Preliminary Results

1. Preliminary Results

2. Number of Patients Attempting Suicide during Follow-up by Treatment Condition *One EC patient completed suicide (n = 60) (n = 60) Includes all participants during the one to two year follow-up

3. Survival Curves for Days until First Suicide Attempt by Treatment Condition 1.0 14 of 60 (23%) of CT+EC patients 0.9 0.8 Cummulative survival 0.7 26 of 60 (43%) of EC patients Cummulative Survival 0.6 0.5 0.4 0 183 366 549 732 Days

4. Total Number of Subsequent Suicide Attempts by Treatment Condition (n = 60) (n = 60) Includes all participants during the one to two year follow-up

5. Beck Depression Inventory by Treatment Condition p = .04 Follow-up Month

6. Beck Hopelessness Scale by Treatment Condition p = .04 Follow-up Month

8. The Cognitive Therapy Protocol

9. Cognitive Therapy for Suicide Attempters: General Description • Brief (10 sessions) and flexible • Active, directive, semi-structured, and problem focused • Standard cognitive therapy practices (e.g. setting agenda, setting homework) • Focus on problem of suicide behavior • Identify and restructure thoughts/beliefs  suicidal behavior • Increase adaptive use of social supports and compliance with health care

10. CLINICAL TRIALS WITH SUICIDAL IDEATORS OR ATTEMPTERS POPULATION TREATMENT RESULTS DEPRESSED OUTPATIENTS 12 C.T. vs. IMIPRAMINE C.T. LESS HOPELESS RUSH & BECK, 1978 N = 44 DERUBEIS & HOLLON, 2001 N = 60 DEPRESSED OUTPATIENTS 20-28 C.T. vs. DRUG THERAPY C.T. LESS SUICIDAL THAN PLACEBO BROWN ET AL., 2001 N = 27 SUICIDAL BORDERLINES 50 C.T. LESS SUICIDE IDEATION SALKOVSKIS ET AL., 1990 N = 20 SUICIDE ATTEMPTERS 5 C.T. vs. T.A.U. HOPELESSNESS IDEATION ATTEMPTS SUICIDE ATTEMPTERS UP TO 5 C.T. vs. T.A.U. DEPRESSION RATE OF ATTEMPTS EVANS ET AL., 1998; MANUAL ASSISTED COGNITIVE THERAPY N = 34

11. Ongoing Management • Directly inquire about suicidal thinking and behavior during visits • Evaluate access to lethal methods • Explain nature of depression and treatment to patient • Focus on compliance with treatment • Focus on alcohol or drug use

12. Structure of the Therapy Session • Brief Update and Mood Check • Assessment of Suicide/Homicide Risk (if indicated) • Medication Check (if taking medication) • Alcohol and Substance Abuse Check (if indicated) • Bridge from Previous Session • Set Session Agenda • Discussion of Agenda Items • Assign Homework • Final Summary and Feedback

13. Session #: 1 2 34 5 6 7 8 9 10 Early Sessions • Introduction of Cognitive Model • Cognitive conceptualization of the suicide attempt • Problem solving orientation • Suicide as a (maladaptive) attempt to solve to one’s problems • Short-term beneficial vs. long-term detrimental • Problem solving skills • Developing reasons for living • Problem and Goal List • Transforming Hopelessness into Hope

14. Case Conceptualization Early Experiences Physically and sexually abused by father Strict Baptist Upbringing/Taught what “good girls do and don’t do” Physically and verbally abusive relationship with Ex-Boyfriend Crack Addiction  Core Beliefs I am unlovable and shameful Other people are only out for themselves  Conditional Beliefs If other people do not love me, then I am a nobody If I don’t protect myself, I will be taken advantage of

15. Session #: 1 2 34 5 6 7 89 10 Middle Sessions • Changing maladaptive beliefs • Addressing problem solving deficits • Developing reasons for living • Addressing impulsivity • Increasing compliance with health care professionals • Increasing Social Support

16. Session #: 1 2 34 5 6 7 89 10 Middle Sessions: Specific Strategies • Coping Cards • Crisis plan and Steps for Reducing Suicidal Thoughts • Construction of a Hope Box/Survivor Kit • Activities in Choosing to Live (e.g., pros and cons of attempting/committing suicide) • Social Support List • Removal of Means to Harm

17. Session #: 1 2 34 5 6 7 89 10 Middle Sessions: Problem Solving • Identify and list problems • Connect problems in living to suicidality • Focus on functionality/adaptiveness of response(s) • Generate alternatives and plans • Weigh pros and cons of possible solutions • Work out discrete tasks to achieve solution • Review the consequences of the solution

18. Session #: 1 2 34 5 6 7 8 9 10 Later Sessions • Relapse Prevention Task • Anticipating Lapses • Termination • Review of Treatment • Abandonment • Ethical issues • Extensions (if necessary) • Booster Sessions (if necessary)

19. Relapse Prevention Task • Explain rationale, describe exercise and obtain informed consent • Three Steps: • Imagine chain of events, thoughts and feelings leading to attempt • Imagine sequence of events again, but respond to maladaptive thoughts and images • Imagine future scenario likely to trigger suicidal reaction • Debrief patient

20. Sequence in Borderline Patient NOBODY AT PARTY IF IGNORED I’M NOTHING I’M ALL ALONE I WANT TO DIE SERIOUS SUICIDE ATTEMPT HAVE TO KILL MYSELF NOW IT’S OK

21. SEQUENCE TO USING AND ATTEMPTING • - I CAN’T HANDLE THIS • I HATE THE WAY PEOPLE TREAT ME • - NO POINT IN KEEPING TRYING • I NEED RELIEF OR ESCAPE • SCREW IT ALL • - I MIGHT AS WELL HAVE A SMOKE, ETC. JOB OR INTERPERSONAL SETBACK • CONSEQUENCES: • RUN OUT OF MONEY • BLAME/REJECTION • SHAME/GUILT • I’M A LOSER • DIRTY ADDICT • I HAVE NO CONTROL DRUG USE • NOTHING I CAN DO • MY PROBLEMS ARE GETTING WORSE • IT WILL BE THIS WAY FOREVER • I JUST NEED TO END IT ALL SUICIDAL

22. CONCEPTUALIZATION OF BORDERLINE PERSONALITY DISORDER DICHOTOMOUS REPRESEN-TATIONS EXTREME INTER-PRETATION INTENSE CRAVING IMPULSES EXTREME AFFECT IDEALIZE OR DEMONIZE • SUBSTANCE ABUSE • VIOLENCE • CLINGING • DEMANDING • SELF-MUTILATION • SUICIDE AMBIVALENCE LOVE/HATE

23. CONSIDERING OTHER EXPLANATIONS • EX: SUICIDAL WOMAN WHOSE PARTY FAILED • ACCESS TO PAST POSITIVES • EX: FRIENDS ALWAYS ATTENTIVE IN THE PAST • PERSPECTIVE RE DISTRESS & CRAVINGS: • THESE PASS IN TIME • ADAPTIVE PROBLEM-SOLVING WHEN SUICIDAL • CAN CALL A FRIEND, GO FOR A WALK, ETC. • LACK OF RECOGNITION OF OWN LATENT STRENGTHS • TOLERATING DYSPHORIA • CONTROLLING URGES • SOLVING PERSONAL PROBLEMS Lack of Adaptive Strategies

24. Negative Beliefs About Self-Control • I CAN’T CONTROL MY IMPULSES. • MY CRAVING IS SO STRONG I HAVE TO GIVE IN TO IT. • THIS IS THE ONLY WAY I CAN RELIEVE MY TENSION, ANXIETY, SADNESS, ANGER, SHAME, OR GUILT. • I SHOULD NOT HAVE TO CONTROL MYSELF. • I HAVE THE RIGHT TO DO WHAT I WANT – EVEN IF IT HURTS ME OR OTHER PEOPLE. • IF OTHERS TREAT ME BADLY, I HAVE TO TEACH THEM A LESSON. • IF I DON’T ASSERT MYSELF, NOBODY WILL LISTEN TO ME. • I DON’T CARE ABOUT THE CONSEQUENCES

25. IMPULSIVITY • ACTION ORIENTED • EXTREME BELIEFS DEMAND EXTREME ACTION • CRAVINGS, URGES: SHOULDS, MUSTS, OUGHTS • REASSURANCE • DRUGS, FOOD • REVENGE • SELF-MUTILATION • SUICIDE • PERMISSION GIVING • OK BECAUSE I NEED IT BADLY • OK BECAUSE I’M ENTITLED • OK BECAUSE YOU DESERVE TO BE PUNISHED

26. F C H B D A G E I * * A: Patient engages in therapy, begins to trust therapist. B: Patient has relationship problems with son. C: Therapist goes out of state for 10 days. D: Patient makes suicide attempt during his absence. E: Patient is pleased at therapist return. *: Invalid data point. Patient responds badly to therapist inquiry about high BHS score. F: Disengagement from therapy discussed. “I feel abandoned.” G: Patient moves into “dream” house. H: Attracted to another man. “I am the worst person in the world.” Patient hospitalized. I: Happy to see therapist after discharge from hospital.

27. Multiple Suicide Attempters Specific High Risk Subgroups:

28. Multiple Suicide Attempters (MSAs) vs. Single Suicide Attempters (SSAs) • Appear to be a different diagnostic group. Higher levels on virtually all measures of psychopathology (depression, hopelessness, global functioning, substance use, borderline pathology, unemployment, etc.) • Easily assessed • Much greater risk for subsequent suicide attempt

29. Global Assessment of Functioning (GAF) in the Past Year p = .016

30. Number of Lifetime Suicide Attempts and Lethality of Index Attempt ns p = .085

31. Survival Analysis Comparing BPD toNo BPD on Time Until Subsequent Suicide Attempt

32. Summary of Findings • 35% of 153 patients who presented to an urban emergency room following a suicide attempt met criteria for BPD. • Suicide attempters with BPD exhibit greater depression and hopelessness, more social problem-solving difficulties, a greater number of previous suicide attempts and more suicidal ideation. • A survival analysis showed that patients with BPD were at higher risk of re-attempting suicide than those without BPD.

33. Current Study: Diagnostic Picture 35% Psychotic Disorder (n = 55) 65% Nonpsychotic (n = 103) 67% Major Depression with Psychotic Features (n = 37) 85% Major Depression (n = 87) 13% Bipolar I Disorder with Psychotic Features (n = 7) 7% Bipolar I Disorder (n = 7) 1% Depressive Disorder NOS (n = 1) 4% Depressive Disorder NOS plus Psychotic Disorder NOS (n = 2) 15% Schizoaffective (n = 8) 6% Bipolar II Disorder (n = 6) 2% Dysthymia (n = 2)

34. Demographics Older African Americans (Age > 30) are much more likely to be diagnosed with a Psychotic Disorder

35. Is the presence of psychosis associated with increased suicidal ideation? after attempt t(156) = 4.85, p < .001 r = 0.36; R2 = 0.13

36. Does psychosis predict suicidal ideation over and above other symptomatology? Multiple Regression Entered at Step 1: Depression, Hopelessness, Substance Abuse/Dependence, Social Problem Solving Entered at Step 2: Psychotic Disorder

37. Summary of Psychosis and Suicidality Findings • Psychosis associated with suicidal ideation, intent; possibly with lethality • Psychosis predicted subsequent reattempt up to 2 years later • Relationship with ideation and intent remains even after partialing out depression, hopelessness, substance abuse, social problem solving • Depression and Hopelessness appear to mediate relationship with ideation • Hopelessness, Substance Abuse, and Social Problem Solving appear to mediate the relationship with intent

38. CONCLUSIONS • A 10+ COURSE OF CT HAS HAD A PROPHYLACTIC EFFECT ON REPEATED ATTEMPTS (DURING A 24 MONTH OBSERVATION PERIOD) • A HISTORY OF MULTIPLE ATTEMPTS IS PREDICTIVE OF SUBSEQUENT ATTEMPTS. A SINGLE ATEMPT IS UNLIKELY TO LEAD TO A SUBSEQUENT ATTEMPT • BPD, DRUG ABUSE (WITH OR WITHOUT ALCOHOL), AND PSYCHOTIC DEPRESSIVE DISORDER ARE PREDICTORS OR REATTEMPTS

39. LIMITATIONS OF STUDY • PREVIOUS ATTEMPT DATA AND SOME OF REATTEMPT DATA ARE BASED ON VERBAL REPORTS • EVALUATORS WERE NOT BLIND TO TREATMENT CONDITIONS • ENRICHED CARE COMPONENT IS ATYPICAL OF TREATMENT AS USUAL • THERAPY BY TRAINED THERAPISTS LIMITS GENERALIZABILITY

40. QUALITATIVE ANALYSIS OF SUICIDE ATTEMPTERS BACKGROUND: Diagnoses (Depression, etc.); Substance Use/Abuse; Previous Attempts SEQUENCE: • Precipitating Situations (Rejection, etc.) • Reaction: Cognitive/Affective (Depressed, etc.) • Behaviors: Impulsive (e.g., Drug Use) • Interpersonal • Reaction: Cognitive/Affective (Hopeless) • Behavior: Suicide Attempt

41. BELIEFS ABOUT CONTROL QUESTIONNAIRE FOR SUICIDE ATTEMPTERS

42. Percentage of Suicide Attempters Subsequently Hospitalized at Six Months from Baseline CT + EC EC

43. Total Number of Days Spent in the Hospital at Six Months from Baseline CT + EC EC