As discussed elsewhere, there are over 80 randomized controlled trials (RCTs) of treatments where suicide-related outcomes are the primary focus [20,62]. Within clinical science, RCTs are the gold standard of what has proven effective in a causal manner because of their reliance on experimental designs and a-priori hypothesis testing. RCTs that have replicated results, particularly when results have been replicated by independent investigators rise to the top of the list when we consider empirically validated interventions. There are a number of interventions that have shown promise in a single RCT, for example, the Attempted Suicide Short Intervention Program (ASSIP) and Mentalization-Based Therapy [63,64]. However, we will focus on treatments that have been replicated and have independent RCT support. These include four distinct treatments/interventions that have been shown to effectively target suicidality.

Dialectical Behavior Therapy Treatment

The most notable and heavily researched treatment that has been shown to reduce suicidal behaviors regardless of the intent to die, is Dialectical Behavior Therapy (DBT) [65,66]. DBT has four main components: individual therapy, skills training, phone coaching, and a consultation team. DBT’s main goal is to teach the patient skills to regulate emotions and improve relationships with others (suicidality is always targeted at the forefront of care). Skills are taught through validation and acceptance with a genuine focus on behavioral change. DBT was one of the first evidence-based treatments shown to be effective in decreasing repetitive self-harm behaviors and suicide attempts. More recent results have demonstrated DBT’s continued impact on decreasing suicidal behaviors among high risk individuals such as those with borderline personality disorder [67], and decreasing suicide ideation [68] and self-harm [69] among adolescents. However, while DBT has shown impressive results in managing suicidal behaviors [70], it is not solely devoted to treating suicidality, and replicated results for reliably decreasing suicidal ideation are not consistent across all DBT RCTs.

Cognitive Therapy for Suicide Prevention

Another effective treatment that targets the “suicidal mode” is Cognitive Therapy for Suicide Prevention (CT-SP) [71]. CT-SP treats the clinical characteristics of suicidal behaviors [72] by using various cognitive therapy techniques, which have proven successful for treating an extensive array of psychiatric disorders [73]. In a well-powered RCT (with a deliberately longer follow-up period than previous RCTs—18 months), Brown and colleagues [71] found that patients in CT-SP treatment were 50% less likely to attempt suicide compared to those in the usual care treatment group. The researchers also found significant reductions in levels of depression and hopelessness in the CT-SP treatment group compared to the control. This study showed high internal validity; replication of the data in a real world setting (e.g., a community-based outpatient setting) with varied samples (e.g., those who have not attempted suicide, but with severe ideation) is a pending next step for the researchers of CT-SP [71].

Brief Cognitive Behavior Therapy for Suicidal Patients

Brief Cognitive Behavior Therapy (BCBT) was used in one well-powered RCT with suicidal, active duty U. S. Army Soldiers and was shown to be effective for reducing suicide attempts [29]. As its name indicates, this modality is brief (i.e., 12 sessions) to accommodate short-term treatment environments. This variation of CBT suicide-focused care emphasizes: common effective treatment elements, developing skills (e.g., emotion regulation, mindfulness), a focus on the suicidal mode, and the development of self-management. Rudd and colleagues followed soldiers for 24 months [29] and found that compared to treatment as usual, those in the brief CBT group were 60% less likely to attempt suicide.

The Collaborative Assessment and Management of Suicidality

Jobes describes the Collaborative Assessment and Management of Suicidality (CAMS) as a distinctive therapeutic framework that targets suicidality [32]. As a framework, not a new psychotherapy, the CAMS intervention does not require clinicians to give up their theoretical orientation or abandon reliable techniques. Indeed, CAMS is a “non-denominational” approach where potentially any treatment can be used within the framework [31]. In RCTs comparing CAMS to usual care control conditions there is strong evidence that CAMS significantly reduces suicidal ideation [74–76] and overall psychiatric distress [74,76]; it also increases hope and retention to care [74]. In on RCT comparing DBT to CAMS, CAMS did as well as DBT in reducing suicidal attempts and self-harm behaviors [77]. Beyond the initial four published RCTs, five additional CAMS RCTs are in various stages of completion and will add to this growing body of literature.

Stepped Models of Care

Finally, because this journal broadly addresses public health issues, it is important to wrap up our discussion by focusing on some major considerations that impact clinical care before we discuss two different conceptual models for thinking about suicide-specific clinical care that might optimize treatment outcomes and thereby save more lives.

The Stigma of Mental Health Care and Suicidality

In the investigation of the challenges posed by suicidal risk, one of the most striking issues is that the majority of suicidal people simply do not seek mental health treatment. Indeed, in their review of the literature Luoma et al. found that only 19% sought mental health care in the month prior to their death [78], while 32% sought mental health care in the year prior to their suicide. Using National Violent Death Reporting System data, Niederkrotenthaler and colleagues [79] found that only 38.5% suicide decedents were engaged in mental health care within two months of their death.

Furthermore, a sample of 198 suicidal people noted that “using the mental health system” was their #4 coping strategy (preceded by “spirituality/religious practices,” “talking to someone and companionship,” and “positive thinking”) [41]. Frankly, many suicidal people do not want to seek professional treatment because of their negative attitudes towards mental health care [80]. As Allen and colleagues have noted [42], when suicidal people do seek professional care (e.g., ED-based care), they want something different than what they get (e.g., a more humanistic and person-centered clinical response).

Matching Different Treatments to Personalize Suicidal Treatment

Despite the aforementioned concerns, we believe that the notion of prescriptive suicide-focused treatments is now increasingly possible. As shown in the lower half of Figure 1, the discussion begins with suicidal people who do not want to seek professional care. As we noted, this population make up the majority of the suicidal population. We can aspire to educate, provide access to the National Lifeline, and if they touch healthcare systems, perhaps we can endeavor to provide caring follow-up.

However, beyond these largely public health-oriented approaches, we do not know exactly how to reach this group. Perhaps the evolving lived-experience perspective and peer-support movement can provide a more accessible and less stigmatizing approach for this population.

Figure 1. Different suicidal states include suicidal ideators (SI), suicide attempters (SAs), and multiple SAs. For those that seek mental health care: (SI) may be best matched to the Collaborative Assessment and Management of Suicidality (CAMS), SAs may be best matched to Cognitive Therapy for Suicide Prevention (CT-SP) or Brief Cognitive Behavior Therapy (BCBT), and dysregulated individuals with borderline personality disorder (BPD) with a multiple SA history may be best matched to Dialectical Behavior Therapy (DBT). Those that are suicidal but do not seek mental health treatment may be best matched to those with live-experienced and peer-based supports. Lifeline = the United States national suicide prevention lifeline phone number: 1-800-273-TALK (8255).

Considering the upper half of the Figure 1, for those suicidal people seeking mental health care, in an ideal world, machine-learning algorithms could be used to optimally route patients to proven treatments that are best suited to care for different suicidal states—a version of empirically-based prescriptive suicide-focused treatments. It should be noted that similar components (e.g., stabilization planning, lethal means safety, etc.) tend to be integral in each of these effective treatments. As a final note, while focusing on suicide attempts and deaths is important and necessary, we also need to bring more attention to the massive population of seriously suicidal ideators, who represent the figurative iceberg under the water of the suicide prevention challenge, if we want to reduce suicidal attempts and completions [3].

From an even larger perspective, Figure 2 (adapted from an earlier figure that appears in [81]) depicts a “stepped care” model for suicide care. The healthcare costs, represented on the y-axis, are probably the single biggest force shaping healthcare practices in the real world. To this end, the top of the pyramid notes the most expensive systems-level interventions (i.e., inpatient psychiatric hospitalization) down to the least expensive interventions nearer the bottom of the pyramid. Moreover, the bottom layer reflects the need to grow a massive paraprofessional community of caring people who are trained to work with people at risk. Jobes has therefore called for the development of a “National Mental Health Service Corps” (similar to the United States Peace Corps founded in the 1960s) that could create a large community of volunteers and (or) provide caring individuals who could serve in a range of capacities, such as screening and peer-based support with proper training and supervision [82]. There will never be enough clinical providers to meet the needs of 10.6 million adults with serious suicidal thoughts (in the United States example). Indeed, such personnel could provide much needed care on the National Lifeline, which is currently facing significant capacity issues.

Figure 2. The y-axis is mental health care costs; the steps of the pyramid correspond from the bottom to the top with the least restrictive intervention the most restrictive intervention. ASSIP = Attempted Suicide Short Intervention Program; BCBT = Brief Cognitive Behavior Therapy; CAMS = Collaborative Assessment and Management of Suicidality; CT-SP = Cognitive Therapy for Suicide Prevention; DBT = Dialectical Behavior Therapy; MI = Motivational Interviewing; PACT = Post Admission Cognitive Therapy; TMBI = Teachable Moment Brief Intervention.

As we move up the levels of systems within the pyramid, the use of different evidence-based treatments described in this article can be layered in each level of clinical care. Ultimately this stepped care model provides a way of thinking broadly to providing cost-effective, least-restrictive, evidence-based care for those at risk for suicide. If we truly aim to make a lifesaving difference, public and mental policy shaped by this kind of approach might make a meaningful difference by reducing suicides and suicide-related suffering in all its forms.

Summary and Conclusions

We have argued in this article that to move the field of mental health forward in terms of suicidal risk, we must move away from a “one-size-fits-all” approach to working with suicidal people. Rather, an approach that matches different evidence-based suicide-focused treatments (i.e., DBT, CT-SP, BCBT, and CAMS) to different suicidal states is clearly needed. We also need thoughtful conceptual models and progressive evidence-based policies (e.g., Zero Suicide) to optimally engage those suicidal people who do not seek care. Finally, an array of professional and paraprofessional approaches (e.g., including the support of those with lived experience) and various services are needed to better support those people who battle with suicidal thoughts, feelings, and behaviors.

Conflicts of Interest: David Jobes has conflicts to disclose related to grant funding from the National Institute of Mental Health and the American Foundation for Suicide Prevention; he receives book royalties from the American Psychological Association Press and Guilford Press; and he is the founder of CAMS-care, LLC (a professional training and consultation company). Samantha Chalker has no conflicts to disclose.

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Full article originally published September 26, 2019 in International Journal of Environmental Research and Public Health

The Problem: Suicide is a Major Public Health Issue

Suicide accounts for almost 800,000 deaths per year [1] around the world. In the United States suicide is the 10th leading cause of death with approximately 47,000 total deaths in 2017 and 1.4 million American adults attempted suicide in that same year [2]. While suicidologists and public health officials are understandably preoccupied with suicide deaths and suicide attempts, Jobes and Joiner [3] have recently reflected on the massive population of people who experience suicidal ideation and all too often escape the attention of our suicide prevention research, clinical treatments, and even national health care policies. In the United States, 10,600,000 American adults experience serious suicidal thoughts [4]—a worrisome cohort that dwarfs the populations of those who attempt and die by suicide.

To fully address the many challenges to clinical suicide risk reduction we will consider: the history of mental health care and its legacy for suicidal patients, the notion of mindsets about how to best help care for suicidal people, various contemporary developments that may be changing mindsets about clinical suicide prevention, the historic pursuit of suicidal typologies, evidence-based suicide-focused treatments, and finally a stepped care public health model.

History of Suicide Prevention

The history of the field of mental health and the treatment of suicidal patients is rather sordid and includes many disturbing developments over the years. Prior to European enlightenment, the mentally ill were largely understood to be deviants possessed by the devil and (or) evil spirits; religious exorcisms were frontline “treatments” [5]. It is interesting to note that some form of ritual exorcism exists across the major world religions (e.g., Christianity, Judaism, Hinduism, and Islam). It was not until the latter 18th century that mentally ill “lunatics” began to be understood and treated with more compassion as patients with an illness. The innovative French doctor Phillippe Pinel famously ordered in 1795 that mentally ill patients be released from their chains at a large asylum named la Salpetriere outside of Paris. This launched the notion of “moral treatment,” which helped change perceptions about mental illness and how such people with these illnesses should be treated [6]. Unfortunately, the continued association of mental illness with “asylums” of this era and in the years that followed does not seem either enlightened or particularly moral.

Early “treatments” of the mentally ill were crude and physically harmful (e.g., bloodletting and trephination—the drilling of holes in the cranium) [5]. Various methods of inducing seizures or comas were explored and collectively referred to as shock therapies in the early 20th century [7]. There was extensive experimentation using electricity that ultimately resulted in the development of electro-convulsive therapy (ECT), which in the present day has been found to be helpful as a last resort for patients with treatment-resistant, severe depression [8]. Massive doses of insulin were repeatedly administered to patients with schizophrenia to induced comas—insulin coma therapy (ICT) [9]. Behavior-altering surgeries such as lobotomies and cingulotomies were used often in the mid-20th century to control patient behavior [5].

Psychopharmacology Treatment of Suicidal Patients

Psychiatric care of the mentally ill took a notable turn in the 1950s with the advent of first-generation antipsychotic medications. The evolution of psychotropic medications has been extensive and has come to shape the prevailing assumptions about suicidal patients—that treating a mental disorder is the key to reducing the symptoms of suicidal ideation and behavior.

While medications have undoubtedly helped many who suffer from mental disorders, there is extensive evidence that targeting and treating mental disorders has little or mixed impact on suicidal risk [10–12]. Despite the widespread use of medication, there is fairly limited data (based on randomized controlled trials—RCTs) about the efficacy of medicine on suicidality [13]. For example, the emergent use of ketamine on suicidal ideation for a few days [14] has short-lived e for some suicidal patients. There is meta-analytic support for lithium carbonate among suicidal bipolar patients [15] and one un-replicated RCT has shown that clozapine can reduce suicidal ideation and attempts among thought-disordered patients [16]. Data on the effectiveness of anti-depressants with suicidal risk are quite mixed [10]. Notably, there are now three meta-analyses showing that treating mental disorders has little to no impact on suicidal ideation and behavior [10–12]. Notwithstanding the lack of evidence, prominent experts (e.g., [17]) insist on the primacy of treating mental disorders to reduce suicidal risk, even trivializing the effectiveness of suicide-focused psychological treatments that have been proven to work by replicated data from rigorous randomized controlled trials.

Legacy of Mental Health

So, what is the legacy of our history of managing and treating mentally ill people? On the one hand, humanity has been able to move from superstition and fantastic explanations for abnormal behavior to a more clinical and interventive approach. On the other hand, the legacy has created a “doctor knows best” mentality marked by a custodial, coercive, and paternal model that largely centers on controlling behaviors, by force if necessary. Relevant to our present consideration of the suicidal patient, a further remnant of this history is the idea that suicidal people belong in the hospital and that being suicidal is by definition “crazy,” so we must therefore treat this particular form of insanity. There are of course consequences to such considerations. Indeed, there is evidence that negative views of inpatient psychiatric care and fear of being hospitalized may compel suicidal patients to not be forthright with their clinical provider about their suicidal thoughts [18]. Moreover, insisting on the pre-eminence of treating mental disorders (particularly using only medicine) for suicidal risk defies the extensive evidence-base that supports the effectiveness of targeting and treating suicidal ideation and behaviors independently of psychiatric diagnoses (refer to [19]).

A Fixed Mindset about Suicidal Patient Care?

To be balanced and fair, we agree that countless suicidal people have likely been helped by inpatient psychiatric care and psychotropic medications. Nevertheless, the previously discussed lack of suicide-specific evidence is rather striking. To this end, Jobes has argued that some contemporary providers may make assumptions about the presumed effectiveness of inpatient care and the use of medicine on suicidal risk [20]. Importantly, such presumptions can have a major impact on the patient’s clinical disposition, and even the course of their entire life. What is particularly concerning is that some clinicians may find themselves not always working in the patient’s best interest due to countertransference issues or fear of litigation should a patient take their life. In turn, such issues and fears may lead to overly defensive practices (e.g., hospitalizing a patient who has passive suicidal thoughts). Moreover, such practice behaviors may be shaped by wishful thinking that a three to six-day hospital stay or that treating the mental disorder with medicine is actually more effective for suicidal risk than alternative approaches that are supported by the data.

Thus, there may be a misguided notion that a “one-size” approach (i.e., a brief hospitalization and medication to treat the disorder) will work for all suicidal patients [21]. Another way of understanding the possible insistence by some that these approaches are effective can be explained by Stanford psychologist Carol Dweck’s [22] notion of a psychological “mindset.” Dweck’s empirical work has shown the existence of two distinct mindsets: a “fixed” mindset versus a “growth” mindset. Her research shows how these mindsets are reliably associated with different outcomes for personal and professional success, and a growth mindset is much more adaptive and linked to successful outcomes.

Given this line of thinking, is it possible that many mental health providers have developed a certain fixed mindset about what is best for a suicidal person? It is hard for anyone to say with certainty, but in our view, the effective assessment and treatment of suicidal risk requires a growth mindset so that we are better able to embrace suicide-focused approaches that are supported by RCT evidence. Also, we must collectively develop a growth mindset at the public health policy level to fully appreciate that a “one-size” approach to suicidality does not sufficiently address the worldwide challenge of suicidal risk [21].

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