COGNITIVE APPROACHES TO SUICIDE Center for Disease Control and Prevention February 6, 2004 Aaron T. Beck, M.D. Gregory K. Brown, Ph.D. University of Pennsylvania

REVIEW OF STUDIES I. CLASSIFICATION

NIMH TASK FORCE 1969 ATTEMPTED SUICIDE 1.Degree of Intent 2.Degree of Medical Lethality SUICIDE IDEATION 1.Degree of Intent 2.Degree of Medical Lethality COMPLETED SUICIDE 1. Degree of Intent

Definition of a Suicide Attempt “a potentially self-injurious behavior with a nonfatal outcome, for which there is evidence (either explicit or implicit) that the person intended at some (nonzero) level to kill himself/herself.” Source: O’Carroll, Berman, Maris, Moscicki, Tanney, & Silverman (1996)

Intentional Self-Injury Behavior Suicide Intent Definite Uncertain/ Potential None Definite Definite Suicide Attempt (1) Possible Suicide Attempt (2) Suicide Ideation Uncertain Possible Suicide Attempt (3) Possible Suicide Attempt (4) Mild Suicide Ideation None Intentional Self-Injury Behavior without Suicide Intent (5) Possible/ Potential Self-Injury Behavior without Suicide Intent (6)

II. ASSESSMENT

INSTRUMENT DEVELOPMENT 1.MEDICAL LETHALITY (BIOLOGICAL DAMAGE) SCALE 2.SUICIDE INTENT SCALE (FOR ATTEMPTERS) POST-SUICIDE SCALE a. Psychological Autopsy 4.SUICIDE IDEATION SCALE

5.HOPELESNESS SCALE 6.SUICIDE IDEATION AT WORST POINT 7.WISH TO LIVE – WISH TO DIE SCALE 8.BECK DEPRESSION INVENTORY – SUICIDE ITEM

CONSTRUCT VALIDITY 1.DEPRESSION SCALE, SUICIDE INTENT SCALE, POST SUICIDE INTENT SCALE, AND HOPELESSNESS SCALE CORRELATE SIGNIFICANTLY WITH MEDICAL LETHALITY

2.HOPELESSNESS CORRELATES MORE STRONGLY THAN DOES DEPRESSION WITH LETHALITY (INCLUDING DEATH). a.Hopelessness-intent correlation is high when depression is partialed out, but not vice-versa. b.Hopelessness correlation persists across all demographic and diagnostic groups. c.Hopelessness as a mediator between stressors and suicide.

III. PREDICTION OF SUICIDE

Risk Factors for Psychiatric Patients Sampled 6,891 psychiatric outpatients Conducted National Death Index search Identified 49 suicide cases All patients received structured interviews and standardized assessment measures Source: Brown, Beck, Steer, & Grisham (2000)

Predictive Validity Source: Brown, Beck, Steer, & Grisham (2000)

Adjusted Hazard Ratios For Suicide with Psychiatric Outpatients

Predictive Validity of Standardized Measures for Completed Suicide with Psychiatric Outpatients Odds Ratios Measure: Cut-off Score:> 22> 8> 2>

Wish to Die vs. Wish to Live and Completed Suicide with Psychiatric Outpatients Percent Who Committed Suicide N = 21 of 637 N = 23 of %.4% Odds Ratio = 7.4 (95% CI: ), p <.001

SUICIDE ATTEMPTERS

TENTATIVE CLASSIFICATION OF ATTEMPTERS 1.“PERSONALITY DISORDER” VS “DEPRESSIVES” “BORDERLINES” VS “NON-BORDERLINE DEPRESSIVES” b. CLASSICAL DEPRESSIVE: - Attempt related to steady progression of depression a. BORDERLINES: - More repeats - High degree of reactivity - Low control

CHARACTERISTICS OF ATTEMPTERS PERSONALITY DISORDERS ATTEMPT WHEN DISTRESSED 1.“Self-medicate” with drugs to relieve distress 2.Often feel shame, guilt, hopeless, after drug and then attempt 3.Low tolerance for frustration or distress 4.Poor problem solving 5.Defective self-control 6.More reality problems

DEPRESSIVE (n = 109) PERSONALITY DISORDER (n = 182) MALE27.5%53.3% WHITE53.2%51.6% AGE (YEARS)30.7%28.1% MARRIED24.8%14.5% SINGLE34.9%47.5% WIDOWED4.6%2.8% SEPARATED/ DIVORCED 31.2%27.9% COHABITATING4.6%7.3% SUICIDE AT 5 YR FOLLOW-UP 4.6%8.2%

CHARACTERISTICS OF EPISODIC DEPRESSIVE ATTEMPTERS ATTEMPT SUICIDE AT DEPTH OF DEPRESSION (IF NOT RETARDED) 1.Profound hopelessness and generalized cognitive distortions 2.Suicide ideation only during episode

Odds Ratios for Suicide with Suicide Attempters *p <.05

Sensitivity of Reaction to Attempt for Completed Suicide Percent Who Committed Suicide N = 9 of 176 N = 5 of 199N = 10 of 101 5% 2.5% 10% Odds Ratio:

Wish to Die vs. Wish to Live and Completed Suicide with Psychiatric Outpatients Percent Who Committed Suicide N = 21 of 637 N = 23 of %.4% Odds Ratio = 7.4 (95% CI: ), p <.001

IV: INTERVENTION

Cognitive Therapy for Suicide Attempters NIMH / CDC

Study Design

Inclusion and Exclusion Criteria Inclusion Criteria: –Patient must be evaluated at the ED within 48 hours of attempting suicide –Patient must complete a full baseline assessment within 3 weeks of making the attempt –Age 16 or older –Patient must have at least two verifiable contacts with telephone numbers –Must be able to provide informed consent Exclusion Criteria: –A severe incapacitating medical disorder that would prevent participation in psychotherapy

Recruitment 538 Patients Referred 186 were unable to be contacted 164 were excluded (not true attempters)  Of the 188 Eligible Patients Contacted 68 (36%) refused  120 Baselines Completed with 60 Patients assigned to CT+EC and 60 Patients assigned to EC

Sample Description

Age and Gender Mean Age 33.2 years SD = 9.7

Ethnicity %

Marital Status 7%

Yearly Income 66% Unemployed or Disabled

Method of Suicide Attempt Overdose 58% Cut 17% Jump 13% Hang 6% Traffic 3% CO2 3%

Type of Drug Used in Overdose

Psychiatric Diagnoses Mean Number of Axis I Diagnoses was 3 Most Patients had Major Depression with Co-Morbid Substance Use Disorder

Substance Use Diagnoses

Participation Bias 0.32, Other (n = 13) 0.22, African American (n = 151) 1.49, Caucasian (n = 89) CI (95%) OR Yes % (n=180) No % (n=112) Ethnicity Consent