Collaborative Assessment And Management Of Suicidality Research Articles

Child and adolescent suicide: contributing risk factors and new evidence-based interventions

ABSTRACTOur goal of this special issue is to detail and describe the current epidemiology of suicide among children and adolescents, as well as highlight important risk factors and evidence-based treatment options. To accomplish this, our issue is organized in two major sections: (1) contributing factors to the emergence of child and adolescent suicide, and (2) evidence-based treatment of child and adolescent suicide. Within the issue, authors discuss risk factors of anxiety, sleep problems, child sexual abuse, and violence perpetration, and conclude with treatment considerations including the Collaborative Assessment and Management of Suicidality (CAMS) and safety planning. Across studies, it is clear that there is an urgent need to better understand and effectively treat child and adolescent suicide.

Effects of the Collaborative Assessment and Management of Suicidality (CAMS) Model: A Secondary Analysis of Moderation and Influencing Factors

In a randomized controlled trial, we found that suicidal patients who received Collaborative Assessment and Management of Suicidality (CAMS) reported greater improvements in suicidal ideation and mental health distress compared to participants who received treatment as usual (TAU). Here, we explored moderators and mediators of the effectiveness of CAMS. Compared to TAU, CAMS was more effective in reducing suicidal ideation when the working alliance, in particular its bond subcomponent, was low. In terms of reducing mental health distress, CAMS was superior to TAU only for participants who did not use illicit drugs and, more tentatively, only for patients without borderline personality traits. We suggest that CAMS may repair a difficult vantage point in terms of poor working alliance in patients with suicide ideation. To obtain superior benefits of CAMS upon more general mental health distress in patients with drug abuse or borderline traits, these problems may need to be more explicitly targeted in parallel.

A systematic review of efficacy of Collaborative Assessment and Management of Suicidality (CAMS) in managing suicide risk and deliberate self-harm in adult populations.

Evaluate the efficacy of Collaborative Assessment and Management of Suicidality (CAMS) in managing suicide risk and deliberate self-harm in adults. Ten databases were searched for publications referring to CAMS or the Suicide Status Form. Results were evaluated by two reviewers. Limited evidence that CAMS is effective in reducing suicide risk and deliberate self-harm in adult populations. Although CAMS appears to show promise in managing suicidal patients across a range of measures, further evidence is needed to clarify its efficacy in managing suicide risk and deliberate self-harm.

Managing suicidality within specialized care: A randomized controlled trial

BackgroundSuicide prevention is a core task in mental health services. Our objective was to determine whether Collaborative Assessment and Management of Suicidality (CAMS) reduced suicidal thoughts and behaviors and mental health distress more effectively than treatment as usual (TAU) in a heterogeneous patient population within specialized mental health care services. MethodsIn this observer-blinded pragmatic randomized controlled trial participants who scored 13 or above on Beck's Scale for Suicide Ideation-Current (BSSI-C) were included from seven in- and outpatient units. Primary outcome was suicidal ideation (BSSI-C). Secondary outcomes were mental health distress measured by the Outcome Questionnaire–45, and suicidal behaviors measured by the Suicide Attempt Self-Injury Count. Patients were assessed at baseline and after 6 and 12 months. ResultsThe final intent-to-treat analyses included 78 participants (mean age 35.9 years, SD = 14.5, 41 females). The majority were depressed (65%), had a secondary diagnosis (73%) and 32% suffered from borderline personality disorder or borderline traits. After 6 months, CAMS participants reported lower levels of suicidal ideation compared to TAU (β = −4.29, 95% CI = −8.32 to −0.27, p = .036). Larger changes in mental health distress were observed for CAMS participants after 6 months (β = −11.87, 95% CI = −22.99 to −0.76, p = .036) and 12 months (β = −13.70, 95% CI = −24.88 to −2.51, p = .017). LimitationsThe modest sample size rendered the trial unable to detect small between-group differences. ConclusionsCAMS reduced suicidal ideation and mental health distress more efficiently than TAU in a heterogeneous patient population within specialized care.

Assessing the Reliability of the CAMS Rating Scale Using aGeneralizability Study.

Background: An important consideration when conducting randomized controlled trials is treatment differentiation. Direct observation helps ensure that providers in different treatment groups are delivering distinct interventions. One direct observation method is the use of a measure to rate clinician performance when delivering an intervention. Aims: This generalizability study evaluated the reliability of the CAMS Rating Scale (CRS), a measure used to assess delivery of the Collaborative Assessment and Management of Suicidality (CAMS). Method: Digitally recorded tapes of clinicians delivering either CAMS or Enhanced Care-As-Usual (E-CAU) were coded using the CRS. Sessions (N=36) were each coded by two raters, and encompassed four clinicians, four time points, and 34 unique patients across two treatment groups. A reliability coefficient (i.e., G coefficient) and the percentages of variance contributed by each component of the measurement model were obtained. Results: The CRS reliably differentiates CAMS from E-CAU, minimizes measurement error relative to expected variance sources, and continues to demonstrate high inter-rater reliability. Limitations: The absence of blind raters, a formal training protocol for the rating team, and ratings from all clinician-patient dyads at all time points was a limitation. Conclusion: The CRS is a reliable treatment differentiation measure that can play an integral role in studies evaluating CAMS.

The psychometric properties of the Collaborative Assessment and Management of Suicidality rating scale.

The CAMS Rating Scale (CRS) is an adherence measure for the Collaborative Assessment and Management of Suicidality (CAMS), a suicide-specific clinical intervention. This study examined the ability of the CRS to assess adherence to CAMS. Video-recorded therapy sessions of clinicians delivering either CAMS or Enhanced Care-As-Usual (E-CAU) were rated with the CRS. These ratings (N = 98) were used to evaluate criterion validity, internal consistency, and factor structure. Criterion validity and factor analyses did not support the organization of the CRS into its current subscales. Furthermore, the identified factor model and item-level statistics revealed weak CRS items. Finally, internal consistency was higher among CAMS clinicians than among clinicians delivering E-CAU. These results establish the CRS as a measure that can effectively assess the adherence to CAMS in its current form. Potential revisions to future iterations of the CRS are discussed.

The collaborative assessment and management of suicidality (CAMS) versus enhanced care as usual (E-CAU) with suicidal soldiers: Moderator analyses from a randomized controlled trial

ABSTRACTGiven historically high rates of suicide among military personnel over the past decade the present study analyzed whether key demographic, military, and research-based variables moderated clinical treatment outcomes of 148 suicidal active duty US Army soldiers. This is a secondary analysis of data from a randomized controlled trial comparing the collaborative assessment and management of suicidality (CAMS) to enhanced care as usual (E-CAU; Jobes et al., 2017). Nine potential moderator variables were derived from the suicidology literature, military-specific considerations, and previous CAMS research; these were sex, age, marital status, race, lifetime suicide attempts, combat deployments, time in service, initial distress, and borderline personality disorder diagnosis. The clinical outcomes included six suicide- and mental health-related variables. Six of the eight significant moderator findings in this study showed CAMS outperforming E-CAU in certain subgroups with medium to large effect sizes ranging from 0.48 to 1.50. Collectively, the results suggest that CAMS was associated with the greatest improvement among lower complexity soldier patients, particularly those with lower initial distress and fewer deployments. Those who were married or older generally responded better to CAMS, although the results were not entirely consistent with respect to age. CAMS’s effectiveness for married soldiers and those with lower initial distress was a particularly robust finding that persisted when adjusting more stringently for multiple testing. This study sheds light on several factors associated with the success of CAMS among suicidal soldiers that can assist in matching the treatment to those that may benefit the most.

A stepped care approach to clinical suicide prevention.

Despite the enormous humanitarian and economic toll of suicide, mental health systems of care are largely underprepared to work effectively with suicidal individuals and suicide is a leading "Sentinel Event" in U.S. health care settings (The Joint Commission, 2016). In response to these concerns, a recent policy initiative called "Zero Suicide" has advocated a systems-level response to the suicidal risk within health care and this policy initiative is yielding positive results (Hogan & Goldstein Grumet, 2016). Along these lines, a "stepped care" approach developed by Jobes (2016) has been adapted and used within the Zero Suicide curriculum as a model for systems-level care that is suicide-specific, evidence-based, least-restrictive, and cost-effective. The Collaborative Assessment and Management of Suicidality (CAMS) is an example of one suicide-specific evidence-based clinical intervention that can be adapted and used across the full range of stepped care service settings (Jobes, 2016). This article describes various applications and uses of CAMS at all service levels and highlights CAMS-related innovations. It is argued that psychological services are uniquely poised to make a major difference in clinical suicide prevention through a systems-level approach using evidence-based care such as CAMS. (PsycINFO Database Record

Testing an App-Assisted Treatment for Suicide Prevention in a Randomized Controlled Trial: Effects on Suicide Risk and Depression

Suicide is a global public health problem and effective psychological interventions are needed. The objective of the present study was to evaluate the effect of an app-assisted suicide prevention treatment on suicide risk and depression. One hundred twenty-nine participants were randomized to treatment as usual (TAU), consisting of psychotherapy adhering to the framework of Collaborative Assessment and Management of Suicidality (CAMS), with (TAU+APP, N = 60) or without (TAU, N = 69) access to a mobile application (i.e., LifeApp’tite). Suicide risk and symptoms of depression were assessed pre- and posttherapy, and at 4-month follow-up. The TAU+APP group showed a smaller decrease on self-reported suicide risk at the end of treatment, corresponding to a medium between-group effect size (p = .008, d = 0.46). At the 4-month follow-up this was the case only at the trend level, where the effect size was also of a smaller magnitude (p = .057, d = 0.30). No differences between the treatment groups were observed on self-reported depressive symptoms, either immediately following treatment (p = .732, d = 0.05) or at follow-up (p = .467, d = 0.11). The unexpected negative effect concerning suicide risk points to crucial consideration of issues pertaining to timing, dosing, and content when adding new technology to existing treatments both in this and other populations.

Understanding Therapists' Work With Suicidal Patients: An Examination of Qualitative Data.

The collaborative assessment and management of suicidality (CAMS) serves as a framework for maintaining a collaborative relationship between the therapist and patient. This study used an original coding manual to examine responses to open-ended questions to better understand the ways in which therapists use CAMS collaboratively as well as their reasons for adhering (or not adhering) to certain aspects of the framework. Results suggest differences in treatment application based on therapist characteristics including amount of experience, intensity of training received, and experience of a patient suicide attempt. Implications of this research include informing therapists interested in using the CAMS framework about the specific ways in which implementation can be made collaborative. Further, this research helps to shed light on how experiencing a client's death by suicide can impact therapists' future work with suicidal clients.

A Randomized Controlled Trial of the Collaborative Assessment and Management of Suicidality versus Enhanced Care as Usual With Suicidal Soldiers

Objective: This study describes a randomized controlled trial called “Operation Worth Living” (OWL) which compared the use of the Collaborative Assessment and Management of Suicidality (CAMS) to enhanced care as usual (E-CAU). We hypothesized that CAMS would be more effective than E-CAU for reducing suicidal ideation (SI) and suicide attempts (SA), along with secondary behavioral health and health care utilization markers for U.S. Army Soldier outpatients with significant SI (i.e., > 13 on Beck’s Scale for Suicide Ideation). Method: Study participants were 148 Soldiers who presented to a military outpatient behavioral health clinic. There were 73 Soldiers in the experimental arm of the trial who received adherent CAMS; 75 Soldiers received E-CAU. Nine a-priori treatment outcomes (SI, past year SA, suicide-related emergency department (ED) admits, behavioral health-related ED admits, suicide-related inpatient psychiatric unit (IPU) days, behavioral health-related IPU days, mental health, psychiatric distress, resiliency) were measured through assessments at Baseline and at 1, 3, 6, and 12 months post-Baseline (with a 78% retention of intent-to-treat participants at 12 months). Results: Soldiers in both arms of the trial responded to study treatments in terms of all primary and secondary outcomes (effect sizes ranged from 0.63 to 12.04). CAMS participants were significantly less likely to have any suicidal thoughts by 3 months in comparison to those in E-CAU (Cohen’s d = 0.93, p=.028). Conclusions: Soldiers receiving CAMS and E-CAU significantly improved post-treatment. Those who received CAMS were less likely to report SI at 3 months; further group differences were not otherwise seen.

A controlled comparison trial of the Collaborative Assessment and Management of Suicidality (CAMS) in an inpatient setting: Outcomes at discharge and six-month follow-up

This controlled comparison trial evaluated a suicide-specific intervention, the Collaborative Assessment and Management of Suicidality (CAMS), in an extended-stay psychiatric inpatient setting. Multiple outcomes were examined for 104 patients, half of whom received individual therapy from therapists trained in CAMS. The comparison group was selected from a larger pool through Propensity Score Matching to ensure comparability on age, sex, treatment program, number of prior suicide attempts, and severity of suicidal ideation. Results showed that a) all patients improved significantly across a wide range of measures, including depression, suicidal ideation, functional disability, and well-being; b) these gains were durable over a 6-month post-discharge period; and c) patients treated by a CAMS-trained individual therapist improved significantly more from admission to discharge across all measures. Differences between CAMS and non-CAMS patients were no longer statistically significant at 6-month follow-up, although statistical power was compromised due to attrition. Although replication studies are needed, these findings suggest that interventions specifically tailored for suicidal patients may have advantages compared to usual, intensive inpatient treatment, perhaps by addressing psychological vulnerabilities specific to the population. The lack of significant differences at follow-up suggest that post-treatment contact may be needed to maintain advantages associated with this and similar interventions.

Collaborative Assessment and Management of Suicidality (CAMS) compared to treatment as usual (TAU) for suicidal patients: study protocol for a randomized controlled trial.

BackgroundCollaborative Assessment and Management of Suicidality (CAMS) is a therapeutic framework that appears promising to reduce suicidal ideation and suicidal cognition. CAMS has not previously been evaluated in a standard specialized mental health care setting for patients with suicidal problems in general. In this pragmatic randomized controlled trial (RCT) we will investigate if CAMS is more effective than treatment as usual (TAU) in reducing suicidal thoughts and behaviors. Effects will also be investigated on mental health and symptom relief in general and upon readmissions to inpatient units.Methods/designThe study is a multicenter, observer-blinded, superiority, two-armed RCT which will include patients from four clinical departments at Vestre Viken Hospital Trust, Norway. We aim to include 100 patients with moderate to strong suicidal problems, as defined by a score of 13 or more on Beck’s Scale for Suicide Ideation - Current. Patients are included regardless of diagnosis. Randomization will be performed using a stratified four-block procedure with treatment unit as the stratification variable. The duration of treatment will vary depending on patients’ needs and clinical assessments. Patients are interviewed by research staff at four checkpoints: baseline, 2 weeks, 6 months, and 12 months. Central outcome measures are the Beck Scale for Suicide Ideation - Current, Outcome Questionnaire – 45, and Suicide Attempt Self-Injury Count.DiscussionThis pragmatic trial is effectuated within the Public Health Care System in Norway, where patients have multiple problems and diagnoses and therapists have a high work load. Results from this trial are highly generalizable to a typical everyday clinical setting, and one should expect similar results if CAMS is implemented in the future as a standard component in specialized mental health care systems.Trial registrationOpen Science Framework: DOI 10.17605/OSF.IO/JHRM2. Registered 5 July 2015. ClinicalTrials.gov: NCT02685943. Registered on 8 February 2016.

EFFECTIVENESS OF DIALECTICAL BEHAVIOR THERAPY VERSUS COLLABORATIVE ASSESSMENT AND MANAGEMENT OF SUICIDALITY TREATMENT FOR REDUCTION OF SELF-HARM IN ADULTS WITH BORDERLINE PERSONALITY TRAITS AND DISORDER-A RANDOMIZED OBSERVER-BLINDED CLINICAL TRIAL

Many psychological treatments have shown effect on reducing self-harm in adults with borderline personality disorder. There is a need of brief psychotherapeutical treatment alternative for suicide prevention in specialized outpatient clinics. The DiaS trial was designed as a pragmatic single-center, two-armed, parallel-group observer-blinded, randomized clinical superiority trial. The participants had at least two criteria from the borderline personality disorder diagnosis and a recent suicide attempt (within a month). The participants were offered 16 weeks of dialectical behavior therapy (DBT) versus up to 16 weeks of collaborative assessment and management of suicidality (CAMS) treatment. The primary composite outcome was the number of participants with a new self-harm (nonsuicidal self-injury [NSSI] or suicide attempt) at week 28 from baseline. Other exploratory outcomes were: severity of borderline symptoms, depressive symptoms, hopelessness, suicide ideation, and self-esteem. At 28 weeks, the number of participants with new self-harm in the DBT group was 21 of 57 (36.8%) versus 12 of 51 (23.5%) in the CAMS treatment (OR: 1.90; 95% CI: 0.80-4.40; P = .14). When assessing the effect of DBT versus CAMS treatment on the individual components of the primary outcome, we observed no significant differences in the number of NSSI (OR: 1.60; 95% CI: 0.70-3.90; P = .31) or number of attempted suicides (OR: 2.24; 95% CI: 0.80-7.50; P = .12). In adults with borderline personality traits and disorder and a recent suicide attempt, DBT does not seem superior compared with CAMS for reduction of number of self-harm or suicide attempts. However, further randomized clinical trials may be needed.

Successful Treatment of Suicidal Risk.

In this article we focused on analyzing surveyed patient-generated responses based on two outcome questions derived from a suicide-specific framework called the Collaborative Assessment and Management of Suicidality (CAMS): Q1 - "Were there any aspects of your treatment that were particularly helpful to you? If so, please describe these. Be as specific as possible." Q2 - "What have you learned from your clinical care that could help you if you became suicidal in the future?" To develop a reliable coding system based on formerly suicidal patients' responses to two open-ended prompts and examine most frequently identified themes. The present study utilized a consensual qualitative research process to examine responses of clinically resolved suicidal patients, based on the CAMS resolution criteria (i.e., three consecutive CAMS sessions reporting the effective management of suicidal risk), to two Suicide Status Form (SSF) outcome questions (n = 49 for Q1, and n = 52 for Q2). Reliable coding systems were developed and used to determine major themes of successful patient responses. The results of this study provide insight into patients' experiences of a successful treatment for suicidal risk with larger implications for suicide-specific treatments in general.

RCT evaluating provider outcomes by suicide prevention training modality: in-person vs. e-learning

Purpose – The purpose of this paper is to evaluate provider outcomes in response to two modes of suicide prevention training (e-learning and in-person) and a control group. The Collaborative Assessment and Management of Suicidality (CAMS) was adapted for e-learning delivery to US Veterans Administration mental health providers. Outcomes include: self-evaluated beliefs, ability, and self-efficacy in managing suicidal patients. Design/methodology/approach – This study used a multicenter, randomized, cluster design to test the effectiveness of e-learning vs in-person conditions CAMS for changes in provider outcomes. Findings – Survey scores showed significant improvements for both the e-learning vs control and the in-person vs control between pre-intervention and post-intervention; however, the e-learning and in-person conditions were not significantly different from each other. Research limitations/implications – Limitations of the study include that there were drop-outs over the study period and the survey questions may not have captured all of the aspects of the CAMS training. Practical implications – Results suggest that e-learning training modules can provide comparable outcomes to in-person training for suicide prevention. Social implications – More providers may have accessible training materials for managing suicidal patients. Originality/value – Currently practicing providers now can choose between two equivalent training modalities for improving the management of suicidality in their patients.

Treating suicidal risk in a post-healthcare reform era

Purpose– The purpose of this paper is to fully consider the potential changes in clinical suicide prevention that may evolve after the passing of the Patient Protection and Affordable Care Act (ACA). The authors argue that it is wise to anticipate demand for suicide-specific evidence-based treatments (EBTs) moving forward. The authors outline current best practices in clinical suicide prevention, and describe the Collaborative Assessment and Management of Suicidality (CAMS) as an example of how a suicide-focussed EBT can adapt to some predicted changes.Design/methodology/approach– This conceptual paper first presents an overview of the main effects of ACA within the behavioral health care (BHC) system. Next, the authors review contemporary approaches to the treatment of suicidal patients, as well as current treatment limitations. The authors present CAMS as a model of a suicide-focussed EBT that holds promise for use in the post-ACA era. To close, the authors discuss anticipated changes in suicide treatment and illustrate that CAMS is adaptable to these changes.Findings– ACA mandates several changes: implementation of EBTs, better preventative care, integrated treatment models, and improved healthcare administration. A central effect of ACA in BHC is the increased use of EBTs. Therefore effective EBTs for suicide prevention are described.Originality/value– Anticipating how ACA will affect clinical suicide prevention is necessary, as it is historically a very challenging area of treatment within BHC and a significant public health concern. This paper highlights the importance of the use suicide-specific EBTs.

Impact of a Suicide-Specific Intervention within Inpatient Psychiatric Care: The Collaborative Assessment and Management of Suicidality.

A growing body of literature indicates that suicidal patients differ from other psychiatric patients with respect to specific psychological vulnerabilities and that suicide-specific interventions may offer benefits beyond conventional care. This naturalistic controlled-comparison trial (n=52) examined outcomes of intensive psychiatric hospital treatment (mean length of stay 58.8days), comparing suicidal patients who received individual therapy from clinicians utilizing the Collaborative Assessment and Management of Suicidality (CAMS) to patients whose individual therapists did not utilize CAMS. Propensity score matching was used to control for potential confounds, including age, sex, treatment unit, and severity of depression and suicidality. Results showed that both groups improved significantly over the course of hospitalization; however, the group receiving CAMS showed significantly greater improvement on measures specific to suicidal ideation and suicidal cognition. Results are discussed in terms of the potential advantages of treating suicide risk with a suicide-specific intervention to make inpatient psychiatric treatment more effective in reducing risk for future suicidal crises.

Implementation of Online Suicide-Specific Training for VA Providers

Due to the gap in suicide-specific intervention training for mental health students and professionals, e-learning is one solution to improving provider skills in the Veterans Affairs (VA) health system. This study focused on the development and evaluation of an equivalent e-learning alternative to the Collaborative Assessment and Management of Suicidality (CAMS) in-person training approach at a Veteran Health Affairs medical center. The study used a multicenter, randomized, cluster, and three group design. the development of e-CAMS was an iterative process and included pilot testing. Eligible and consenting mental health providers, who completed a CAMS pre-survey, were randomized. Provider satisfaction was assessed using the standard VA evaluation of training consisting of 20 items. Two post training focus groups, divided by learning conditions, were conducted to assess practice adoption using a protocol focused on experiences with training and delivery of CAMS. A total of 215 providers in five sites were randomized to three conditions: 69 to e-learning, 70 to in-person, 76 to the control. The providers were primarily female, Caucasian, midlife providers. Based on frequency scores of satisfaction items, both learning groups rated the trainings positively. In focus groups representing divided by learning conditions, participants described positive reactions to CAMS training and similar individual and institutional barriers to full implementation of CAMS. This is the first evaluation study of a suicide-specific e-learning training within the VA. The e-CAMS appears equivalent to the in-person CAMS in terms of provider satisfaction with training and practice adoption, consistent with other comparisons of training deliveries across specialty areas. Additional evaluation of provider confidence and adoption and patient outcomes is in progress. The e-CAMS has the potential to provide ongoing training for VA and military mental health providers and serve as a tutorial for psychiatrists in preparation for specialty boards.

Applying the collaborative assessment and management of suicidality (CAMS) to suicidal adolescents.

Applying the collaborative assessment and management of suicidality (CAMS) to suicidal adolescents.