Evidence-Based Psychotherapies forSuicide Prevention

Future DirectionsGregory K. Brown, PhD, Shari Jager-Hyman, PhD

From the PerePhiladelphia, P

Address coPsychiatry, UnPhiladelphia P

0749-3797/http://dx.do

S186 Am J

Psychotherapeutic interventions targeting suicidal thoughts and behaviors are essential for reducingsuicide attempts and deaths by suicide. To determine whether specific psychotherapies areefficacious in preventing suicide and suicide-related behaviors, it is necessary to rigorously evaluatetherapies using RCTs. To date, a number of RCTs have demonstrated efficacy for severalinterventions focused on preventing suicide attempts and reducing suicidal ideation. Althoughthese studies have contributed greatly to the understanding of treatment for suicidal thoughts andbehaviors, the extant literature is hampered by a number of gaps and methodologic limitations.Thus, further research employing increased methodologic rigor is needed to improve psychother-apeutic suicide prevention efforts. The aims of this paper are to briefly review the state of the sciencefor psychotherapeutic interventions for suicide prevention, discuss gaps and methodologiclimitations of the extant literature, and suggest next steps for improving future studies.(Am J Prev Med 2014;47(3S2):S186–S194) & 2014 American Journal of Preventive Medicine

Introduction

The development and implementation of effectiveinterventions are imperative for reducing rates ofsuicide and related behaviors. In response to the

ongoing need for effective treatments aimed at prevent-ing suicide and self-directed violence, the NationalAction Alliance for Suicide Prevention’s (Action Alli-ance) Research Prioritization Task Force (RPTF)1 hasproposed the following Aspirational Goal focused onpsychotherapeutic interventions: “…develop widelyavailable, more effective and efficient psychosocial inter-ventions targeted at individuals, families, and communitylevels.”The current paper has three main aims in discussing

this Aspirational Goal. First, with a focus on RCTs, thestate of the science for evidence-based psychotherapyinterventions for suicidal ideation and behavior isreviewed. Second, limitations of the current researchand suggestions for future research are discussed. Finally,a step-by-step pathway for evaluating psychotherapyinterventions for suicide prevention is proposed.

lman School of Medicine of the University of Pennsylvania,ennsylvaniarrespondence to: Gregory K. Brown, PhD, Department ofiversity of Pennsylvania, 3535 Market Street, Room 2032,A 19104-3309. E-mail: gregbrow@mail.med.upenn.edu.$36.00i.org/10.1016/j.amepre.2014.06.008

Prev Med 2014;47(3S2):S186–S194 & 2014 Ame

State of the Science of Evidence-BasedTreatments for Suicide PreventionSeveral RCTs2–5 have demonstrated promising results inreducing suicide attempts and self-directed violence. Acomprehensive review of the literature is beyond thescope of this paper; however, reviews2–5 were used toidentify studies to include in this brief review. A selectionof studies yielding positive effects will be highlighted andpresented in Table 1. Briefly, cognitive therapy for suicideprevention (CT-SP)6; cognitive–behavioral therapy(CBT)7; dialectical behavior therapy (DBT)8; problem-solving therapy (PST)9; mentalization-based treatment(MBT)10; and psychodynamic interpersonal therapy(PIT)11 have all evidenced positive effects for preventingsuicide attempts or self-directed violence in adults.More specifically, recent suicide attempters who

received CT-SP were 50% less likely to reattempt thanparticipants who received enhanced usual care (EUC)with tracking and referrals.6 CBT plus treatment as usual(TAU) also reduced self-harming behaviors relative toTAU alone.7 For individuals with borderline personalitydisorder (BPD), DBT demonstrated a greater reduction insuicide attempts relative to community treatment byexperts.8 However, DBT was not statistically more effec-tive than a manualized general psychiatric managementcondition, consisting of case management, dynamicallyinformed psychotherapy, and medication management.12

Also focused on BPD, MBT, a psychoanalyticallyoriented partial hospitalization program, was more

rican Journal of Preventive Medicine � Published by Elsevier Inc.

Table 1. Summary of select RCTs

Authors SampleStudy

interventionControlcondition

Outcomevariables

Follow-upintervals Main findings

Bateman andFonagy(1999)10

Adults with BPDreferred topsychiatric unit

Partialhospitalization(n¼19)

Standardpsychiatriccare (n¼19)

Suicideattempts

3, 6, 9, 12, 15,18 months

Patients who received the study interventionexperienced a significant reduction in attemptsfrom admission to 18 months (Kendall’s W¼0.59,χ2(3)¼33.5, po0.001)

Blum et al.(2008)13

Adults with BPD STEPPS plusTAU (n¼65)

TAU (n¼59) Suicideattempts

1, 3, 6, 9, 12months

No differences in time to first suicide attemptbetween STEPPS þ TAU and TAU groups;χ2(1)o0.1, p¼0.994

Brown et al.(2005)6

Adults recruitedfrom ED followinga suicide attempt

CT (n¼60) EUC (n¼60) Suicidalideation,suicideattempts

1, 3, 6, 12, 18months

At 6 months, using the Kaplan–Meier method,estimated reattempt-free probability: CTgroup¼0.86 (95% CI¼074, 0.93); usual care¼0.68 (95% CI¼0.54, 0.79)At 18 months, estimated reattempt-freeprobability: CT¼0.76 (95% CI¼0.62, 0.85); usualcare¼0.58 (95% CI¼0.44, 0.70)Patients in the CT condition had a significantlylower reattempt rate (Wald χ2¼3.9, p¼0.049) andwere 50% less likely to reattempt than the usualcare group (hazard ratio¼0.51, 95% CI¼0.26, 0.997)There were no significant group differences insuicidal ideation

Bruce et al.(2004)21

Depressed olderadults recruitedfrom primary care

Structured,team-basedinterventionincludingcitalopram þpsychotherapy(n¼320)

TAU (n¼278) Suicidalideation

4, 8, 12months

Rates of suicidal ideation declined faster for theintervention group (12.9% decline from baseline)than the TAU group (3.0% decline from baseline;p¼0.01 for all depressed patients, p¼0.006 forpatients with MDD)

Comtois et al.(2011)17

Adults evaluatedfor suicideattempt orimminent risk butjudged safe fordischarge

CAMS (n¼16) E-CAU (n¼16) Suicideattempts,suicidalideation

2, 4, 6, 12months

Participants who received CAMS made fewersuicide attempts than those who received E-CAUat 2-, 4-, and 6-month follow-upsa

Suicidal ideation improved significantly for CAMSpatients, reaching 89% reduction at 12 months,RR¼0.11, 95% CI¼0.04, 0.30; at 12 months,E-CAU patients reported significantly worsesuicidal ideation than CAMS patients (RR¼4.81,95% CI¼1.61, 14.33)

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Table 1. Summary of select RCTs (continued)

Authors SampleStudy

interventionControlcondition

Outcomevariables

Follow-upintervals Main findings

Davidson et al.(2006)14

Adults with BPDand an episode ofDSH within thepast 12 months

CBT þ TAU(n¼53)

TAU (n¼49) Suicidal acts 6, 12, 18, 24months

After 24 months, there was a greater reduction innumber of suicidal acts in the intervention groupcompared to the TAU group (mean difference¼–0.91, p¼0.020)

Diamond et al.(2010)19

Adolescentsidentified assuicidal byscreening duringprimary care orED visits

ABFT (n¼35) EUC (n¼31) Suicidalideation

6, 12, 24weeks

At the 12-week assessment, patients receivingABFT demonstrated a significantly greater rate ofimprovement in suicidal ideation than patientsreceiving EUC, F(1, 64)¼12.60, p¼0.001ABFT had a significant effect on clinical recovery(SIQ-JRr13) of suicidal ideation at all time points;at 6 weeks, 69.7% of ABFT patients and 40.7% ofEUC patients reported suicidal ideation in thenormative range, OR¼3.35, 95% CI¼1.15, 9.73,χ²(1)¼5.07, p¼0.02; at 12 weeks, 87.1% of ABFTpatients and 51.7% of EUC patients reportedideation in the normative range, OR¼6.30, 95%CI¼1.76, 22.61, χ²(1)¼8.93, p¼0.003; at 24weeks, 70% of ABFT patients and 34.6% of EUCpatients reported ideation in the normative range,OR¼4.41, 95% CI¼1.43, 13.56, χ²(1)¼7.01,p¼0.008

Guthrie et al.(2001)11

Adults presentingto ED after self-poisoning

Psychody-namicinterpersonaltherapydelivered inhome (n¼58)

TAU (n¼61) Suicidalideation

1, 6 months At the 6-month follow-up assessment, patientsreceiving the study intervention reported lowerlevels of suicidal ideation compared to thosereceiving TAU (differences between means¼ –4.9,95% CI¼ –8.2, –1.6, p¼0.005)

Hatcher et al.(2011)9

Adults presentingto a hospital afterself-harm

PST (n¼522) Usual care(n¼572)

Self-harm 3, 12 months Fewer patients receiving PST reported repeatepisodes of self-harm at the 12-monthassessment than those receiving usual care(RR¼0.39, 95% CI¼0.07, 0.60, p¼0.03)

Huey et al.(2004)16

Youth followingED visit for suicideattempt, ideation,or planning

MSTb Standardtreatmentb

Suicidalideation,suicideattempts

4, 16 months MST was significantly more effective thanstandard treatment at reducing suicide attemptsover 16 months, t(linear)¼2.61, po0.01, t(quadratic)¼3.60, po0.001There were no significant group differences forsuicidal ideation

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Table 1. Summary of select RCTs (continued)

Authors SampleStudy

interventionControlcondition

Outcomevariables

Follow-upintervals Main findings

Linehan et al.(2006)8

Women with BPDwith Z2 episodesof self-harm in thepast 5 years,including Z1within the past 8weeks

DBT (n¼52) Communitytreatment byexperts(n¼49)

Suicidalideation,suicideattempts

4, 8, 12, 16,20, 24 months

Fewer patients receiving DBT had suicide attemptsthan those receiving treatment by experts (23.1%vs 46%, hazard ratio¼2.66, p¼0.005, NNT¼4.24,95% CI¼2.40, 18.07); the mean proportions ofsuicide attempters per treatment group per periodwere 6.2% (95% CI¼3.1%, 11.7%) and 12.2%(95% CI¼7.1%, 20.3%) for the DBT and controlgroups, respectivelyFewer patients receiving DBT than communitytreatment by experts had non-ambivalent suicideattempts (5.8% vs 13.3%, p¼0.18, Fisher’s exacttest and NNT¼13.3, 95% CI¼5.28, 25.41)There were no significant group differences forsuicidal ideation

McMain et al.(2009)12

Adults with BPDwith Z2 suicidalor non-suicidalself-injuriousepisodes in thepast 5 years, Z1episode in thepast 3 months

DBT (n¼90) Generalpsychiatricmanagement(n¼90)

Frequency andseverity ofsuicidalepisodes

4, 8, 12months

There were no significant group differences forsuicidal episodes

Slee et al.(2008)7

Adults whorecently engagedin deliberate self-poisoning or self-injury

CBT þ TAU(n¼40)

TAU (n¼42) Self-harm,suicidalcognition

3, 6, 9 months At 9 months, patients who received CBT þ TAUhad significantly greater reductions in self-harmthan those who received TAU alone (po0.05)CBT þTAU patients had significantly decreasedsuicidal cognitions as compared to TAU patients atthe 3- (po0.05), 6- (po0.05), and 9-month(po0.01) assessments

Stewart et al.(2009)18

Adults intreatmentfollowing a suicideattempt

CBT (n¼11),PST (n¼12)

TAU (n¼9) Suicidalideation,suicideattempts

4 weeks (PST),7 weeks (CBT),

2 months(TAU)

CBT was the most effective treatment for reducingsuicide attempts; patients receiving CBT made noattempts during the study, whereas patientsreceiving PST and TAU made an average of 0.33attempts and 0.22 attempts, respectivelySuicidal ideation decreased with both CBT (z¼�2.32, po0.05, r¼0.49) and PST (z¼�2.39,po0.05, r¼0.49); decreases in suicidal ideationwere greater for the PST than TAU group (U¼26.5,pr0.05, r¼0.49)

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Table1.S

ummaryof

select

RCTs

(con

tinue

d)

Autho

rsSa

mple

Stud

yinterven

tion

Con

trol

cond

ition

Outcome

varia

bles

Follow-up

intervals

Mainfind

ings

Unü

tzer

etal.

(2006)20

Older

adults

with

MDDor

dysthymia

IMPA

CT

interven

tion

(n¼9

06)

Usual

care

(n¼8

95)

Suicidal

idea

tion

6,1

2,1

8,2

4mon

ths

Fewer

patie

ntsreceivingtheIM

PACTinterven

tion

than

usua

lcarerepo

rted

thou

ghts

ofsuicideat

6(OR¼0

.54,9

5%

CI¼

0.37,0

.78,p

¼0.001),12

(OR¼0

.54,9

5%

CI¼

0.40,0

.73,p

o0.001),18

(OR¼0

.52,9

5%

CI¼

0.36,0

.75,p

o0.001),an

d24

(OR¼0

.65,95

%CI¼0

.46,0.91

,po0.01

)mon

ths

Fewer

patie

ntsreceivingtheIM

PACTinterven

tion

repo

rted

thou

ghts

ofde

athor

dyingat

6(OR¼0

.62,9

5%

CI¼

0.49,0

.78,p

o0.001),12

(OR¼0

.44,9

5%

CI¼

0.35,0

.56,p

o0.001),18

(OR¼0

.62,9

5%

CI¼

0.49,0

.79,p

o0.001),an

d24

(OR¼0

.72,95

%CI¼0

.57,0.92

,p¼0

.01)

mon

ths

Woo

det

al.

(2001)15

Adolescents

referred

tomen

tal

health

services

afterde

liberate

self-ha

rm

Group

therap

y(n¼3

2)

Rou

tinecare

(n¼3

1)

Rep

etition

ofself-ha

rm,

suicidal

thinking

6wee

ks,7

mon

ths

Participan

tswho

received

grou

ptherap

ywereless

likelyto

repe

atself-ha

rmthan

thosewho

received

routinecare

(OR¼6

.3,6

5%

CI¼

1.4,2

8.7)

Therewereno

sign

ificant

grou

pdifferen

ces

rega

rdingsuicidal

thinking

Note:

Onlyou

tcom

esrelatedto

suicideidea

tionan

dattemptsarerepo

rted

.aNostatistical

analyses

werepe

rformed

fortheseresults.

bStud

ydidno

tindicate

thenu

mbe

rof

participan

tspe

rcond

ition

.AB

FT,attachm

ent-b

ased

family

therap

y;BPD

,borde

rline

person

ality

disorder;C

AMS,

collabo

rativeassessmen

tand

man

agem

ento

fsuicida

lity;CBT,cogn

itive–be

havioraltherap

y;CT,cogn

itive

therap

y;DBT,

dialectical

beha

vior

therap

y;DSH

,deliberateself-ha

rm;E

-CAU

,enh

ancedcare

asusua

l;ED

,emerge

ncyde

partmen

t;EU

C,e

nhan

cedusua

lcare;

IMPA

CT,

ImprovingMoo

d:Prom

otingAccess

toCollabo

rativeTrea

tmen

t;MDD,m

ajor

depressive

disorder;M

ST,m

ultisystemictherap

y;NNT,

numbe

rne

eded

totrea

t;PS

T,prob

lem-solving

therap

y;RR,riskratio

;SIQ-JR,S

uicide

Idea

tion

Que

stionn

aire–Junior;S

TEPP

S,system

straining

forem

otiona

lpredictab

ility

andprob

lem

solving;

TAU,treatmen

tas

usua

l

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effective than general psychiatric servicesin reducing suicidal and self-mutilatoryacts.10 Similarly, relative to TAU alone,PST plus usual care resulted in a decreasein repeat hospitalizations for self-harm inindividuals with a history of previous self-harm.9 Finally, four home-based sessionsof interpersonal therapy were more effec-tive than TAU in reducing suicidal idea-tion and repeated self-harm in individualswho self-poisoned.11

Although a number of suicide-prevention interventions have evidencedefficacy, other interventions, includingsystems training for emotional predict-ability and problem solving13 and CBT forCluster B personality disorders,14 havenot been supported empirically. For acomprehensive review of negative find-ings, please see previous reviews.2–5

Fewer studies15,16 have demonstratedefficacy for psychotherapy interventionsin reducing self-directed violence in ado-lescents. Wood and colleagues15 found thatadolescents who received developmentalgroup therapy (consisting of componentsof CBT, DBT, and psychodynamic grouptherapy) plus TAU were less likely toengage in repeated deliberate self-harmon two or more occasions than thosewho received TAU alone. Finally, multi-systemic therapy, an intensive family-based treatment, reduced the frequencyof suicide attempts compared to treatmentreceived during inpatient hospitalization.16

In addition to psychosocial interven-tions designed to prevent suicideattempts, several psychotherapy treat-ments directly target suicidal ideation.Specifically, collaborative assessment andmanagement of suicidality (CAMS),17

CBT,18 PST,18 and PIT11 have resultedin the reduction of suicidal ideation inadults. CAMS, a therapeutic frameworkfocused on identifying causes of suicidalideation and treatment goals for reducingsuicidal ideation, was associated withsignificantly greater and sustained reduc-tion of suicidal ideation at 12 monthspost-treatment compared to TAU.17 Sim-ilarly, both PST and CBT resultedin greater reduction of suicidal ideationthan TAU.16 Attachment-based family

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therapy, which focuses on strengthening the parent–adolescent attachment bond, has also demonstratedpromise in reducing suicidal ideation in suicidal adoles-cents relative to EUC.19

Finally, to our knowledge, two studies have demon-strated efficacy in reducing suicidal ideation in depressedolder adults in primary care settings.20,21 The ImprovingMood: Promoting Access to Collaborative Treatmentstudy determined that a collaborative, team-basedapproach to treating depression resulted in a greaterreduction of suicidal ideation than usual care. ThePrevention of Suicide in Primary Care Elderly: Collabo-rative Trial intervention, consisting of a clinical algo-rithm for treating geriatric depression in primary caresettings and care management, was more effective inreducing suicidal ideation than EUC.

Limitations of the Current State of theScienceAlthough the aforementioned RCTs represent importantfirst steps in gaining a deeper understanding of effectivesuicide prevention strategies, several gaps and methodo-logic concerns limit conclusions that can be drawn fromthese studies. Several significant gaps in the literatureshould be noted. First, given the paucity of RCTs poweredto detect deaths by suicide, it is unknown whether deathby suicide (rather than suicide attempts) can be preventedby psychotherapy. Moreover, it is unclear as to whetherthe reduction of suicide attempts or ideation via psycho-therapy actually reduces deaths by suicide.Second, many studies focused on suicide prevention

exclude patients at imminent risk for suicide, making itimpossible to determine whether interventions that areefficacious for lower-risk patients are also efficacious forthose at highest risk.22 Third, there are limited psycho-therapy RCTs focused on preventing suicide attempts formany at-risk populations, including older adults; Veteransor military service members; lesbian, gay, bisexual, trans-gender, queer, and two-spirit (LGBTQ2) populations;Native Americans and other minority groups; and survi-vors of suicide or suicide attempts. It is unclear whether theresults of existing RCTs generalize to these populations.Additionally, the majority of psychotherapy interven-

tions for suicidal thoughts and behaviors have beenconducted in outpatient settings, and very few RCTs havebeen conducted in acute care settings, such as emergencydepartments, inpatient units, and crisis hotlines. Thedevelopment of interventions for these settings is partic-ularly important given that many high-risk patients onlypresent to acute care services and never receive additionalpsychosocial treatment. The dearth of knowledge abouteffective treatments for inpatient settings is especially

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alarming given that the current standard of care is to admithigh-risk patients to inpatient units. This suggests thatpatients who are at high risk for suicide may not receiveappropriate evidence-based treatments to prevent suicide.A final gap in the extant research examining the

efficacy of psychotherapy interventions for suicide pre-vention is the failure to replicate studies in whichtreatments have been found to be efficacious. It isespecially critical that replication trials be conducted byindependent researchers, as in some cases replicationstudies conducted outside of the original research groupshave failed to demonstrate the same beneficial effects.12

A variety of methodologic limitations of the existingresearch hamper the ability to draw firm conclusionsregarding the effectiveness and generalizability of varioussuicide prevention efforts (limitations have been pub-lished elsewhere1–4). First, a lack of consensus regardingterms and operationalized definitions used to describesuicide, attempts, ideation, and other related behaviorslimits the ability to generalize across studies and replicatefindings. Researchers also often neglect to use reliableand validated measures of suicidal ideation and behav-iors, making it difficult to understand the specificbehaviors measured and targeted by the interventionsin question.In addition, many previously published RCTs do not

provide detailed psychotherapy manuals. The absence oftreatment manuals creates significant challenges for dis-semination and implementation efforts in the communityand precludes appropriate replication studies. Furthermore,researchers often neglect to include measures assessing theintegrity of the study intervention. It is important to assessthe extent to which study therapists adhere to the theoryand practice of the intervention of interest.An additional common methodologic problem is that

studies are underpowered to adequately detect treatmenteffects, causing potentially efficacious treatments to yieldnegative results owing to lack of power rather than lack ofefficacy. Moreover, very few studies include descriptions ofpower analyses, making it difficult to determine the reasonsfor failing to find positive effects. Other studies conductpower analyses based on unlikely or biased estimates ofeffects, leading to inadequate estimates of sample sizes.Conservative estimates are necessary to ensure that sam-ples are powered sufficiently to detect effects.Given that RCTs are generally longitudinal, attrition is

common and results in an additional methodologic issueof handling missing data. This is particularly problematicwhen dropout rates differ across treatment conditions,which may result in biased results.7 As recommended inthe CONSORT guidelines for reporting RCT results,intention-to-treat analysis is a helpful statistical approachto handling missing data to minimize bias.23

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Other methodologic limitations encountered in theextant literature include potential threats to externalvalidity by choosing highly selective samples11; failureto use blind investigators, assessors, or patients or specifywhether blinding was implemented; potential measure-ment bias (e.g., using differential measurement intervalsand methods for assessing primary outcomes in inter-vention and control groups10); failure to identify, meas-ure, and control for potential non-study co-interventions(e.g., pharmacotherapy); and analyses capitalizing ondifferences in baseline characteristics.16

It is also advised that researchers focus on a priorianalyses and refrain from making firm conclusions onthe basis of unplanned, underpowered subgroup analy-ses. Finally, stratified randomization is an important toolin preventing Type I errors and imbalance betweentreatment groups, particularly for smaller trials in whichknown factors influence treatment responsiveness.

Next Steps and Breakthroughs NeededAlthough the existing RCTs have created an importantjumping-off point for evaluating future psychotherapeuticinterventions for suicide attempts and ideation, muchwork remains. The adoption of the following recommen-dations may lead to increased methodologic rigor withwhich suicide research is conducted, and in turn, thedevelopment and dissemination of treatments that reducesuicidal ideation, suicide attempts, and ultimately, suicide.Given that the current lack of consensus of terms and

definitions leads to difficulty in interpreting results andaggregating findings across studies, an important short-term goal is to adopt an agreed-upon nomenclature forall studies addressing suicide-relevant thoughts andbehaviors, such as the self-directed violence nomencla-ture proposed by the CDC’s National Center for InjuryPrevention and Control.24 It is then essential to employvalid and reliable measures to assess these constructs.The Columbia Suicide Severity Rating Scale (C-SSRS25)

is one such measure endorsed by the U.S. Food and DrugAdministration for use in pharmaceutical trials. It wouldalso be beneficial to use an agreed-upon measure forpsychotherapy trials. Furthermore, to achieve continuityacross studies, it would be helpful for all studies to use thesame endpoints in reporting outcomes, thereby increasingthe ease with which results can be aggregated acrossstudies via meta-analyses.There is also a need for methods to address ambiguous

suicide behavior that may not neatly fit into a specificcategory of suicidal thoughts or behaviors. One potentialsolution to this problem is to form suicide adjudicationboards to review ambiguous behaviors and reach aconsensus regarding appropriate classification.26

An additional short-term goal is to develop interven-tions designed for high-risk populations, including olderadults, Veterans or military service members, LGBTQ2individuals, minority groups, and survivors of suicide orsuicide attempts as indicated by empirical research. Thereis also a need for methods to screen and treat high-riskindividuals in acute care settings, including emergencydepartments, crisis hotlines, and inpatient units.As previously mentioned, many studies assessing the

efficacy of treatments for suicide prevention are under-powered. Although preliminary studies to determineacceptability and feasibility of specific interventions arenecessary, large-scale RCTs that are adequately poweredto detect treatment effects are also imperative. This is truefor studies assessing treatments focused on reducingsuicidal thoughts, suicide attempts, and other self-directed violence, as well as those designed to evaluatetreatments for the prevention of deaths by suicide.Because suicide is a low base rate behavior, very large

samples are required to conduct adequately poweredtrials. Multi-site collaborations allow the collection ofdata from large samples while reducing financial andorganizational burden on any one site. In addition, theuse of standardized outcome measures and data sharingmay facilitate meta-analytic approaches and circum-vent problems associated with inadequately poweredstudies.Further development and dissemination of treatments

specifically targeting suicidal ideation are also necessary,particularly for populations such as older men who havethe highest rates of suicide of any age group.27 Despitetheir increased rate of deaths by suicide, older adults areless likely to make suicide attempts than individuals inany other age group.28 Suicidal ideation may thus serve asthe only warning sign of future suicides in older adults,making it especially important to specifically targetsuicidal ideation in this population. As frequent attemptsare less common in this population, treatments focusedon preventing attempts may be less appropriate.Because suicidal ideation is a dimensional construct

that waxes and wanes over time, RCTs should includeappropriate measures for tracking fluctuations in suicidalideation. The use of ecological momentary assessment,for example, would provide much-needed insight intothe fluctuation of suicidal ideation and inform thedevelopment of timely interventions that specificallytarget changes in suicidal ideation.Very little is known about whether positive effects of

psychotherapies for suicide prevention extend beyondlaboratory settings. In addition to efficacy trials, effec-tiveness trials are also needed to assess whether specifictreatments work in real-world settings. Moreover, inorder to increase external validity of psychotherapy trials,

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it is important that inclusion and exclusion criteria resultin samples that reflect patients as they present in the realworld (e.g., the exclusion of potential participants who donot misuse substances may result in a biased sample ofsuicide attempters10).There is a need to better develop mechanisms to ensure

that the individuals at risk of suicide have access totreatments that work. In designing interventions,researchers should consider ways to increase the feasi-bility and ease with which treatments can be disseminatedand adapted to various settings. For example, futurepsychotherapies that can be implemented in rural settingsusing telehealth technologies are needed.In addition, researchers are encouraged to clearly

communicate the specific treatment components neces-sary to successfully implement interventions in non-laboratory settings. Another potential approach toincreasing the availability of evidence-based treatmentsis to develop innovative electronic health interven-tions (e.g., smartphone applications, texting, web-basedinterventions, or chat rooms) as either widely availablestand-alone interventions or adjunctive treatments toface-to-face interventions. Finally, further research isneeded to determine the cost-effectiveness and costutility of psychotherapy studies for suicide prevention.As researchers continue to find support for treatments

that reduce suicidal thoughts and behaviors, it is necessaryto identify potential mechanisms of actions that account fortherapeutic change. Thus, in addition to asking whether atreatment works, it is essential to ask why a treatmentworks. This can be achieved by including measures assess-ing constructs underlying treatment effects, such asimprovements in hopelessness or emotion regulation.Identifying mechanisms of action will allow for the

Figure 1. Proposed step-by-step research pathway for conductinED, emergency department; MH, mental health; PC, primary care; SDV, self

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development of more efficient, targeted treatments andmay provide insight into which treatments work bestfor whom.In addition to identifying treatments that are effective in

reducing suicide ideation and behaviors, it is also impor-tant to understand which treatments have not garneredsupport in psychotherapy trials. Systematic trial registra-tion is one method for reducing the “file-drawer effect” inwhich negative findings are not presented to the public.Given the gaps and methodologic flaws in the literature

focused on psychotherapy interventions for suicide pre-vention, additional research is needed to determine theefficacy of existing and future treatments. Thus, we proposea general step-by-step research pathway for conductingfuture RCTs with high-risk patients for examining theefficacy of new psychotherapy treatments (Figure 1).The first step of this paradigm is to identify high-risk

subjects by using agreed-upon nomenclature (e.g., CDCnomenclature) as well as validated and reliable assess-ment measures. These high-risk patients can be recruitedfrom a variety of settings including emergency depart-ments, inpatient units, mental health outpatient clinics,and primary care. Following recruitment and initialassessment to determine eligibility, it is recommendedthat patients be randomly assigned to either (1) theco-active intervention condition, which may includemedication, treatment as usual, a comparative therapy,or follow-up services, or (2) the same co-active interven-tion plus a suicide-specific study intervention condition.Alternatively, depending on the question of interest, it

may be more appropriate to omit the co-active inter-vention for participants who are randomized to thesuicide-specific study intervention condition. In orderto gain an understanding of the pathways by which

g RCTs-directed violence; Ss, subjects

Brown and Jager-Hyman / Am J Prev Med 2014;47(3S2):S186–S194S194

treatment affects the outcome of interest (i.e., suicidalideation, suicide attempts, or suicides), it is imperative toexamine moderators of the study treatment and potentialmechanisms of actions. Elucidating the moderators andmechanisms at play will inform the development of moreefficient and targeted future interventions. This paradigmwill also allow for increased understanding of the relationbetween reductions in suicidal ideation and reductions insuicide attempts or deaths by suicide.

ConclusionsDespite important advances in the development andevaluation of psychotherapeutic treatments for suicideprevention, additional research is needed to improve thecurrent state of the science. A focus on filling the gaps inthe literature and increasing methodologic rigor withwhich RCTs of suicide-prevention psychotherapies areconducted will lead to increasingly effective treatmentsfor reducing suicidal ideation, attempts, and deaths.

Publication of this article was supported by the Centers forDisease Control and Prevention, the National Institutes ofHealth Office of Behavioral and Social Sciences, and theNational Institutes of Health Office of Disease Prevention.This support was provided as part of the National Institute ofMental Health-staffed Research Prioritization Task Force ofthe National Action Alliance for Suicide Prevention.

No financial disclosures were reported by the authors ofthis paper.

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