidal SDV (CDC, 2013). Here again, a shift has emerged since 2001, when 323,370 Americans presented at emergency rooms for self- inflicted injuries, representing an age- adjusted rate of 112.82 per 100,000 and a ratio of nonlethal to lethal (n = 30,622) SDV of 10.56.

It is important to note that these numbers do not account for the presence of suicidal intent and, as such, it is entirely plausible that a number of these cases are better classified as nonsuicidal self- injury or nonsuicidal self- directed violence rather than suicide attempts; however, the use of emergency room data also undoubtedly severely underestimates the total number of suicide attempts that occur in the United States, as a substantial number of suicide attempts that result in no or minimal injury likely result in either no medical attention or limited care in alternative, nonemergency medical settings. As such, although nonlethal and lethal SDV can be accurately conceptualized as low base- rate behaviors, the scope of their impact on society is nonetheless considerable.

High- Risk Populations and Environments

The primary aim of this book is to describe the evidence supporting, methods for utilizing, and feasibility of implementing brief cognitive behavioral therapy for suicidal patients across diverse groups and clinical settings. Outpatient mental health settings, inpatient psychiatric settings, emergency departments, primary care, and military settings will be specifically considered in depth in later chapters. Before presenting such information, however, it seems worth noting why these settings were chosen and in what ways suicide represents a substantial problem for each.

Suicide Attempts Among Patients in Outpatient Mental Health Settings

Although outpatient mental health services can, in some ways, be seen as an indicator of less clinical severity than those treating patients with inpatient services, the veracity of such views can vary by setting, patient, and primary diagnostic presentations. Consequently, the presence of suicide attempts resulting in death remains a legitimate possibility. Indeed, efforts have been made to develop systematic methods for assessing suicide risk across outpatient settings (e.g., Joiner, Walker, Rudd, & Jobes, 1999), and evidence- based treatments specifically designed for highly suicidal patients have been created specifically for such populations (e.g., dialectical behavior therapy; Linehan & Heard, 1992).

Because outpatient populations represent such a diverse group, establishing a single rate of nonlethal versus lethal suicide attempts in such settings is challenging, and any such numbers should be interpreted within the context of the institutional environment (e.g., military versus civilian) and diagnostic composition (e.g., inpatient eating disorder treatment facilities versus inpatient units for acutely suicidal individuals) of the sample. Using two cohorts of veterans who utilized Veterans Affairs (VA) hospitals in 1997 and 2001, for instance, Desai, Rosenheck, and Desai (2008) reported a rate of death by suicide of 8.94 per 100,000 in outpatients as compared to 18.29 per 100,000 in inpatients; however, as we discuss in greater detail later in this chapter, these data were drawn from a period of time when the rate of death by suicide in military personnel was substantially lower than it is today. Steer, Brown, and Beck (2006) followed a group of 6,891 civilian outpatients over the course of 10 years and reported that the daily hazard rate for death by suicide decreased rapidly during the first 3 years after an initial psychiatric evaluation before reaching a level too low to predict, with 49 (0.7%) individuals dying by suicide during the course of the follow- up period. This group, however, encompassed a broad array of suicide risk and diagnostic statuses and does not necessarily speak to an overall trend in outpatient settings in general. Indeed, if a particular outpatient setting sees a higher proportion of clients diagnosed with conditions characterized by greater suicide risk (e.g., borderline personality disorder, bipolar disorder; Frances, Fyer, & Clarkin, 1986; Hawton, Sutton, Haw, Sinclair, & Harriss, 2005; Skodol et al., 2002), it would be reasonable to assume that rates of nonlethal and lethal suicide attempts would likely rise as well, highlighting the need for such settings to incorporate brief evidence- based treatments that directly impact suicide risk.

Suicide Attempts Among Patients in Inpatient Psychiatric Settings

Inpatient hospitalization for suicidal clients has undergone considerable change over the past several decades, with the length of stay and feasibility of insurance coverage for such stays diminishing (e.g., Olfson, Gameroff, Marcus, Greenberg, & Shaffer, 2005). This, along with debate regarding the effectiveness of repeated inpatient stays, has led many to advocate for caution in the use of inpatient hospitalization (e.g., Jobes, 2006; Jobes, Rudd, Overholser, & Joiner, 2008). In some areas, the number of available inpatient beds has decreased dramatically, further contributing to changes in how decisions about this treatment modality occur. For example, between 1995 and 2001, the Department of Veterans Affairs (VA) closed two- thirds of their previously available inpatient beds (Desai et al., 2008). The need for inpatient hospitalization in moments of severe and imminent risk remains largely uncontested; however, it is important to consider the risk of suicide attempts in such settings and the best practices for preventing such outcomes.

A number of studies have indicated that the majority of inpatient psychiatric units utilize “no- suicide contracts” with patients, in which the patient signs his or her name on a binding contract (although such contracts are not truly legally binding) to indicate that they agree not to make a suicide attempt during the course of treatment (e.g., Drew, 2001). Importantly, evidence indicates that these contracts are at best ineffective (e.g., Jobes et al., 2008; Rudd, Mandrusiak, & Joiner, 2006) and at worst iatrogenic (e.g., Drew, 2001). As such, the form of treatment reserved for acute crises (inpatient psychiatric units) is characterized by the frequent use of a problematic procedure.

Compounding this situation is the frequency with which suicide attempts occur in inpatient units. Although, like suicide in general, this phenomenon is a low base- rate outcome, the raw numbers are nonetheless problematic. In 2003, the American Psychiatric Association reported a total of roughly 1,500 deaths by suicide in inpatient units in the United States. Furthermore, it noted that one in three of those deaths occurred while individuals were on 15- minute checks in which hospital staff regularly checked on the safety of the patient. Approximately 75% of those deaths resulted from hanging, with jumping from a high place serving as the second leading cause (Joint Commission Sentinel Event Report, 1998). More recently, Mills, King, Watts, and Hemphill (in press) examined rates of suicide attempts within inpatient mental health units in Veterans Affairs (VA) hospitals between the years of 1999 and 2011 and found that a total of 243 suicide deaths occurred in such settings over that time period, with the most frequent methods being hanging (43.6%), cutting (22.6%), and strangulation (15.6%).

These numbers highlight the point that simple hospitalization in and of itself may not be sufficient as a treatment option and that even when staff diligently check on the safety of patients on a regular and fairly high- frequency schedule, prevention of death by suicide cannot always be assured. This highlights the discomforting fact that even in settings where means for suicide can be highly restricted, a patient with a strong desire to die can ...