A controlled trial of individual cognitive behavior therapy for unipolar mood disorders with suicidal ideation outpatients: exploring risk and protective factors

Abstract

This thesis had two major aims: the first was aimed to test the efficacy of an Individual Cognitive Behavior Therapy for treatment of unipolar mood disorders with suicidal behavior and the second was to evaluate the risk and protective factors for suicidal behavior among patients with unipolar mood disorders in Malaysia. A review of literature on suicidal behavior in Malaysia suggested that lack of suicidal behavior-related measurements has been hindrance in identification of the risk and protective factors for suicidal behaviors. In addition, the investigation of variables that predicts treatment outcomes for patients with unipolar mood disorders with suicidal behavior has also beenhampered. This review chapter (Chapter 2; parts of them have been published in Comprehensive Psychiatry, 2014 and The Scientific World Journal, 2014) sets the scene for the following empirical chapters.Since most of the instruments used are not validated in Malaysia, thus the next 4 chapters validated two measuring instruments of risk factors and two measuring instruments for protective factors for suicidal behavior (other fours measures were not included as chapters due to limitation in words allowed in this thesis). The validated instruments and other measures were used to identify the risk and protective factors for suicidal behavior as well as to test the efficacy of Individual Cognitive Behavior Therapy (ICBT) for patients with unipolar mood disorders with suicidal behavior.Chapter 3, on Positive and Negative Suicide Ideation (PANSI) Inventory (submitted for publication), Chapter 4, on Beck Hopelessness Scale (BHS), Chapter 5, on Satisfaction With Life Scale (SWLS; published in Comprehensive Psychiatry, 2014), and Chapter 6, is on Reasons For Living Inventory (RFL; published in Comprehensive Psychiatry, 2014). The Exploratory and Confirmatory Factor Analyses were used to examine the psychometric properties and to establish the reliability and validity of these instruments. These measures were validated using the sample size of 483 from both medical and psychiatry patients. All the measures were found to have good reliability and validity using the exploratory and confirmatory factor analyses.Chapter 7 compared the two groups and the results showed that psychiatry patients had significantly higher mean scores on risk factors (hopelessness, psychological distress, depressive, anxiety and stress symptoms) and lower mean scores on protective factors (reasons for living, self esteem, hopefulness, satisfaction with life and social support) for suicidal behavior as compared to medical patients. In addition, patients with suicidal ideation had significantly higher mean scores on risk factors and lower mean scores on protective factors for suicidal behavior as compared to patients without suicidal ideation. And finally, there was a significant interaction between diagnosis (psychiatry patients with suicidal ideation, psychiatry patients without suicidal ideation, medical patients with suicidal ideation and medical patients without suicidal ideation) and suicidal behavior (suicidal ideation).Chapter 8 is a controlled trial comparing the Treatment As Usual (TAU) (N=36) with TAU + Individual Cognitive Behavior Therapy (ICBT) (TAU+ICBT) (N=36) groups. All the outpatients were diagnosed as suffering from unipolar mood disorders with suicidal ideation according to DSM IV-TR criteria. Eight sessions of manualised ICBT were given and each session lasted for 90 minutes. The measures of depressive symptoms (BDI-T and DASS-D), measures of suicidal ideation symptoms (PANSI-T and BSS-T), measures of risk factors for suicidal behavior (DASS-T, DASS-D, BHS-T, DASS-A, DASS-S) and measures of protective factors for suicidal behavior (RFL-T, RSE-T, AHTS-T, PRS-T, SWLS-T, PSR-FR, PSR-FM, SCB, MO, RF, FS, FSD, and CC) were administered at pre, mid, post, 3 months follow-up and 6 months follow-up for both groups. The TAU groups received outpatient treatment as usual by the psychiatrists of the hospital. The results showed that the TAU+ICBT groups consistently and significantly scored better on most of measures when compared to the TAU group. In addition, the TAU+ICBT group improved at earlier stage and the rate of improvement was significantly faster than the TAU group. The TAU group had significant improvement on seven dependent measures only. Thus the addition of the ICBT to TAU produced a more generalized and significant improvement on all the measures of depressive symptoms, measures of suicide ideation symptoms, measures of risk and protective factors of unipolar mood disordered with suicidal ideation patients.The general discussion of the whole thesis was presented in chapter 9, which ties together all the major significant findings from the previous chapters in the general context. The first empirical chapters on assessments were discussed and provided the base for discussions of chapter seven on psychopathology of mood disordered patients with suicidal behavior. Following that the findings of controlled trial on Individual Cognitive Behavioral Therapy of unipolar mood disorders with suicidal ideation in Malaysia was discussed and put in the general context of literature. The discussions were concluded with several strengths of this thesis, limitations of the studies and directions for future research.