Abstract
BackgroundAttempted suicide is the main risk factor for suicide and repeated suicide attempts. However, the evidence for follow-up treatments reducing suicidal behavior in these patients is limited. The objective of the present study was to evaluate the efficacy of the Attempted Suicide Short Intervention Program (ASSIP) in reducing suicidal behavior. ASSIP is a novel brief therapy based on a patient-centered model of suicidal behavior, with an emphasis on early therapeutic alliance.Methods and FindingsPatients who had recently attempted suicide were randomly allocated to treatment as usual (n = 60) or treatment as usual plus ASSIP (n = 60). ASSIP participants received three therapy sessions followed by regular contact through personalized letters over 24 months. Participants considered to be at high risk of suicide were included, 63% were diagnosed with an affective disorder, and 50% had a history of prior suicide attempts. Clinical exclusion criteria were habitual self-harm, serious cognitive impairment, and psychotic disorder. Study participants completed a set of psychosocial and clinical questionnaires every 6 months over a 24-month follow-up period.The study represents a real-world clinical setting at an outpatient clinic of a university hospital of psychiatry. The primary outcome measure was repeat suicide attempts during the 24-month follow-up period. Secondary outcome measures were suicidal ideation, depression, and health-care utilization. Furthermore, effects of prior suicide attempts, depression at baseline, diagnosis, and therapeutic alliance on outcome were investigated.During the 24-month follow-up period, five repeat suicide attempts were recorded in the ASSIP group and 41 attempts in the control group. The rates of participants reattempting suicide at least once were 8.3% (n = 5) and 26.7% (n = 16). ASSIP was associated with an approximately 80% reduced risk of participants making at least one repeat suicide attempt (Wald χ2 1 = 13.1, 95% CI 12.4–13.7, p < 0.001). ASSIP participants spent 72% fewer days in the hospital during follow-up (ASSIP: 29 d; control group: 105 d; W = 94.5, p = 0.038). Higher scores of patient-rated therapeutic alliance in the ASSIP group were associated with a lower rate of repeat suicide attempts. Prior suicide attempts, depression, and a diagnosis of personality disorder at baseline did not significantly affect outcome. Participants with a diagnosis of borderline personality disorder (n = 20) had more previous suicide attempts and a higher number of reattempts.Key study limitations were missing data and dropout rates. Although both were generally low, they increased during follow-up. At 24 months, the group difference in dropout rate was significant: ASSIP, 7% (n = 4); control, 22% (n = 13). A further limitation is that we do not have detailed information of the co-active follow-up treatment apart from participant self-reports every 6 months on the setting and the duration of the co-active treatment.ConclusionsASSIP, a manual-based brief therapy for patients who have recently attempted suicide, administered in addition to the usual clinical treatment, was efficacious in reducing suicidal behavior in a real-world clinical setting. ASSIP fulfills the need for an easy-to-administer low-cost intervention. Large pragmatic trials will be needed to conclusively establish the efficacy of ASSIP and replicate our findings in other clinical settings.Trial registrationClinicalTrials.gov NCT02505373
Highlights
The high toll of deaths by suicide is a major global public health problem [1]
Based on guidelines for clinicians formulated by an international working group [27], we developed a brief therapy program for patients who have recently attempted suicide, the Attempted Suicide Short Intervention Program (ASSIP)
Prior suicide attempts were reported by 50%; 26% had a history of multiple prior suicide attempts
Summary
The high toll of deaths by suicide is a major global public health problem [1]. In spite of a broad range of prevention efforts, suicide rates have not declined [2]. In the Brown et al study, which included 120 participants who had attempted suicide, the intervention group received at least ten (up to 24) sessions of cognitive therapy with an emphasis on developing safety plans for future suicidal crises. The cognitive therapy group had a significantly lower reattempt rate and a 50% reduced risk of reattempting suicide during 18 months of follow-up. In their study with 152 active-duty soldiers, Rudd and co-workers found that a brief cognitive-behavioral therapy with 12 to 16 or more sessions plus usual mental health care (including case managers) was associated with a 60% lower risk of attempting suicide during 24 months of follow-up. Factors that are protective against suicide include effective clinical care for mental, physical, and substance abuse disorders; connectedness to family and community; and problem solving and conflict resolution skills. Fifteen to 25 percent of people who attempt suicide make another attempt, and five to ten percent eventually die by suicide
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