An Initial Feasibility Study of Brief Cognitive Behavioral Therapy for Suicidal Inpatients
Trial Snapshot
- Phase
- Not Applicable
- Status
- Completed
- Sponsor
- Hartford Hospital
- Enrollment
- 8
- Locations
- 2
- Primary Endpoint
- Suicidal Ideation Intensity as Measured by the Columbia-Suicide Severity Rating Scale (C-SSRS) Intensity Subscale.
Study Overview
Brief Summary
Suicide is a major public health problem. Although inpatient treatment provides immediate stabilization and crisis management, the risk of suicide post-discharge is substantial. Approximately one third of all suicides by individuals with mental disorders occur in the 90 days following hospitalization. Cognitive behavioral therapy (CBT) has been shown to reduce both suicidal ideation and behavior in outpatients. However, to date, the efficacy of inpatient CBT for suicide prevention is not clear. This study aims to 1) develop and implement a brief CBT treatment for suicide prevention for inpatients, 2) conduct a brief feasibility test and collect initial pilot data on efficacy, and 3) collect preliminary data on the effects of CBT on implicit cognitive suicide associations. In Phase 1, the investigators will work with an expert in CBT for suicide prevention to modify his treatment protocol for use with inpatients, and meet with this expert for a 2-day protocol training. In Phase 2, the investigators will conduct an initial feasibility trial with 5-10 inpatients recruited from the Institute of Living inpatient units. Participants will be recruited within 24 hrs of admission or later and will provide written informed consent prior to any study procedures. Enrolled participants will undergo a clinical assessment by an independent evaluator (IE) that will include diagnostic/symptom assessments, assessment of suicide risk using the Columbia-Suicide Rating Scale, and an implicit association test (IAT). Participants will receive up to 10 daily sessions of CBT (depending on length of stay), lasting 1 hour, following the manualized protocol developed in Phase 1. Participants will then meet with the IE again for reassessment after the 10th session or within 24 hr prior to discharge, whichever comes first. After discharge, participants will have a telephone interview at 1 month, 2 month, and 3 month follow-up. The IE will administer the C-SSRS during these calls. The proposed study will yield feasibility and initial efficacy data that will be used to inform a grant proposal to the American Foundation for Suicide Prevention. That proposal will fund a randomized controlled trial of CBT vs. treatment as usual. Concurrently, the investigators will develop an in-house program to train other staff in the protocol, and will submit a second grant to investigate the efficacy of the training program as well as the efficacy of CBT by those clinicians.
Detailed Description
Rationale. Suicide is a major public health problem: suicidal ideation affects 14% of the adult U.S. population, and as many as 5% have a lifetime history of suicide attempts.1 Among individuals with depressive disorders, there is an 11% mortality rate from suicide.2 Although inpatient treatment provides immediate stabilization and crisis management, the risk of suicide post-discharge is substantial. Approximately one third of all suicides by individuals with mental disorders occur in the 90 days following hospitalization.3 A review of nearly 2 million adult psychiatric inpatients found that the suicide rate in the 90 days after discharge for patients diagnosed with depressive disorders was 235.1 per 100,000 person-years, markedly higher than that in the US general population (14.2 per 100,000 person-years).4
Cognitive behavioral therapy (CBT) has been shown to reduce both suicidal ideation and behavior.5-8 Though specific protocols vary, typical interventions include problem-solving training,9 cognitive restructuring,10 and training in emotion regulation skills.11 To date, most of the existing research on CBT has been in outpatient samples, and the efficacy of inpatient CBT for suicide prevention is not clear.
Project Aims. The aims of the proposed project are to:
- develop and implement a brief CBT for suicide prevention on the adult inpatient units;
- conduct a brief feasibility test and collect initial pilot data on efficacy; and
- collect preliminary data on the effects of CBT on implicit cognitive suicide associations.
Method. The investigators selected Rudd et al.'s12 CBT protocol for the proposed project. This protocol was tested in a randomized controlled trial (RCT) of outpatients and resulted in a significant reduction in suicide attempts over a 24-month follow-up assessment (hazard ratio = 0.38); those receiving CBT were 60% less likely to make a suicide attempt than were those receiving treatment as usual.13 Of the 6 RCTs that measured suicidal behavior, this was the strongest behavioral effect documented.7
Study Design
- Study Type
- Interventional
- Allocation
- Na
- Intervention Model
- Single Group
- Primary Purpose
- Treatment
- Masking
- None
Eligibility Criteria
- Ages
- 18 Years to 65 Years (Adult, Older Adult)
- Sex
- All
- Accepts Healthy Volunteers
- No
Inclusion Criteria
- •males and females
- •age 18-65 inclusive
- •fluent in English (speaking, reading, and writing)
- •having made a suicide attempt within one week preceding admission. Admission will be defined as admission to either Hartford Hospital medical floor (in cases where medical stabilization is required prior to transfer to IOL) or to IOL (in cases where medical stabilization is not required). A suicide attempt will be defined as behavior that is self-directed and deliberately results in injury or the potential for injury to oneself for which there is evidence, whether explicit or implicit, of intent to die.
Exclusion Criteria
- •age <18 or ≥66 years old
- •history of schizophrenia spectrum disorder
- •history of mental retardation or organic brain illness
- •current substance use disorder
- •active mania or other psychiatric or medical condition that would preclude informed consent or participation in the trial, in the investigator's opinion
- •ECT included on patient's inpatient treatment plan. Patients who are referred for ECT after starting the study will be withdrawn from the study.
Outcomes
Primary Outcomes
Suicidal Ideation Intensity as Measured by the Columbia-Suicide Severity Rating Scale (C-SSRS) Intensity Subscale.
Time Frame: Pre-treatment, after treatment which was an average of 16 days, and through follow up, an average of 3 months post-treatment
The CSSRS intensity subscale measures frequency, duration, controllability, deterrents, and reasons for suicidal ideation. The scale ranges from 2-25 with higher scores indicating more severe suicidal ideation.
Secondary Outcomes
- Structured Interview Guide for the Hamilton Rating Scale for Depression (SIGH-D)(Pre-treatment through post-treatment up to 24 days, 16 days on average)
Investigators
David Tolin
Director, Anxiety Disorders Center
Hartford Hospital