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Suicide-Specific Psychotherapy for the Treatment of Suicidal Crisis: A Review of Clinical Effectiveness

CADTH Rapid Response Report: Summary with Critical Appraisal

, , , and .

Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; .

Abbreviations

AAQ-II

Acceptance and Action Questionnaire-II

BAI

Beck Anxiety Inventory

C-SSRS

Columbia-Suicide Severity Rating Scale

CAMS

Collaborative Assessment of Management of Suicidality

CD-RISC

Connor-Davidson Resilience Scale

CI

Confidence interval

CT/SP

Cognitive Therapy for Suicide Prevention

DBT-BSI

Dialectical Behavior Therapy-Brief Suicide Intervention

DERS

Difficulties in Emotion Regulation Scale

DT

Dialectic Therapy

E-CAU

Enhanced Care As Usual

ED

Emergency department

MBT

Mentalization based therapy

OHS

Optimism and Hope Scale

OQ-45

Outcome Questionnaire-45

PHQ

Patient Health Questionnaire

PIT

Psychodynamic Interpersonal Therapy

PRISMA

Preferred Reporting Items In Systematic review and Meta-Analyses

PST

Problem solving therapy

RCT

Randomized controlled trial

RT

Relaxation therapy

SASI-C

Suicide Attempt and Self-Injury Count

SCID

Structured Clinical Interview for DSM-IV

SCS

Suicide Cognitions Scale

SD

Standard deviation

SF-36

Medical Outcomes Study Short Form-36

SSI

Scale for Suicide Ideation

SUSI

Skills Used Since the Intervention

TAU

Treatment as usual

THI

Treatment History Interview

WHO

World Health Organization

WHO-5

World Health Organization Well-Being Index

WHODAS

World Health Organization Disability Assessment Schedule

Context and Policy Issues

Suicide is an important contributor to worldwide mortality, accounting for 1.4 per cent of all deaths in 2015 and described by the World Health Organization (WHO) as the second leading cause of death in adolescents and young adults aged 15 to 29.1 In Canada, suicide accounted for almost 12 in every 100,000 deaths in 2009, with males and adults aged 40 to 59 being more likely to commit suicide.2 In addition to the devastating loss of those who commit suicide, families and loved ones of those affected are left with grief,3 risk of mental illness,4,5 and a higher risk of suicide.6

In Canada, mental illness has been identified as a factor in an estimated 90 per cent of suicides;2 however, it is important to acknowledge that the causes of suicide are multifactorial and can include traumatic and stressful life circumstances, social, cultural, and psychological factors, combined with personal feelings of pain, desperation, and hopelessness.3,6,7 Suicide risk can be characterized as chronic or imminent; is challenging to define, and the outcome of suicide is very difficult for clinicians to predict.8

In 2016, the Public Health Agency of Canada published its “Federal Framework for Suicide Prevention” that states several key objectives to supporting a vision of suicide prevention, including reducing the stigma around suicide; increasing awareness and resources to prevent suicide, and; stimulating research into suicide prevention.6 It highlights the importance of conceptualizing and addressing suicide prevention along a continuum of risk, from early prevention of suicide in those not yet at risk, through to providing support and resources to those bereaved by suicide (also called ‘postvention’).6 In the middle of this conceptual continuum is the prevention of suicide in those at risk, or at high risk, of suicide.6

Research into interventions for the prevention of suicide has been developing for decades, with cognitive behavioural therapy (CBT)9–12 and problem-solving-based13–15 interventions being described repeatedly in the literature. In addition to these, several suicide-specific interventions have been developed and evaluated to prevent suicide among those at risk, including Dialectical Behavior Therapy (DBT), Cognitive Therapy for Suicide Prevention (CT-SP), and the Collaborative Assessment and Management of Suicidality (CAMS).16 One systematic review reported that interventions designed to directly address suicidality — as opposed to other mental health constructs — may have important benefits on suicide outcomes.17 Nonetheless, research describing suicide prevention interventions has been described as insufficient.18

Suicide-specific psychotherapies have, nonetheless, been identified as potentially beneficial interventions for those at a high risk of suicide, or experiencing a suicidal crisis.19 Thus, this report aims to synthesize available evidence on the clinical effectiveness of suicide-specific psychotherapies, and comparative clinical effectiveness of suicide-specific psychotherapies in those experiencing a suicidal crisis.

Research Questions

  1. What is the clinical effectiveness of suicide-specific psychotherapies versus psychotherapies without a suicide-specific focus for the treatment of suicidal crisis?
  2. What is the comparative clinical effectiveness of the various suicide-specific psychotherapies for the treatment of suicidal crisis?

Key Findings

Three randomized controlled trials, and two reports of one non-randomized cohort study were identified describing the clinical effectiveness of suicide-specific interventions versus interventions without a suicide-specific focus for those experiencing a suicidal crisis. One of the included randomized controlled trials examined United States military personnel whereas the remaining studies examined civilian patients and individuals. The two reports of a non-randomized study described pilot results in the earlier paper and longer-term follow-up in the later paper. No eligible studies were identified describing the comparative clinical effectiveness of two or more suicide-specific interventions for suicidal crisis.

Three randomized controlled trials reported improvements in suicidal ideation and behaviour after both suicide-specific and non-suicide-specific interventions; but described no consistent, statistically significant differences overall between groups of patients receiving these interventions. Two reports of a non-randomized study emphasized a statistically significant improvement in suicidal ideation and behaviour between hospital admission and discharge for inpatients receiving a suicide-specific intervention versus a non-suicide-specific intervention; however, these relative improvements were not sustained at six months of follow up. Other outcomes investigated included measures of mental health, well-being, and health care utilization. Similar to the suicide-specific outcomes, included studies generally reported improvements in mental health, well-being and health care utilization outcomes in patients receiving either suicide-specific or non-suicide-specific interventions; however, sustained differences between treatment groups were not observed. Authors of most included studies suggested that suicide-specific and non-suicide-specific interventions are effective interventions for patients experiencing suicidal crisis. However, given the lack of long-term or consistent data supporting the comparative effectiveness of suicide-specific versus non-suicide specific interventions; research from additional studies remains necessary.

Methods

Literature Search Methods

A limited literature search, with main concepts appearing in title or major subject heading, was conducted on key resources including Medline, PsycINFO, PubMed, The Cochrane Library, University of York Centre for Reviews and Dissemination (CRD) databases, Canadian and major international health technology agencies, as well as a focused Internet search. No filters were applied to limit retrieval by publication type. Where possible, retrieval was limited to the human population. The search was also limited to English language documents published between January 1, 2010 and April 26, 2018.

Selection Criteria and Methods

One reviewer screened and selected each of the citations returned from the literature searches. In the first level of screening, titles and abstracts were reviewed and potentially relevant articles were retrieved in full-text to be assessed for eligibility. A second, independent reviewer completed the screening and selection of full-text articles, which was based on the inclusion criteria presented in Table 1:

Table 1. Selection Criteria.

Table 1

Selection Criteria.

Exclusion Criteria

Articles were excluded if they did not meet the selection criteria outlined in Table 1, did not use a comparative design, or were duplicate publications.

Critical Appraisal of Individual Studies

Included randomized and non-randomized studies were critically appraised by one reviewer using the Down’s and Black Checklist.20 Summary scores were not calculated; rather, findings from critical appraisal were tabulated (Appendix 3 Appendix 3) and a review of the strengths and limitations for each included study were described narratively.

Summary of Evidence

Quantity of Research Available

A total of 695 citations were identified in the literature search. Following screening of titles and abstracts, 650 citations were excluded and 45 potentially relevant reports from the electronic database search were retrieved for full-text review. Two potentially relevant publications were also identified from the search of grey literature. Of these 47 potentially relevant reports, 42 were excluded for various reasons, and five publications describing four studies were deemed eligible for inclusion in this review. The four eligible studies were three RCTs, and two reports of a non-randomized study. Appendix 1 presents the PRISMA flowchart21 outlining the study selection process. Additional references of potential interest are provided in Appendix 5.

Summary of Study Characteristics

Study Design

Three RCTs22–24 and two reports of a non-randomized cohort study25,26 were identified in this review. All of the studies were prospective, with duration of follow-up ranging from inpatient hospital discharge to 12 months.22–26 The two reports of the non-randomized cohort study presented data from the same study at different points in time, with the later publication reporting data from a larger number of patients with longer duration of follow-up.25,26

Country of Origin

All of the studies eligible for and included in this review were conducted in the USA.22–26

Patient Population

The three RCTs all examined outpatients with significant suicidal ideation,22–24 whereas the reports of the non-randomized study examined inpatients.25,26 One RCT focused its investigation on 148 United States (US) Army soldier outpatients from a military medical centre — a majority of whom were male i.e., 76.7% and 84% in the intervention and comparison arms, respectively — with a mean age of 26.8 years (±SD 5.9, range 18 to 48).23 Eligible patients had a score of 13 or greater on the Beck Scale for Suicidal Ideation.23 Another RCT recruited people from the community with a score of 10 or more on the Scale for Suicidal Ideation who were not otherwise receiving mental health care.24 Ninety-three individuals were assigned to treatment randomly, with patients in the intervention arm having a mean age of 38.6 years (SD ±15.0) and being 57% male; whereas patients in the comparison group had a mean age of 41.8 years (SD ±15.3) and were 62% male. The third RCT randomized 38 outpatients from a mental health outpatient clinic using a ‘next-day appointment’ approach.22 Patients had a score of 13 or more on the Scale for Suicidal Ideation-Current, and a mean age of 36.8 years (SD ±10.1); 38% of whom were male.22

Patients in the non-randomized cohort study were recruited from an inpatient psychiatric facility.25,26 In the earlier of the two papers reporting on the study 52 patients were assigned to treatment, with males representing eight of the 26 patients in the intervention arm and seven of 26 patients in the comparison arm26 The mean age of participants in the intervention arm was 32.42 years (SD ±14.19) and in the comparison arm was 33.31 years (SD ±13.19).26 The later report added 52 patients for a total 104 patients assigned to treatment with a mean age of 31.44 (SD ±13.91) in the intervention group and 32.92 years (SD ±14.56) in the comparison group.25 Of 52 patients in each treatment group, 18 were male in the intervention arm and 19 were male in the comparison arm.25

Interventions and Comparators

Three of the four included studies in this review examined the Collaborative Assessment and Management of Suicidality (CAMS) intervention,22,23,25,26 while the remaining study investigated the effects of the Dialectical Behavior Therapy-Brief Suicide Intervention (DBT-BSI) as the experimental treatment.24 The CAMS intervention used in three of the four included studies of this review were described similarly, with a minimum of either three or four sessions until suicidal symptoms had been successfully resolved.22,23,25,26 The RCT investigating the DBT-BSI sought to examine its effect as a brief intervention in a next-day appointment context using one 45-60 minute session of clinician-led, suicide specific therapy.

Comparators in the three of four studies that examined CAMS were treatment as usual (TAU)25,26 or enhanced care as usual (E-CAU),22,23 with protocols that generally were designed to mirror those in the corresponding experimental group. Similarly, in the study examining DBT-BSI, the comparison group received one 45-60 minute clinician-led session of relaxation therapy.24

Outcomes & Measures

In general, outcomes reported within the included studies in this review can be conceptualized as representing three categories i.e., suicide-specific, mental health and well-being, and health care utilization outcomes.

Suicidality

The four studies included in this review examined suicide-specific outcomes with suicidal ideation reported by all.22–26 The three included RCTs used the Scale for Suicide Ideation (SSI),22–24 with one RCT specifically reporting use of the Scale for Suicide Ideation-Current (SSI-C).23 The SSI and SSI-C are reported to contain 19 items with higher scores indicating higher levels of suicidality.22–24 One report described a ‘medium difference’ in suicidal ideation between 0.5 and 0.6 (p.154); though, the authors did not specify which scale this was in reference to.24 No other description of a minimal clinically important difference on any other outcome was described by any of the included studies. The non-randomized reports described use of both the Columbia-Suicide Severity Rating Scale (C-SSRS) and the Beck Scale for Suicide Ideation (BSS) to measure suicidal ideation.25,26 The C-SSRS was described as a measure of four distinct constructs with higher scores indicating higher levels of suicidality.25,26 The BSS was described as a set of 21 statements across 19 items, with an implication that higher scores indicate higher levels of suicidality.25,26 Other suicide-specific outcomes described within the included studies were suicidal cognitions25,26 and suicidal behaviours — which described self-injury, suicide attempt(s), and/or suicide.22–24 Suicidal cognition was reported in two papers using the Suicide Cognitions Scale (SCS), which is an 18-item, self-reported instrument with scores ranging from 18 to 90.25,26 Suicidal and self-injurious behaviors were measured using the Suicide Attempt and Self-Injury Count (SASI-C) in two RCTs,22,23 and the Lifetime Parasuicide Count in another RCT.24 Further details describing items and scoring of these instruments were not reported.22–24

Mental health and well-being

Mental health and well-being outcomes were also reported in all four included studies, including depression, anxiety, psychological distress and general mental health, emotional dysregulation, resilience or coping (focusing on skills use since the intervention), hope or hopelessness, reasons for living, functional disability, and well-being.22–26 Depression was a common outcome of interest with three of five reports describing its measurement — all of which reported use of the Patient Health Questionnaire (PHQ), which was described as a 9-item self-report instrument querying depressive symptoms in the past two weeks.24–26 One of these studies also reported separately on anxiety measured using the Beck Anxiety Inventory (BAI); a 21-item self-report instrument soliciting information on anxious symptoms within the past week.24 Mental health function and psychological distress were also reported by two included studies measured using the Outcome Questionnaire-45 (OQ-45) with 45 items producing a score between zero and 180, and higher scores indicating a poorer outcome.22,23 One of these studies additionally measured mental health using the Medical Outcomes Study Short Form-36, version 2 (SF-36) using 36 self-reported items to produce a score between zero and 100, with higher scores indicating better mental health.23 Hope or hopelessness were also outcomes of interest in three included reports, one of which reported use of the Optimism and Hope Scale (OHS),22 while the other two described using the Beck Hopelessness Scale (BHS).25,26 While the former instrument uses 14 self-reported items to measure optimism and hopefulness,22 the latter uses 20 self-reported items to measure negative thoughts about the future.25,26 The Structured Clinical Interview for DSM-IV (SCID) was used in one study as a diagnostic measure of Axis I disorders in the DSM-IV.23 Emotional dysregulation was reported in one study using the Difficulties in Emotion Regulation Scale (DERS) — a 39-item, self-reported instrument.24 Skills use (operationalized as coping) and resilience were measured in two of the four included studies, with one using the DBT Ways of Coping Checklist (i.e., both 12- and 38-item self-report subscales of the full scale examining skills use) where higher scores represent increased use of coping strategies,24 and; the other using the Connor-Davidson Resilience Scale (CD-RISC) which uses 25 items addressing coping and adversity, and generating a score ranging from zero to 100, with higher scores indicating higher levels of resilience.23 One of these studies further measures skills use with a study-designed and - specific questionnaire — the Skills Used Since the Intervention (SUSI) — though, further details were not reported regarding this instrument.24 Related to these constructs, another study used the Acceptance and Action Questionnaire-II (AAQ-II) to measure psychological flexibility with seven self-reported items.25 Reasons for living were examined in one study using the Reasons for Living Scale (RFL), which queries 48 self-reported items.22 And finally, functional disability and well-being were investigated in one study using two self-reported instruments; the five-item World Health Organization Well-Being Index (WHO-5) and the 12-item WHO Disability Assessment Schedule 2.0 (WHODAS).25

Health care utilization

Health care utilization was reportedly measured in four of the five reports in this review;22–25 three of which described RCTs reporting use of various versions of the Treatment History Interview (THI).22–24 The THI was described as an interviewer-administered measure soliciting patient-reported information on emergency department (ED) and physician visits, inpatient hospital days and pharmacological treatments.22–24 All of the studies reporting use of this measure described shortened and/or modified versions — with two studies describing short-form versions,22,24 and another describing a short-form version modified specifically for use in a military context.23 The fourth paper did not pre-specify measurement of health care utilization outcomes, but did report these in the results with no particular measure described.25

Additional details regarding the characteristics of included publications are provided in Appendix 2.

Summary of Critical Appraisal

Randomized Controlled Trials

The RCTs included in this review22–24 demonstrated both strengths and limitations. Firstly, clarity of reporting is critical to a transparent assessment of the strengths and limitations of studies included in any review. Observed strengths in reporting across all three trials included a clear description of the aims and objectives of the study, characteristics of eligible patients, and interventions of interest.22–24 Limitations in reporting common to all three RCTs were a lack of description of possible adverse events associated with the interventions and unclear reporting of probabilities associated with the findings.22–24 While two RCTs clearly reported main outcomes, findings, and random variability in the data presented,23,24 one did not.22 One of the RCTs clearly reported a list of principal confounders,24 while two RCTs did not clearly report on potential confounding variables.22,23

It was not possible to assess any of the items addressing external validity for the included RCTs, as details about the representativeness of subjects asked to participate; patients who consented to participate, and; the interventions administered, were either not reported or not reported in enough detail to assess.22–24 Because external validity could not be ascertained for the RCTs, it remains unclear whether their findings can appropriately be applied to other, similar patients. An understanding of internal validity in general, and risk of bias in particular, is critical to informing the interpretation of a study. In this review, risk of bias was found to vary across the three RCTs i.e., while all of the studies showed no evidence of unplanned analyses, standard follow-up for all patients under investigation, ostensibly appropriate statistical analyses, no evidence of a lack of compliance with the interventions, and a clear description of the outcome measures used; none of the three RCTs reported whether patients were blinded to their intervention allocation status.22–24 One RCT reported that some outcome assessors were blinded to treatment allocation whereas other assessors were not,23 and; two RCTs did not report information about the blinding of outcome assessors.22,24

Risk of confounding is an important consideration in weighing whether the effect demonstrated in a study can be isolated to the intervention and comparator of interest as opposed to other, extraneous variables. The risk of any confounding was similarly found to be variable across the RCTs included in this review.22–24 While all three trials recruited patients from the same setting, randomized patients to treatment, and accounted for losses to follow up, they also failed to report on concealment of the randomized allocation of patients to treatment.22–24 And though two RCTs specified that patients were recruited over the same period of time,22,24 the third did not specify the timeframe for patient recruitment.23 Further, while confounding variables were adjusted for appropriately in one RCT,24 two RCTs did not describe adjustment for confounders.22,23

Finally, sample size calculations were not reported in two of the RCTs included in this review,22,23 whereas one RCT reported having a sufficient sample size to ascertain a “medium effect” on suicidal ideation24 (p. 154) — though, the authors did not provide the calculation supporting this statement. An assessment of study power is critical as part of considering the adequacy of a sample size used and the consequent probability of avoiding a Type II error i.e., finding an apparent effect among the sampled patients in a study where no effect actually exists

Non-Randomized Studies

The non-randomized cohort study and its two reports25,26 similarly demonstrated both strengths and limitations during critical appraisal. While both papers clearly reported the aim and objectives of the study, patient characteristics and random variability in the data, neither report clearly described adverse events, loss to follow-up or probability values.25,26 One paper partially described main outcomes and clearly described the main findings,25 while the other did not.26 Conversely, while one report clearly described the interventions of interest and potential confounding variables,26 the other did not.25 Given that the size of the study population in the later paper was double that described within the earlier paper, a clear description of these study parameters would be necessary to adequately inform critical appraisal.

Because the source population was not described in either of the reports of the non-randomized studies,25,26 external validity could not be determined. Thus, the generalizability of the studies’ findings remains uncertain.

Risk of bias was similar between the two papers, with both demonstrating strengths by reporting no evidence of unplanned analyses, consistent follow-up for all patients observed, no evidence of a lack of compliance with the interventions and a clear description of the outcome measures used in the study.25,26 Both papers also demonstrated limitations in that there was no description of blinding either patients or outcome assessors to the interventions and methods for statistical analyses were not clearly reported.25,26 Because of these particular risks of bias, the internal validity of this study cannot definitively be ascertained.

The risk of confounding is particularly important in non-randomized studies and was found to be handled appropriately in the reports of the non-randomized studies, as the investigators reported recruiting patients from the same centre and using propensity score matching to select patients for study.25,26 Nonetheless, patients were not randomized to treatment, the timeframe for recruitment was not reported in either paper25,26 and loss to follow-up was either not reported26 or only partially accounted for.25 Finally, no power calculation was reported in either paper.25,26

Additional details regarding the strengths and limitations of included publications are provided in Appendix 3.

Summary of Findings

What is the clinical effectiveness of suicide-specific psychotherapies versus psychotherapies without a suicide-specific focus for the treatment of suicidal crisis?

Suicidality, mental health and well-being and, health care utilization were reported in all four included studies.

Suicidality

Suicidality was reported as either suicidal ideation (also measured as suicidal cognition in one study)26 or suicidal behaviour (including self-injury, suicide attempt and/or suicide) and was measured in all four studies included in this review.22–26

Suicidal ideation was reported in all four included studies in this review.22–26 Sustained, statistically significant differences in suicidal ideation between CAMS and standard care comparator interventions were not observed using any measure of this outcome in any of the included studies.22,23,25,26 Similarly, no significant differences in suicidal ideation were found in the one study examining DBT-BSI versus relaxation therapy.24 One RCT examining 32 patients reported no statistically significant difference in suicidal ideation in a repeat-measures analysis, but did highlight a statistically significant improvement in CAMS patients at 12 months compared to those receiving E-CAU.22 Another RCT measured the proportion of patients with suicidal ideation at five points across time and reported a statistically significant difference favouring CAMS patients at three months follow-up (i.e., P = 0.028); however, no other statistically significant differences between CAMS and E-CAU were found at any other follow-up time point, nor were any differences in mean scores using the SSI-C.23 The two reports of non-randomized analyses emphasized a statistically significant improvement in CAMS patients between hospital admission and discharge in one (BSS)26 and three (C-SSRS, BSS, and SCS)25 measures of suicidal ideation or suicidal cognition (P < 0.05);26 however, the between-group difference was no longer observed at six months of follow-up.25

Four of five included papers reported on suicidal behaviours — including self-injury, suicide attempt, and/or suicide — reported no statistically significant differences in numbers, proportions of patients, or median SASII counts between the suicide-specific versus non-suicide specific interventions investigated.22–25 One of these studies did report finding a significant improvement in Item 9 of the PHQ-9 for CAMS patients at hospital discharge as compared to TAU patients; however, this difference was no longer observed at six months follow-up; nor was any statistically significant between-group difference observed in numbers of patients re-hospitalized at six-month follow up.25

Mental health and well-being

Two RCTs comparing CAMS against E-CAU found no statistically significant, overall between-group differences in any mental health outcomes investigated i.e., general mental health and resilience,23 psychological distress, reasons for living and hope.22 While the authors of both trials emphasized that both CAMS and E-CAU interventions resulted in improvements in mental health outcomes across time, one study conceded that no statistically significant between-group differences were observed,23 whereas the other highlighted a statistically significant improvement in CAMS patients at 12 months follow up in two of three measures of mental health and well-being (though; improvements were not observed earlier in the study).22 Further, the RCT comparing DBT-BSI with RT observed no statistically significant differences between treatment arms in emotional dysregulation, skills use, depression or anxiety.24

While the two papers describing findings from a non-randomized cohort study reported a statistically significant improvement in depression, well-being, and functional disability between hospital admission and discharge in patients assigned to CAMS versus those assigned to TAU,25,26 no between-group differences were observed at six-months follow-up.25 Results from the BHS and AAQ-II were reported from hospital admission to discharge, indicating a short-term, significant difference in favour of CAMS.25,26

Health care utilization

Four of the five included papers in this review reported on health care utilization outcomes22–25 Three of these four reports described no statistically significant between-group differences in ED admissions (for suicidality or other behaviour-related reasons), days admitted, contacts with mental health services, or re-hospitalization following discharge,23–25 whereas the fourth paper reported only raw data per group describing ED admissions and days admitted with no statistics describing between-group comparisons.22

Appendix 4 presents a table providing a detailed summary of the main study findings and authors’ conclusions.

What is the comparative clinical effectiveness of the various suicide-specific psychotherapies for the treatment of suicidal crisis?

No eligible studies were identified addressing the comparative clinical effectiveness of two or more suicide-specific interventions for treating patients with suicidal crisis, therefore, no summary can be provided.

Limitations

There were some important limitations with the evidence identified in this review describing suicide-specific interventions for individuals with suicidal crisis. Firstly, definitions of suicidal crisis and suicide-specific interventions were not always explicit, requiring the use of judgement. Second, evidence was identified describing only two types of suicide-specific interventions i.e., the Collaborative Assessment and Management of Suicidality (CAMS) and the Dialectical Behavior Therapy-Brief Suicide Intervention (DBT-BSI). Third, evidence comparing two of more suicide-specific interventions was not identified, preventing an assessment of the comparative effectiveness of these interventions. As well, all of the studies identified within this review were conducted in the United States of America (USA) and may therefore have limited generalizability to the mental health care context in Canada. Moreover, given the particular salience of suicide-specific interventions in a military context, only one of the four studies identified addressed this particular population.

It is important to acknowledge the five reports included in this review all demonstrated important strengths and weaknesses in reporting, internal and external validity. Importantly, sample sizes may not have been adequate to detect a clinically important difference, with only one study describing a power calculation sufficient to detect a medium difference in outcomes23 and the remaining studies not addressing study power.22,24–26 As well, while the non-randomized studies included in this review used propensity score matching to assign patients to treatment, the lack of a randomized design and blinded treatment assignment poses a risk to the internal validity of the findings, and therefore must be interpreted with caution.

Importantly, while no studies included in this review demonstrated overall, sustained and statistically significant relative improvement in patients assigned to suicide-specific versus non-suicide-specific intervention,22–26 some discordance between the conclusions of included studies was observed. While two reports of non-randomized studies25,26 and one smaller-sample RCT22 emphasized improvements in patients receiving suicide-specific intervention at one or more points in time, two RCTs with larger sample sizes reported no statistically significant improvements across the duration of the studies.23,24 Caution is thus warranted in the interpretation of the findings of this review given these observed limitations.

Conclusions and Implications for Decision or Policy Making

This review identified four eligible studies reported across five papers comparing suicide-specific and non-suicide specific interventions in individuals experiencing a suicidal crisis. Three studies were randomized controlled trials (RCTs) investigating between 32 and 148 individuals; the latter of which examined United States (US) military personnel. Two reports described pilot and longer-term follow-up data from a non-randomized cohort study of 52 and 104 patients, respectively. Three studies examined the Collaborative Assessment and Management of Suicidality (CAMS) and one study investigated the Dialectical Behavior Therapy-Brief Suicide Intervention (DBT-BSI) as the experimental intervention. No studies were identified comparing suicide-specific interventions to one another.

Overall, sustained and consistent improvements in suicidal patients receiving suicide-specific interventions were not reported by any of the four included studies in this review.22–26 Two larger RCTs both concluded that no significant differences were observed between either CAMS in 148 active-duty military personnel (12-month follow-up) or DBT-BSI in 93 suicidal outpatients (12-week follow-up) compared with either enhanced care as usual (E-CAU) or relaxation therapy (RT), respectively. The consistency in a null effect observed across these two RCTs is notable; however, each trial investigated different populations and experimental interventions rendering any comparison of the findings of these studies challenging. Notably however, one RCT that was not eligible for inclusion in this review compared non-suicide-specific DBT and treatment as usual (TAU) in 91 high-risk veterans, and similarly found no relative effect of DBT in suicidal and mental health outcomes at six months follow-up.27 Likewise, an RCT ineligible for inclusion in this review investigated the effect of CAMS versus DBT in patients with borderline personality disorder and found no difference in suicidal behavior at 28 weeks of follow up,28 corroborating the null effects reported in the larger RCTs included in this review (albeit, in a different population and with comparison of two suicide-specific interventions).

The remaining studies in this review included one smaller RCT examining CAMS versus E-CAU in 32 patients, reporting no statistically significant differences in multiple, early measurements of suicidal and mental health outcomes, but a statistically significant difference between treatment groups at 12 months follow-up. Conversely, two reports of non-randomized studies comparing CAMS and treatment as usual (TAU) found statistically significant differences between hospital admission and discharge with no sustained effect observed at six months follow-up. These discordant findings vis-à-vis timing of an observed effect are worth considering; however, as it concerns an intervention’s capacity to modify suicidality during a crisis in the short- versus long-term, it could be argued that if an intervention demonstrates effectiveness in the short-term, this may be sufficient. Though, long-term improvements in suicidality are arguably important as well. Nonetheless, given the small sample sizes and inconsistency in these findings of these studies — both within studies across time, and compared to the other studies included in this review — their findings should be interpreted with caution.

Considering the limitations of the studies included within this review in their totality, our findings should likewise be interpreted with caution. Importantly, additional studies employing rigorous methods and addressing the clinical effectiveness and comparative clinical effectiveness of suicide-specific interventions for patients experiencing a suicidal crisis will help reduce uncertainty concerning their effects on suicidality and other related outcomes. Finally, studies conducted in a Canadian context may better establish generalizability to our population.

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Appendix 1. Selection of Included Studies

Image app1f1

Appendix 2. Characteristics of Included Publications

Table 2Characteristics of Included Primary Clinical Studies

First Author, Publication Year, CountryStudy DesignPopulation CharacteristicsIntervention and Comparator(s)Clinical Outcomes, Measures, and Follow-Up
Randomized Controlled Trials (RCTs)
Jobes, 201723

USA		Single-centre, parallel-group RCT (some outcomes assessed blind; other outcomes not assessed blind)Participants
148 outpatient soldiers with significant suicidal ideation i.e., score of ≥13 on Beck Scale for Suicidal Ideation

Male sex (%)
Intervention = 76.7
Comparator = 84.0

Mean age (±SD), range in years
Full sample = 26.8 (5.9), 18-48

Setting
Army medical centre		Intervention
Collaborative Assessment and Management of Suicidality (CAMS): 3 sessions of suicide-specific therapy using the Suicide Status Form (SSF) until suicidal symptoms are successfully managed

Comparator
Enhanced care as usual (E-CAU): at least 1 clinician led session per week for at least 4wks until the reason for referral was resolved		Outcomes
  • Suicidal ideation
  • Suicide attempts
  • Health care utilization
  • Mental health


Measures
  • Scale for Suicide Ideation-Current (SSI-C)
  • Suicide Attempt Self-Injury Count (SASI-Count)
  • Structured Clinical Interview for DSM-IV (SCID)
  • Treatment History Interview-Military (THI-M)
  • Connor-Davidson Resilience Scale (CD-RISC)
  • Outcome Questionnaire-45 (OQ-45)
  • Medical Outcomes Study Short Form-36, version 2 (SF-36)


Follow-up duration = 12mos
Ward-Ciesielski, 201724

USA		Single-centre, parallel group, single-blind (outcome assessor(s)) RCTParticipants
93 individuals with suicidal ideation i.e., a score of ≥10 on the Scale for Suicidal Ideation, recruited from the community and not receiving psychiatric care

Male sex (%)
Intervention = 57
Comparator = 62

Mean age (±SD), range in years
Intervention = 38.6 (15.0)
Comparator = 41.8 (15.3)

Setting
University-based outpatient clinic		Intervention
One 45 to 60min clinician led session of Dialectical Behavior Therapy-Brief Suicide Intervention (DBT-BSI)

Comparator
One 45 to 60min clinician led session of Relaxation training (RT)		Outcomes
  • Suicidal ideation
  • Emotional dysregulation
  • Skills use
  • Depression
  • Anxiety
  • Health care utilization
  • Self-injury


Measures
  • Scale for Suicide Ideation (SSI)
  • Difficulties in Emotion Regulation Scale (DERS)
  • DBT Ways of Coping Checklist (DBT-WCCL)
    • 38-item
    • 12-item
  • Skills Used Since the Intervention (SUSI)
  • Patient Health Questionnaire Depression Module (PHQ)
  • Beck Anxiety Inventory (BAI)
  • Treatment History Interview (THI)
  • Lifetime Parasuicide Count


Follow-up duration = 12 wks
Comtois, 201122

USA		Single centre, parallel group, single-blind RCTParticipants
32 patients with significant suicidal ideation i.e., score of ≥13 on the Scale for Suicidal Ideation-Current (SSI-C)

Male sex (%)
Total sample = 38

Mean age (±SD)
Total sample = 36.8 (10.1)

Setting
Outpatient, ‘next-day appointment’ crisis mental health centre		Intervention
Collaborative Assessment and Management of Suicidality (CAMS): minimum 4 sessions using the Suicide Status Form (SSF) until suicidal symptoms are successfully resolved (usually within ~12 sessions)

Comparator
Enhanced Care as Usual (E-CAU): minimum 4 sessions with psychiatric clinician over the course of 1-3mos until suicidal symptoms are successfully resolved (usually within ~12 sessions)		Outcomes
  • Suicidal ideation
  • Suicidal behaviours
  • Psychological distress
  • Reasons for living
  • Hope
  • Health care utilization


Measures
  • Client Satisfaction Questionnaire (CSQ)
  • Scale for Suicide Ideation-Current (SSI)
  • Outcome Questionnaire-45 (OQ-45)
  • Reasons for Living Scale (RFL)
  • Optimism and Hope Scale (OHS)
  • Suicide Attempt and Self-Injury Count (SASI-C)
  • Treatment History Interview—Short Form (THI)


Follow-up duration = 12 mos
Non-Randomized Study (2 reports at different time points)
Ellis, 201725

USA		Single-centre, controlled comparison studyParticipants
104 inpatients with suicidal ideation and/or suicide attempt(s)

Male sex (n/N)
Intervention = 18/52
Comparator = 19/52

Mean age (±SD) in years
Intervention = 31.44 (13.91)
Comparator = 32.92 (14.56)

Setting
Inpatient psychiatric clinic		Intervention
Collaborative Assessment and Management of Suicidality (CAMS): minimum 4 sessions of suicide-specific therapy

Comparator
Treatment as usual with intensive inpatient therapy including two psychotherapy sessions per week		Outcome
  • Depression
  • Suicidal ideation
  • Functional disability
  • Well-being


Measures
  • Columbia-Suicide Severity Rating Scale (C-SSRS)
  • Patient Health Questionnaire-9 (PHQ-9)
  • Beck Scale for Suicide Ideation (BSS)
  • Beck Hopelessness Scale (BHS)
  • Suicide Cognitions Scale (SCS)
  • Acceptance and Action Questionnaire-II (AAQ-II)
  • WHO-5 Well-Being Index (WHO-5)
  • WHO Disability Assessment Schedule 2.0 (WHODAS)


Follow-up duration = 6 mos
Ellis, 201526

USA		Single-centre, controlled comparison studyParticipants
Convenience sample of 52 inpatients with suicidal ideation and/or suicide attempt(s)

Male sex (n/N)
Intervention = 8/26
Comparator = 7/26

Mean age (±SD) in years
Intervention = 32.42 (14.19)
Comparator = 33.31 (13.19)

Setting
Inpatient psychiatric clinic		Intervention
Collaborative Assessment and Management of Suicidality (CAMS): minimum 4 sessions of suicide-specific therapy

Comparator
Treatment as usual with intensive inpatient therapy including two psychotherapy sessions per week		Outcome
  • Suicidal ideation
  • Suicide cognitions
  • Hopelessness


Measures
  • Columbia-Suicide Severity Rating Scale (C-SSRS)
  • Patient Health Questionnaire-9 (PHQ-9)
  • Beck Scale for Suicide Ideation (BSS)
  • Beck Hopelessness Scale (BHS)
  • Suicide Cognitions Scale (SCS)


Follow up duration = patient discharge from hospital

AAQ-II = Acceptance and Action Questionnaire-II; BAI = Beck Anxiety Inventory; BHS = Beck Hopelessness Scale; BSS = Beck Scale for Suicide Ideation; C-SSRS = Columbia-Suicide Severity Rating Scale; CAMS = Collaborative Assessment and Management of Suicidality; CD-RISC = Connor-Davidson Resilience Scale; CSQ = Client Satisfaction Questionnaire; DBT-WCCL = DBT Ways of Coping Checklist; DERS = Difficulties in Emotion Regulation Scale; E-CAU = Enhanced care as usual; mo/mos = month/s; N/n = number; OHS = Optimism and Hope Scale; OQ-45 = Outcome Questionnaire-45; PHQ = Patient Health Questionnaire; RCT = randomized controlled trial; RFL = Reasons for Living Scale; SASI-Count = Suicide Attempt Self-Injury Count; SCID = Structured Clinical Interview for DSM-IV; SCS = Suicide Cognitions Scale; SD = standard deviation; SF-36 = Medical Outcomes Study Short Form-36; SSI-C = Scale for Suicide Ideation-Current; SSF = Suicide Status Form; SUSI = Skills Used Since the Intervention; THI-M = Treatment History Interview-Military; WHO-5 = WHO-5 Well-Being Index; WHODAS = WHO Disability Assessment Schedule wks = weeks

Appendix 3. Critical Appraisal of Included Publications

Table 3Strengths and Limitations of Clinical Studies using Down’s & Black Checklist20

StrengthsLimitations
Randomized Controlled Trials (RCTs)
Jobes, 201723
Reporting
  • Aim and objectives, main outcomes, patient characteristics, interventions, main findings, and random variability clearly reported
Internal validity – bias
  • No evidence of unplanned analyses
  • Consistent follow-up for both study groups
  • Statistical tests appear appropriate
  • No evidence of a lack of compliance with the interventions
  • Outcome measures clearly reported
Internal validity – confounding
  • Study subjects recruited from the same centre
  • Study subjects randomized to treatment
  • Loss to follow-up accounted for
Reporting
  • List of principal confounders, losses to follow-up and probability values not clearly reported
  • Adverse events not reported
External validity
  • Representativeness of eligible patients and study participants not clearly described
  • Representativeness of treatment setting partially reported
Internal validity – bias
  • Blinding of study subjects could not be ascertained
  • Some outcome assessors were blinded; others were not
Internal validity – confounding
  • Recruitment timeframe not reported
  • Concealment of randomized assignment not reported
  • Distribution of and/or adjustment for known confounders not reported
Power
  • Study power calculation not described
Ward-Ciesielski, 201724
Reporting
  • Aim and objectives, main outcomes, patient characteristics, interventions, main findings, random variability, principal confounders and loss to follow-up clearly reported
Internal validity – bias
  • Outcome assessors blinded to intervention allocation
  • No evidence of unplanned analyses
  • Consistent follow-up for both study groups
  • Statistical tests appear appropriate
  • No evidence of a lack of compliance with the interventions
  • Outcome measures clearly reported
Internal validity – confounding
  • Study subjects recruited from the same centre over the same period of time
  • Study subjects randomized to treatment
  • Adequate adjustment for confounding
  • Loss to follow-up accounted for
Power
  • Study power calculation described
Reporting
  • Adverse event and probability values not reported
External validity
  • Representativeness of eligible patients, study participants and treatment setting not clearly described
Internal validity – bias
  • Blinding of study subjects could not be ascertained
Internal validity – confounding
  • Concealment of randomization not reported
Comtois, 201122
Reporting
  • Aim and objectives, patient characteristics, and interventions, clearly reported
Internal validity – bias
  • Outcome assessors blinded to intervention allocation
  • No evidence of unplanned analyses
  • Consistent follow-up for both study groups
  • Statistical tests appear appropriate
  • No evidence of a lack of compliance with the interventions
  • Outcome measures clearly reported
Internal validity – confounding
  • Study subjects recruited from the same centre over the same period of time
  • Study subjects randomized to treatment
  • Loss to follow-up accounted for
Reporting
  • Main outcomes and findings, adverse events, random variability, principal confounders and their distribution, loss to follow-up, and probability values either not reported or not clearly reported
External validity
  • Representativeness of eligible patients, study participants and treatment setting not clearly described
Internal validity – bias
  • Blinding of study subjects could not be ascertained
Internal validity – confounding
  • Concealment of randomization not reported
  • Distribution of and/or adjustment for known confounders not reported
Power
  • Study power calculation not described
Non-Randomized Study (2 reports at different time points)
Ellis, 201725
Reporting
  • Aim and objectives, patient characteristics, main findings and, random variability clearly reported
Internal validity – bias
  • No evidence of unplanned analyses
  • Consistent follow-up for both study groups
  • No evidence of a lack of compliance with the interventions
  • Outcome measures clearly reported
Internal validity – confounding
  • Study subjects recruited from the same centre
  • Adequate methods used to account for confounding
Reporting
  • Main outcomes partially described
  • Interventions of interest, principal confounders and their distribution, adverse events, loss to follow-up, and probability values not clearly reported
External validity
  • Representativeness of eligible patients and treatment setting not described
  • Representativeness of study participants not clearly described
Internal validity – bias
  • Blinding of study subjects and outcome assessors could not be ascertained
  • Methods for statistical analyses not reported
Internal validity – confounding
  • Recruitment timeframe not reported
  • Study subjects not randomized to treatment
  • Loss to follow-up partially accounted for
Power
  • Study power calculation not described
Ellis, 201526
Reporting
  • Aim and objectives, patient characteristics, interventions, potential confounders, random variability clearly reported
Internal validity – bias
  • No evidence of unplanned analyses
  • Consistent follow-up for both study groups
  • No evidence of a lack of compliance with the interventions
  • Outcome measures clearly reported
Internal validity – confounding
  • Study subjects recruited from the same centre
  • Adequate methods used to account for confounding
Reporting
  • Main outcomes and findings, adverse events, loss to follow-up, and probability values not reported
External validity
  • Representativeness of eligible patients and treatment setting not described
  • Representativeness of study participants not clearly described
Internal validity – bias
  • Blinding of study subjects and outcome assessors could not be ascertained
  • Methods for statistical analyses not reported
Internal validity – confounding
  • Recruitment timeframe not reported
  • Study subjects not randomized to treatment
  • Loss to follow-up not reported
Power
  • Study power calculation not described

RCTs = Randomized controlled trials

Appendix 4. Main Study Findings and Authors’ Conclusions

Table 4Summary of Findings of Included Primary Clinical Studies

Main Study FindingsAuthors’ Conclusion
Randomized Controlled Trials (RCTs)
Jobes, 201723
Suicidal ideation
  • % patients reporting any suicidal ideation at baseline, 1 mo, 3 mos, 6 mos and 12 mos follow up
    • CAMS
      • 100, 72.9, 36.9, 35.1, 38.6
    • E-CAU
      • 100, 69.1, 61.3, 38.3, 39.7
    • Statistical difference between groups
      • 3mos
        • P = 0.028
      • All other time points
        • P = NS
  • SSI-C score (excluding values of ‘0’) at baseline, 1mo, 3mos, 6mos and 12 mos follow up, median (95% CI)
    • CAMS
      • 20.0 (12.8-33.0), 13.0 (3.5-24.5), 12.5 (2.6-21.9), 10.5 (2.0-22.1), 10.5 (1.5-25.8)
    • E-CAU
      • 19.0 (12.0-30.1), 11.0 (4.0-20.0), 9.5 (3.9-20.2), 9.0 (2.6-20.3), 9.0 (1.0-19.3)
    • Statistical difference between groups
      • NS


Suicide attempts
  • % patients reporting any past-year suicide attempts at baseline and 12 mos follow up, %
    • CAMS
      • 23.3, 11.1
    • E-CAU
      • 21.6, 5.3
    • Statistical difference between groups
      • NS
  • SASII count (excluding values of ‘0’) at baseline and 12 mos, median (95% CI)
    • CAMS
      • 1.0 (1.0-21.4), 1.0 (1.0-1.0)
    • E-CAU
      • 1.0 (1.0-20.1), 1.0 (1.0-1.0)
    • Statistical difference between groups
      • NS


Health care utilization (THI-M)
  • Self-reported ED admissions (validated with electronic health records)
    • Patients with any suicide-related admissions at baseline, 1mo, 3mos, 6mos and 12 mos follow up, %
      • CAMS
        • 38.4, 8.5, 3.0, 6.5, 5.3
      • E-CAU
        • 33.8, 2.8, 6.0, 7.8, 8.6
      • Statistical difference between groups
        • NS
    • Suicide-related inpatient admissions, (excluding values of ‘0’) at baseline, 1mo, 3mos, 6mos and 12 mos follow up, median (95% CI)
      • CAMS
        • 1.0 (1.0-2.0), 1.0 (1.0-1.0), 1.0 (1.0-1.0), 1.0 (1.0-1.0), 1.0 (1.0-2.0),
      • E-CAU
        • 1.0 (1.0-2.8), 1.0 (1.0-1.0), 1.0 (1.0-1.9), 1.0 (1.0-1.9), 1.0 (1.0-1.0)
      • Statistical difference between groups
        • NS
    • Patients with any behavioral-related admissions at baseline, 1 mo, 3 mos, 6mos and 12 mos follow up, %
      • CAMS
        • 39.7, 11.3, 6.0, 6.5, 7.0
      • E-CAU
        • 37.8, 5.6, 10.4, 14.1, 12.1
      • Statistical difference between groups
        • NS
    • Behavioral-related admissions, (excluding values of ‘0’) at baseline, 1mo, 3 mos, 6 mos and 12 mos follow up, median (95% CI)
      • CAMS
        • 1.0 (1.0-2.6), 1.0 (1.0-2.0), 1.0 (1.0-1.0), 1.0 (1.0-1.0), 1.0 (1.0-1.9)
      • E-CAU
        • 1.0 (1.0-3.3), 1.0 (1.0-1.0), 1.0 (1.0-1.8), 1.0 (1.0-1.8), 1.0 (1.0-2.7)
      • Statistical difference between groups
        • NS
  • Self-reported days admitted (validated with electronic health records)
    • Patients with any suicide-related days admitted at baseline, 1mo, 3mos, 6mos and 12 mos follow up, %
      • CAMS
        • 31.5, 7.0, 3.0, 4.8, 7.0
      • E-CAU
        • 21.6, 2.8, 6.0, 7.8, 6.9
      • Statistical difference between groups
        • NS
    • Suicide-related days admitted, (excluding values of ‘0’) at baseline, 1 mo, 3 mos, 6 mos and 12 mos follow up, median (95% CI)
      • CAMS
        • 6.0 (3.6-15.7), 14.0 (4.2-19.5), 6.0 (3.1-8.8), 7.0 (4.2-13.7), 16.0 (2.2-34.5)
      • E-CAU
        • 9.5 (3.8-31.8), 6.5 (6.0-7.0), 8.0 (7.0-19.2), 5.0 (4.1-29.4), 17.5 (1.5-28.0)
      • Statistical difference between groups
        • NS
    • Patients with any behavioral-related days admitted at baseline, 1 mo, 3 mos, 6 mos and 12 mos follow up, %
      • CAMS
        • 31.5, 7.0, 4.5, 4.8, 7.0
      • E-CAU
        • 23.0, 2.8, 6.0, 7.8, 6.9
      • Statistical difference between groups
        • NS
    • Behavioral health-related days admitted, (excluding values of ‘0’) at baseline, 1 mo, 3 mos, 6 mos and 12 mos follow up, median (95% CI)
      • CAMS
        • 6.0 (3.6-15.7), 14.0 (4.2-19.5), 3.0 (3.0-8.7), 7.0 (4.2-13.7), 16.0 (2.2-34.5)
      • E-CAU
        • 10.0 (3.8-31.6), 6.5 (6.0-7.0), 8.0 (7.0-19.2), 5.0 (4.1-29.4), 17.5 (1.5-28.0)
      • Statistical difference between groups
        • NS


Mental health*
  • Connor-Davidson Resilience Scale (CD-RISC) at baseline, 1mo, 3mos, 6mos and 12 mos follow up, mean score (95% CI)
    • CAMS
      • 52.0 (48.2-56.1), 54.2 (50.3-58.2), 58.4 (53.8-62.8), 59.3 (53.5-64.9), 64.5 (59.9-69.3)
    • E-CAU
      • 51.8 (48.0-55.6), 57.5 (53.7-61.1), 61.9 (57.7-66.2), 64.3 (59.4-69.4), 64.8 (60.0-69.6)
    • Statistical difference between groups
      • NS
  • Outcome Questionnaire-45 (OQ-45) at baseline, 1mo, 3mos, 6mos and 12 mos follow up, mean score (95% CI)
    • CAMS
      • 96.1 (89.9-102.6), 80.4 (72.6-87.9), 72.9 (63.7-82.8), 72.4 (62.5-82.0), 70 (60.5-80.2)
    • E-CAU
      • 99.0 (93.9-104.5), 83.3 (75.5-90.8), 80.2 (72.1-88.1), 76.3 (67.9-84.7), 72.2 (63.1-81.7)
    • Statistical difference between groups
      • NS
  • Medical Outcomes Study Short Form-36, version 2 (SF-36) at baseline, 1mo, 3mos, 6mos and 12 mos follow up, mean score (95% CI)
    • CAMS
      • 26 (24.4-27.8), 34.2 (31.5-37.0), 40.2 (36.6-43.6), 40.0 (36.4-43.7), 40.6 (37.1-44.2)
    • E-CAU
      • 26.1 (24.2-28.1), 35.7 (32.9-38.4), 36.9 (34.2-39.9), 39.6 (36.4-42.7), 39.4 (36.5-42.4)
    • Statistical difference between groups
      • NS
“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.” (p. 340)
Ward-Ciesielski, 201724
Suicidal ideation
  • Scale for Suicide Ideation (SSI) scores (range 0-38), n pts, mean (SD)
    • DBT-BSI
      • Phone screening
        • 46, 19.80 (5.20)
      • 1wk
        • 34, 12.79 (7.27)
      • 4wks
        • 35, 11.37 (7.82)
      • 12wks
        • 39 10.62 (8.89)
    • RT
      • Phone screening
        • 47, 18.64 (5.41)
      • 1wk
        • 37, 12.08 (8.71)
      • 4wks
        • 35, 10.89 (8.65)
      • 12wks
        • 30, 8.47 (8.82)
    • Statistical difference between groups
      • NS


Emotional dysregulation
  • Difficulties in Emotion Regulation Scale (DERS) scores (range 39-195), n pts, mean (SD)
    • DBT-BSI
      • Baseline
        • 46, 102.74 (21.91)
      • 4wks
        • 36, 95.00 (24.17)
      • 12wks
        • 39, 91.21 (18.84)
    • RT
      • Baseline
        • 47, 108.76 (23.29)
      • 4wks
        • 39, 100.54 (25.60)
      • 12wks
        • 32, 96.13 (27.67)
    • Statistical difference between groups
      • NS


Skills use
  • DBT Ways of Coping Checklist (DBT-WCCL) scores (range 0-3), n pts, mean (SD)
    • Skills use subscale
      • DBT-BSI
        • Baseline
          • 46, 102.74 (21.91)
        • 4wks
          • 36, 95.00 (24.17)
        • 12wks
          • 39, 91.21 (18.84)
      • RT
        • Baseline
          • 47, 108.76 (23.29)
        • 4wks
          • 39, 100.54 (25.60)
        • 12wks
          • 32, 96.13 (27.67)
      • Statistical difference between groups
        • NS
    • 12-item skills subscale scores (range 0-3), n pts, mean (SD)
      • DBT-BSI
        • Baseline
          • 38, 1.91 (0.40)
        • 4wks
          • 35, 1.90 (0.46)
        • 12wks
          • 37, 1.84 0.56)
      • RT
        • Baseline
          • 40, 1.79 (0.55)
        • 4wks
          • 35, 1.68 (0.57)
        • 12wks
          • 29, 1.90 (0.47)
      • Statistical difference between groups
        • NS
  • Skills Used Since the Intervention (SUSI) scores (range 0-1), n pts, mean (SD)
    • DBT-BSI
      • 1wk
        • 41, 0.98 (0.16)
      • 4wks
        • 35, 0.91 (0.28)
      • 12wks
        • 38, 0.92 (0.27)
    • RT
      • 1wk
        • 38, 0.63 (0.49)
      • 4wks
        • 36, 0.78 (0.42)
      • 12wks
        • 30, 0.60 (0.50)
    • Statistical difference between groups
      • NS


Depression
  • Patient Health Questionnaire Depression Module (PHQ) scores (range 0-27), n pts, mean (SD)
    • DBT-BSI
      • Baseline
        • 45, 16.38 (6.19)
      • 1wk
        • 41, 13.39 (7.30)
      • 4wks
        • 36, 13.17 (6.22)
      • 12wks
        • 39, 12.64 (6.69)
    • RT
      • Baseline
        • 46, 17.33 (5.66)
      • 1wk
        • 39, 14.46 (6.49)
      • 4wks
        • 38, 13.53 (6.79)
      • 12wks
        • 31, 13.10 (7.09)
    • Statistical difference between groups
      • NS


Anxiety
  • Beck Anxiety Inventory (BAI) scores (range 0-63), n pts, mean (SD)
    • DBT-BSI
      • Baseline
        • 46, 12.83 (10.14)
      • 1wk
        • 41, 7.37 (7.90)
      • 4wks
        • 36, 8.22 (8.74)
      • 12wks
        • 39, 7.23 (7.82)
    • RT
      • Baseline
        • 47, 14.26 (9.54)
      • 1wk
        • 39, 8.15 (8.92)
      • 4wks
        • 38, 8.47 (8.97)
      • 12wks
        • 31, 8.45 (9.43)
    • Statistical difference between groups
      • NS


Health care utilization
  • Treatment History Interview (THI)
    • NR
  • Contacts with mental health services (measure not described)
    • DBT-BSI
      • NR
    • RT
      • NR
    • Statistical difference between groups
      • NS


Self-injury
  • Suicide attempt, n pts
    • DBT-BSI
      • NR
    • RT
      • NR
    • Both groups combined
      • 3
    • Statistical difference between groups
      • NS
  • Non-suicidal self-injury, n pts
    • DBT-BSI
      • 7
    • RT
      • 7
    • Statistical difference between groups
      • NS
“The present study compared two brief, one-time interventions for non-treatment-engaged suicidal individuals. We predicted the DBT-BSI would result in greater improvements than the RT; however, there was no evidence of differential rates of change between conditions.” (p. 159)
Comtois, 201122
Suicidal ideation
  • Scale for Suicide Ideation-Current (SSI)
    • Both groups
      • quantitative, descriptive data NR i.e., data only reported graphically and narratively
    • No significant difference between groups, Poisson generalized linear mixed model (repeat measures), RR (95% CI)
      • 0.94 (0.79-1.11)
    • Significant difference between groups, Poisson generalized linear mixed model (12 mos), RR (95% CI)
      • 4.81 (1.61-14.33)


Psychological distress
  • Outcome Questionnaire-45 (OQ-45)
    • Both groups
      • quantitative, descriptive data NR i.e., data only reported graphically and narratively
    • No significant difference between groups, linear mixed model (repeat measures), unstandardized regression coefficient (95% CI)
      • 4.08 (-10.36-25.59)
    • Significant difference between groups, linear mixed model (12 mos), unstandardized regression coefficient (95% CI)
      • 19.65 (4.13-36.65)


Reasons for living
  • Reasons for Living Scale (RFL)
    • Both groups
      • quantitative, descriptive data NR i.e., data only reported graphically and narratively
    • No significant difference between groups, linear mixed model, unstandardized regression coefficient (95% CI)
      • -7.16 (-39.14-29.47)
    • No significant difference between groups, linear mixed model (12 mos), unstandardized regression coefficient (95% CI)
      • -2.78 (-30.89-21.75)


Hope
  • Optimism and Hope Scale (OHS)
    • Both groups
      • quantitative, descriptive data NR i.e., data only reported graphically and narratively
    • No significant difference between groups, linear mixed model, unstandardized regression coefficient (95% CI)
      • -2.55 (-8.01-2.75)
    • Significant difference between groups, linear mixed model (12 mos), unstandardized regression coefficient (95% CI)
      • -4.07 (-8.77to -0.12)


Suicidal behaviours
  • Suicide attempts and self-inflicted injuries at baseline, 4mos, 6mos, and 12mos, mean (SD)
    • CAMS
      • 3.0 (9.3), 0.0 (0.0), 0.2 (0.4), 1.2 (3.9)
    • E-CAU
      • 7.7 (24.5), 0.8 (1.8), 0.0 (0.0), 3.3 (7.6)
    • Statistical difference between groups
      • NR


Health care utilization
  • Self-reported ED admissions – all at baseline, 4mos, 6mos, and 12mos, mean (SD)
    • CAMS
      • 1.5 (1.2), 0.4 (0.5), 0.4 (0.5), 1.3 (1.1)
    • E-CAU
      • 1.6 (0.8), 0.4 (0.7), 0.2 (0.4), 1.0 (2.4)
    • Statistical difference between groups
      • NR
  • Self-reported ED admissions – behavioral health-related only at baseline, 4mos, 6mos, and 12mos, mean (SD)
    • CAMS
      • 1.3 (1.1), 0.1 (0.4), 0.2 (0.4), 0.2 (0.4)
    • E-CAU
      • 1.1 (0.6), 0.4 (0.7), 0.2 (0.4), 0.6 (1.6)
    • Statistical difference between groups
      • NR
  • Self-reported days admitted at baseline, 4mos, 6mos, and 12mos, mean (SD)
    • CAMS
      • 5.5 (5.4), 1.4 (2.5), 3.5 (7.0), 1.4 (4.5)
    • E-CAU
      • 7.0 (7.0), 1.0 (2.3), 1.3 (4.6), 3.2 (8.0)
    • Statistical difference between groups
      • NR
“CAMS was both feasible in this NDA setting and effective in treating suicidal ideation, distress, and hopelessness (particularly at 12 months follow-up).” p. 963
Non-Randomized Study (2 reports at different time points)
Ellis, 201725
Depression
  • Patient Health Questionnaire-9 (PHQ-9), mean score (SD)
    • CAMS at admission (n=52), discharge (n=52), 6mos follow-up (n=18)
      • 18.88 (5.66), 8.83 (6.35), 9.50 (7.82)
    • TAU at admission (n=52), discharge (n=52), 6mos follow-up (n=21)
      • 19.52 (5.62), 13.73 (5.83), 10.53 (5.54)
    • Statistical difference between group mean scores (Tukey’s multiple-range test)
      • Admission to discharge
        • Significant (value NR), favouring CAMS
      • Discharge to 6mo follow-up
        • NS (value NR)


Self-Harm
  • Item 9 (of the PHQ-9), mean score (SD)
    • CAMS at admission (n=52), discharge (n=52), 6mos follow-up (n=18)
      • 1.87 (1.10), 0.52 (0.70), 0.56 (0.86)
    • TAU at admission (n=52), discharge (n=52), 6mos follow-up (n=21)
      • 1.90 (1.01), 1.08 (1.08), 0.82 (0.73)
    • Statistical difference between group mean scores (Tukey’s multiple-range test)
      • Admission to discharge
        • Significant (value NR), favouring CAMS
      • Discharge to 6mo follow-up
        • NS (value NR)


Suicidal ideation
  • Columbia-Suicide Severity Rating Scale (C-SSRS) at admission, discharge, and 6 mos follow up, mean score (SD)
    • CAMS at admission (n=52), discharge (n=52), 6mos follow-up (n=18)
      • 15.92 (4.93), 5.35 (6.88), 7.00 (7.51)
    • TAU at admission (n=52), discharge (n=52), 6mos follow-up (n=21)
      • 16.46 (4.00), 9.07 (6.53), 9.00 (5.29)
    • Statistical difference between group mean scores (Tukey’s multiple-range test)
      • Admission to discharge
        • Significant (value NR), favouring CAMS
      • Discharge to 6mo follow-up
        • NS (value NR)
  • Beck Scale for Suicide Ideation (BSS), mean score (SD)
    • CAMS at admission (n=52), discharge (n=52)
      • 13.75 (9.31), 4.82 (8.02)
    • TAU at admission (n=52), discharge (n=52)
      • 15.06 (9.85), 9.35 (9.63)
    • Statistical difference between group mean scores
      • Significant (value NR), favouring CAMS
  • Statistical Suicide Cognitions Scale (SCS), mean score (SD)
    • CAMS at admission (n=52), discharge (n=52)
      • 53.61 (17.78), 33.27 (16.73)
    • TAU at admission (n=52), discharge (n=52)
      • 59.98 (15.52), 50.79 (16.37)
    • Statistical difference between group mean scores
      • Significant (value NR), favouring CAMS


Functional disability
  • WHO Disability Assessment Schedule 2.0 (WHODAS), mean score (SD)
    • CAMS at admission (n=52), discharge (n=52), 6mos follow-up (n=18)
      • 19.16 (9.35), 7.58 (6.41), 10.89 (7.28)
    • TAU at admission (n=52), discharge (n=52), 6mos follow-up (n=21)
      • 21.37 (11.01), 10.81 (8.60), 10.56 (8.21)
    • Statistical difference between group mean scores (Tukey’s multiple-range test)
      • Admission to discharge
        • Significant (value NR), favouring CAMS
      • Discharge to 6mo follow-up
        • NS (value NR)


Well-being
  • WHO-5 Well-Being Index (WHO-5), mean score (SD)
    • CAMS at admission (n=52), discharge (n=52), 6mos follow-up (n=18)
      • 5.69 (4.41), 13.02 (5.30), 16.20 (4.43
    • TAU at admission (n=52), discharge (n=52), 6mos follow-up (n=21)
      • 4.33 (3.80), 8.62 (4.06), 14.27 (5.55)
    • Statistical difference between group mean scores (Tukey’s multiple-range test)
      • Admission to discharge
        • Significant (value NR), favouring CAMS
      • Discharge to 6mo follow-up
        • NS (value NR)


Other measures
  • Beck Hopelessness Scale (BHS), mean score (SD)
    • CAMS at admission (n=52), discharge (n=52)
      • 12.62 (5.74), 6.25 (5.78)
    • TAU at admission (n=52), discharge (n=52)
      • 15.15 (3.62), 14.42 (3.83)
    • Statistical difference between group mean scores
      • Significant (value NR), favouring CAMS
  • Acceptance and Action Questionnaire-II (AAQ-II), mean score (SD)
    • CAMS at admission (n=52), discharge (n=52)
      • 34.79 (8.78), 24.48 (9.95)
    • TAU at admission (n=52), discharge (n=52)
      • 36.65 (8.57), 33.77 (8.74)
    • Statistical difference between group mean scores
      • Significant (value NR), favouring CAMS
  • Re-hospitalization at any time since discharge from hospital, n pts
    • CAMS (n=NR)
      • 8
    • TAU (n=NR)
      • 4
    • Statistical difference between groups
      • NS (value NR)
  • Suicidal behaviour since discharge from hospital (suicide attempt or suicide), n pts
    • CAMS (n=NR)
      • 3
    • TAU (n=NR)
      • 1
    • Statistical difference between groups
      • P = 0.308
“In this controlled comparison trial, we found that … patients treated by a CAMS-trained individual therapist improved significantly more from hospital admission to discharge relative to patients receiving equivalent treatment but with an individual therapist not trained in CAMS, and d) differences in outcomes favoring the CAMS intervention at discharge were no longer statistically significant at 6 months post-discharge.” (p. 257)
Ellis, 201526
Suicidal ideation
  • Columbia-Suicide Severity Rating Scale (C-SSRS)
    • Results NR
  • Beck Scale for Suicide Ideation (BSS) scores at admission and discharge, mean (SD)
    • CAMS
      • 12.88 (8.70), 1.58 (3.25)
    • TAU
      • 9.44 (9.60), 3.60 (6.71)
    • Statistical difference between groups at discharge
      • P < 0.05


Suicidal cognition
  • Suicide Cognitions Scale (SCS) scores at admission and discharge, mean (SD)
    • CAMS
      • 52.27 (16.21), 26.69 (9.94)
    • TAU
      • 50.68 (14.89), 33.40 (15.84)
    • Statistical difference between groups at discharge
      • P < 0.05


Hopelessness
  • Beck Hopelessness Scale (BHS), scores at admission and discharge, mean (SD)
    • CAMS
      • 12.35 (4.68), 4.35 (1.80)
    • TAU
      • 12.68 (4.86), 7.28 (5.30)
    • Statistical difference between groups at discharge
      • NS (value NR)


Depression
  • Patient Health Questionnaire-9 (PHQ-9) scores at admission and discharge, mean (SD)
    • CAMS
      • 18.96 (5.37), 6.88 (4.48)
    • TAU
      • 18.40 (7.57), 9.04 (7.27)
    • Statistical difference between groups at discharge
      • NS (value NR)
“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 … In conclusion, these data provide solid support for the supplemental benefit of using a suicide-specific intervention for suicidal psychiatric inpatients.” (p. 556, p. 564)

AAQ-II = Acceptance and Action Questionnaire-II; BAI = Beck Anxiety Inventory; BHS = Beck Hopelessness Scale; BSS = Beck Scale for Suicide Ideation; C-SSRS = Columbia-Suicide Severity Rating Scale; CAMS = Collaborative Assessment and Management of Suicidality; CD-RISC = Connor-Davidson Resilience Scale; CI = Confidence interval; CSQ = Client Satisfaction Questionnaire; DBT-BSI = Dialectical Behavior Therapy -Brief Suicide Intervention; DBT-WCCL = DBT Ways of Coping Checklist; DERS = Difficulties in Emotion Regulation Scale; E-CAU = Enhanced care as usual; ED = Emergency department; mo/mos = month/s; N/n = number; NDA = Next-day appointment; NR = not reported; NS = not significant; OHS = Optimism and Hope Scale; OQ-45 = Outcome Questionnaire-45; PHQ = Patient Health Questionnaire; pts = patients; RCT = randomized controlled trial; RFL = Reasons for Living Scale; RT = Relaxation therapy; SASI-Count = Suicide Attempt Self-Injury Count; SCID = Structured Clinical Interview for DSM-IV; SCS = Suicide Cognitions Scale; SD = standard deviation; SF-36 = Medical Outcomes Study Short Form-36; SSI-C = Scale for Suicide Ideation-Current; SSF = Suicide Status Form; SUSI = Skills Used Since the Intervention; TAU = treatment as usual; THI-M = Treatment History Interview-Military; WHO-5 = WHO-5 Well-Being Index; WHODAS = WHO Disability Assessment Schedule wks = weeks

*

Data are reported in a Table 2 across two pages (pp.350-1) with headers that are discordant across pages in their description of mean and median values reported; the data describing mental health outcomes have thus been abstracted with the reader’s best interpretation of what is described in the published manuscript

Appendix 5. Additional References of Potential Interest

Intervention cannot be ascertained as suicide-specific

  • Hvid M, Vangborg K, Sorensen HJ, Nielsen IK, Stenborg JM, Wang AG. Preventing repetition of attempted suicide-II. The Amager project, a randomized controlled trial. Nord J Psychiatry. 2011;65(5):292–8. [PubMed: 21171837]
  • Inagaki M, Kawashima Y, Kawanishi C, Yonemoto N, Sugimoto T, Furuno T, et al. Interventions to prevent repeat suicidal behavior in patients admitted to an emergency department for a suicide attempt: a meta-analysis. J Affect Disord. 2015 Apr 1;175:66–78. [PubMed: 25594513]
  • Mewton L, Andrews G. Cognitive behaviour therapy via the internet for depression: a useful strategy to reduce suicidal ideation. J Affect Disord. 2015 Jan 1;170:78–84. [PubMed: 25233243]
  • Walser RD, Garvert DW, Karlin BE, Trockel M, Ryu DM, Taylor CB. Effectiveness of acceptance and commitment therapy in treating depression and suicidal ideation in veterans. Behav Res Ther. 2015 Nov;74:25–31. [PubMed: 26378720]

Non-comparative study design

  • Ellis TE, Green KL, Allen JG, Jobes DA, Nadorff MR. Collaborative assessment and management of suicidality in an inpatient setting: results of a pilot study. Psychotherapy. 2012 Mar;49(1):72–80. [PMC free article: PMC3752846] [PubMed: 22369081]
  • Nielsen AC, Alberdi F, Rosenbaum B. Collaborative assessment and management of suicidality method shows effect. Dan Med Bull. 2011 Aug;58(8):A4300. [PubMed: 21827722]

About the Series

CADTH Rapid Response Report: Summary with Critical Appraisal
ISSN: 1922-8147

Version: 1.0

Funding: CADTH receives funding from Canada’s federal, provincial, and territorial governments, with the exception of Quebec.

Suggested citation:

Suicide-specific psychotherapy for the treatment of suicidal crisis: a review of clinical effectiveness. Ottawa: CADTH; 2018 May. (CADTH rapid response report: summary with critical appraisal).

Disclaimer: The information in this document is intended to help Canadian health care decision-makers, health care professionals, health systems leaders, and policy-makers make well-informed decisions and thereby improve the quality of health care services. While patients and others may access this document, the document is made available for informational purposes only and no representations or warranties are made with respect to its fitness for any particular purpose. The information in this document should not be used as a substitute for professional medical advice or as a substitute for the application of clinical judgment in respect of the care of a particular patient or other professional judgment in any decision-making process. The Canadian Agency for Drugs and Technologies in Health (CADTH) does not endorse any information, drugs, therapies, treatments, products, processes, or services.

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Bookshelf ID: NBK532315PMID: 30346677

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