ASSIP vs. Crisis Counseling for Preventing Suicide Re-attempts: Outcome Predictor Analysis of a Randomized Clinical Trial Data.

OBJECTIVE: Knowledge of the effectiveness and limits of the suitability of brief interventions in suicide prevention is greatly needed. We investigated subgroup differences and predictors for suicide re-attempts within a clinical trial population recruited for a brief intervention to prevent re-attempts. METHODS: Consenting adult patients receiving treatment for a suicide attempt in Helsinki City general hospital emergency rooms in 2016-2017 (n = 239) were randomly allocated to (a) the Attempted Suicide Short Intervention Program (ASSIP) or (b) Crisis Counseling (CC). Participants also received their usual treatment. Information on primary outcome repeat attempts and secondary outcomes was collected via telephone and from medical and psychiatric records for 2 years. As proportions of re-attempts did not differ significantly between ASSIP and CC (29.2 vs. 35.2%), patients were pooled and predictors for suicide re-attempts were analyzed using Kaplan-Meier and logistic regression analyses. RESULTS: Re-attempts were predicted by participants' younger age (OR 0.965 [0.933-0.998]), previous suicide attempts (OR 2.437 [1.106-5.370]), psychiatric hospitalization in the year preceding baseline (OR 3.256 [1.422-7.458]), and clinical diagnosis of a personality disorder (OR 4.244 [1.923-9.370]), especially borderline personality disorder (OR 5.922 [2.558-13.709]). CONCLUSIONS: Within a population of suicide attempters consenting to a brief intervention trial, the risk of re-attempt was strongly predicted by subjects' young age, history of previous attempts, psychiatric hospitalizations, and personality disorder, particularly borderline personality disorder. The composition of treated populations with regard to these characteristics may strongly influence the observed success of brief interventions. Their potential as moderators of treatment effectiveness and as indicators of the utility of brief interventions warrants further investigation.HIGHLIGHTSDuring the 2-year follow-up, 32% of trial participants reattempted suicide.Rates of reattempts varied and were strongly predicted by clinical subgroup.Subgroup composition may strongly influence brief interventions' observed outcome.

Longitudinal Development of Reasons for Living and Dying With Suicide Attempters: A 2-Year Follow-Up Study.

Background: Clinical interventions for patients after a suicide attempt might include a focus on Reasons for Living (RFL) and/or Reasons for Dying (RFD). The present study examined the longitudinal development of RFL and RFD in patients with and without a suicide-specific intervention - the Attempted Suicide Short Intervention Program (ASSIP). Methods: In this secondary analysis of a 2-year follow-up randomized controlled study, participants completed the Suicide Status Form II to assess RFL and RFD, at baseline, as well as at 6-, 12-, 18-, and 24-months follow-up. Growth models and latent class analysis were used to investigate longitudinal developments in RFL and RFD. Regression models were used to test the association between RFL, RFD and suicidal reattempts and ideation. Results: Cross-sectionally and longitudinally, RFD, but not RFL, were associated with suicide reattempts and suicidal ideation. The number of RFD decreased significantly across the 24 month period (from 1.90 at t1 to 1.04 at t5 in the control group and from 2.32 at t1 to 0.51 at t5 in the intervention group), and this decrease was stronger (b = -0.02; p = 0.004) in the ASSIP group than in the control group. There was no overall change in RFL. Three latent trajectories of RFD were identified: a decreasing (n = 77), a steady high (n = 17) and a trajectory with first increasing and then decreasing RFD (n = 26). The proportion of patients in the ASSIP intervention was highest in the decreasing trajectory and lowest in the steady high trajectory. Patients in the steady high trajectory were characterized by worse mental health and fewer social obligations (partner, children) at baseline. Conclusion: The results confirm the importance of RFD within the suicidal process and show that the number of RFD can be further reduced over the period of 24 months with short interventions such as ASSIP. The relevance of number of RFL in the suicidal process, as protective factor, was not confirmed. In the subgroup of patients whose RFD did not decrease over a long period of time, there is a particularly high risk of suicidal ideation/behavior. Clinical interventions should focus more closely on RFD, their etiology and maintenance.

[Psychotherapy after a suicide attempt-current evidence and evaluation]. / Psychotherapie nach einem Suizidversuch ­ Evidenzlage und Bewertung.

Suicide attempts are considered one of the most important risk factors for suicide. Based on this, various psychotherapeutic treatments for persons after a suicide attempt have been developed and evaluated in recent years. In this article, the current state of efficacy research is outlined, examples of successful suicide-focused psychotherapies are presented, and the current state of research and knowledge is critically reflected upon. The results of two recent Cochrane reviews of psychotherapy following self-injurious behavior in childhood, adolescence, and adulthood, as well as findings from 14 other meta-analyses of psychological suicide prevention published in the past five years, are presented.Cognitive behavioral therapy and dialectical behavioral therapy have been shown to be effective. Overall, however, the averaged effect sizes are of small magnitude and various methodological problems make it impossible to draw far-reaching conclusions. In principle, suicide-specific psychotherapy is of particular importance in individual-centered suicide prevention; however, the empirical foundation and dissemination of appropriate programs are still insufficient.

[ASSIP: A new therapy following suicide attempt]. / ASSIP : nouvelle modalité thérapeutique après un geste suicidaire.

Although patients attempting suicide represent a highly vulnerable population, are often reluctant to care and at high risk of repetition, no specific therapy exist for them in French-speaking Switzerland. ASSIP® (Attempted Suicide Short Intervention Program) fills in this gap. It is a short therapy developed in Bern and being currently implemented in French-speaking Switzerland with the support of the Foundation « Promotion santé suisse ¼ (Swiss health care promotion). ASSIP® intervention is patient-centered and based on a narrative and behavioral approach and reduces suicide reattempts. It aims to jointly understand patient's suicidal process and to help him/her developing personal strategies to prevent repetition and manage future suicidal crisis.

En Suisse romande, les personnes ayant fait une tentative de suicide n'ont actuellement pas de prise en charge thérapeutique spécifique, alors qu'il s'agit d'une population particulièrement vulnérable, souvent réticente aux soins et présentant un risque élevé de récidive. Pour combler ce manque, une thérapie brève en quatre séances élaborée à Berne (l'Attempted Suicide Short Intervention Program (ASSIP)) est en cours d'implantation avec le soutien de la fondation Promotion santé suisse. Proposée en parallèle du traitement habituel, l'ASSIP est basée sur une approche narrative et cognitivocomportementale, centrée sur la personne. Efficace pour prévenir la récidive suicidaire, cette intervention vise à mieux comprendre le processus suicidaire et à permettre aux patients de développer des ressources afin de prévenir et d'agir lors d'une prochaine crise suicidaire.

Pilot RCT of the Attempted Suicide Short Intervention Program (ASSIP) adapted for rapid delivery during hospitalization to adult suicide attempt patients with substance use problems.

OBJECTIVE: The Attempted Suicide Short Intervention Program (ASSIP) was adapted for hospital delivery and to address substance use problems as well as evaluated for feasibility, acceptability, and therapist fidelity in a series of preparatory steps (n = 28) and in a pilot randomized controlled trial, RCT (n = 34). METHOD: In the RCT, patients with suicide attempts and substance use problem(s) with sufficient lengths of stay to deliver three ASSIP therapy sessions in hospital were randomized to adapted ASSIP or treatment as usual control. A blinded assessor identified suicide reattempts over 6-month follow-up with the Columbia-Suicide Severity Rating Scale (C-SSRS) and a comprehensive multi-source method. Treatment process measures and the Scale for Suicidal Ideation (SSI) were also administered. RESULTS: Median hospital stay was 13 days. ASSIP subjects reported high satisfaction with the treatment and high therapeutic alliance. Study therapists showed high fidelity to the modified ASSIP intervention. Repetition of suicide attempt was common in both study groups including a combined 9 (26%) subjects with reattempt based on C-SSRS and 13 (38%) subjects with reattempt based on multiple sources. CONCLUSIONS: Adult suicide attempt patients with substance use problems who require lengthy hospitalizations are at exceptionally high risk and may require additional strategies to lower risk.

Psychopharmacological treatment is not associated with reduced suicide ideation and reattempts in an observational follow-up study of suicide attempters.

BACKGROUND: Disorders of mental health are major risk factors for suicidal behavior and require adequate treatment. However, the effect of psychotropic medication on suicidal behavior is unclear. METHODS: The 120 participants in a randomized clinical trial of a brief therapy for suicide attempters (Attempted Suicide Short Intervention Program, ASSIP) reported on repeated suicide attempts, suicidal ideation, depression, and medication in the treatment as usual (TAU), at baseline, 6, 12, 18, and 24 months follow-up. The RCT had no influence on medication prescribed. Drugs prescribed were categorized as any psychotropic, antidepressants plus lithium, and antipsychotics. To assess the effect of long-term medication we identified participants with periods of continuous use of psychotropics and antidepressants plus lithium over twelve months or more, and medication-free participants for the same drug categories during the same time period. RESULTS: Reattempts and suicide ideation decreased in all drug categories. When comparing participants on medication fulfilling the definition of long-term use with participants without medication, reattempts and suicidal ideation were higher in the psychotropics and the antidepressants/lithium groups. These drug categories were associated with higher depression scores in comparison to no-medication. The survival analysis revealed a higher risk of reattempts in the long-term antidepressants/lithium group in comparison to no-medication. Treatment with the brief psychological therapy ASSIP, added to medication, was associated with a lower risk of reattempts. LIMITATIONS: The study relied on the patients' reports on treatment as usual in a randomized controlled clinical trial. Blood levels of the psychotropic compounds were not assessed. CONCLUSIONS: In this observational study of the TAU condition in a clinical trial of a brief psychological therapy for patients who had recently attempted suicide, psychotropic drug use over twelve months or more was not associated with reduced suicide ideation and reattempts. Depression scores suggest that patients on psychotropic medication had more psychiatric pathology. This may be a confounding factor for the effect of medication on suicidal behavior.

Patients' Satisfaction With the Therapeutic Relationship and Therapeutic Outcome Is Related to Suicidal Ideation in the Attempted Suicide Short Intervention Program (ASSIP).

Background: The therapeutic alliance may be a moderating factor of outcome in the Attempted Suicide Short Intervention Program (ASSIP). Aims: This study investigates the two components of the therapeutic alliance, patients' satisfaction with the therapeutic relationship and therapeutic outcome and their associations with suicidal ideation over time. Method: A total of 120 patients (55% female; mean age = 36 years) with a history of attempted suicide were randomly allocated to either the intervention group (N = 60) or the control group (N = 60). Patients' satisfaction with the therapeutic relationship and outcome were measured with the two subscales of the Helping Alliance Questionnaire. The Beck Scale of Suicide Ideation was used to measure suicidal ideation in this 24-month follow-up study. Results: The ASSIP group showed that patients' satisfaction with therapeutic relationship and outcome increased significantly from the first to the third session. Higher satisfaction with therapeutic outcome correlated significantly with lower suicidal ideation at follow-up. Conversely, the control group showed no significant results. Limitations: The collaborative approach adopted in the initial clinical interview of the control group could possibly have influenced the results of both scales. Conclusion: In particular, the component satisfaction with therapeutic outcome seems crucial to the subjectively perceived satisfaction of treatment and is associated with lower suicidal ideation over time. Thus, an enhanced understanding of components of the therapeutic alliance plays an important role in the development of interventions for suicidal patients.

Attempted suicide short intervention program influences coping among patients with a history of attempted suicide.

BACKGROUND: The development of individual coping strategies for suicidal crises is essential for suicide prevention. However, the influence of a brief intervention and the effect on coping strategies is largely unknown. This study aimed to investigate the influence of the Attempted Suicide Short Intervention Program on the development of coping strategies, in comparison to a control group. METHOD: In this secondary analysis of a 24-month follow-up randomised controlled study, 120 patients (55% female; mean age of 36) with a history of suicide attempts were randomly allocated to either the ASSIP group or to a control group, in addition to treatment as usual. RESULTS: The present study identified 11% less dysfunctional coping in the ASSIP group and 6% more problem-focussed coping compared to the control group after 24-months. The analysis of broader strategies showed a statistically significant group difference regarding self-distraction (after 12-months) and self-blame (after 24-months). In regard to the long-term association between coping strategies and suicidal ideation, active coping and substance use were negatively associated with suicidal ideation in the ASSIP group. Whereas, in the control group, behavioural disengagement and positive reframing were positively and self-distraction was negatively related to suicidal ideation. LIMITATION: The receipt of a clinical interview and suicide risk assessment in the control group could have potentially had an effect on participants' coping mechanisms. CONCLUSION: These results indicate that ASSIP may have an impact on the development of problem-focussed coping strategies. Although a reduction in dysfunctional coping seems to be essential in overcoming suicidal crises.

Reasons for living and dying in suicide attempters: a two-year prospective study.

BACKGROUND: The internal suicide debate hypothesis assumes that in a suicidal crisis, individuals are involved in an internal struggle over whether to live or die. Reasons for living (RFL) and Reasons for dying (RFD) are important individual reasons for staying alive (e.g. family) or wanting to die (e.g. hopelessness) and reflect this internal motivational conflict of the suicidal mind. The aim of this study was to explore the association between RFL and RFD of suicide attempters and current and future suicide ideation and behavior. METHOD: The sample consisted of 60 patients who were admitted at a psychiatric emergency unit in Switzerland following an attempted suicide. They received treatment as usual, participated in an assessment interview and completed self-report questionnaires. Additionally, they were instructed to write down up to five individual RFL and RFD. The number of RFL and RFD responses, depressive symptoms, and suicide ideation were assessed at baseline and 6, 12, and 24 months follow-up. Outcome measures were suicide ideation and repeated suicide attempts. Multiple imputations were used in order to address missing data. RESULTS: The number of RFD responses was the strongest predictor for increased suicide ideation at baseline. The number of RFL responses was not associated with suicide ideation and reattempts. RFD, depressive symptoms, and baseline suicide ideation predicted subsequent suicide reattempt up to 12 months later in simple regression analyses. Mediation analyses suggested that RFD mediated the effect of depressive symptoms at baseline on suicide ideation at 12-months follow-up. CONCLUSION: RFL were unrelated to the mental health of study participants and did not function as protective factor against suicide risk. RFD may be an important motivational driver in the suicidal process. Clinical interventions should focus more on the reduction of RFD than on RFL in suicidal individuals.

Cost-effectiveness of a Brief Structured Intervention Program Aimed at Preventing Repeat Suicide Attempts Among Those Who Previously Attempted Suicide: A Secondary Analysis of the ASSIP Randomized Clinical Trial.

Importance: This is the first cost-effectiveness analysis of a brief therapy, the Attempted Suicide Short Intervention Program (ASSIP), for individuals who attempt suicide. Objective: To explore the cost-effectiveness of the ASSIP intervention in the context of the Swiss health care system. Design, Setting, and Participants: In this economic evaluation, the cost-effectiveness analysis was performed from a health care perspective between January 2017 and April 2018 using data from a randomized clinical trial conducted between June 2009 and December 2014. Participants were individuals who had attempted suicide and were receiving treatment at a psychiatric university hospital in Switzerland that provides inpatient and outpatient services for suicide attempters referred from an emergency department of a general hospital. Interventions: The intervention group received 3 manual-based therapy sessions followed by regular personalized letters over 24 months. The control group was offered a single suicide risk assessment. Main Outcomes and Measures: The main economic analysis explored cost per suicide attempt avoided expressed in 2015 Swiss francs (CHF). Cost-effectiveness planes were plotted and cost-effectiveness acceptability curves calculated. Results: One hundred twenty participants (mean [SD] age, 37.8 [14.4] years; 66 [55%] women and 54 [45%] men) were assigned to an intervention group or a control group, each with 60 participants. At 24 months of follow-up, 5 suicide attempts were reported in the ASSIP group among 59 participants with follow-up data available, and 41 were reported in the control group among 53 participants with follow-up data available. The ASSIP group had higher intervention costs, with CHF 1323 vs CHF 441 for the control group. At 24 months of follow-up, psychiatric hospital costs were lower in the ASSIP group than in the control group, although this difference was not significant (mean [SD], CHF 20 559 [38 676] vs CHF 45 488 [73 306]; mean difference, CHF -16 081; 95% CI, CHF -34 717 to 1536; P = .11). General hospital costs were significantly lower for the ASSIP group. Total health care costs were also lower, but the difference was not significant (mean [SD], CHF 21 302 [38 819] vs 41 287 [74 310]; difference, CHF -12 604; 95% CI, CHF -29 837 to 625; P = .14). In a base-case analysis, ASSIP was dominant, with significantly fewer reattempts at lower overall cost. The intervention had a 96% chance of being less costly and more effective. A sensitivity analysis showed a 96% and 95% chance of ASSIP being more effective and less costly at willingness-to-pay levels of CHF 0 and CHF 30 000, respectively. Conclusions and Relevance: The ASSIP intervention is a cost-saving treatment for individuals who attempt suicide. The findings support the use of ASSIP as a treatment for suicide attempters. Further studies are needed to determine cost-effectiveness in other contexts. Trial Registration: ClinicalTrials.gov Identifier: NCT02505373.

A Novel Therapy for People Who Attempt Suicide and Why We Need New Models of Suicide.

This paper presents a model of suicidal behaviour based on suicide as a goal-directed action, and its implications. An action theoretical model has guided the authors in the development of a brief therapy for individuals who attempt suicide (ASSIP-Attempted Suicide Short Intervention Program). Key elements are an early therapeutic alliance, narrative interviewing, psychoeducation, a joint case conceptualization, safety planning, and regular letters over 24 months. In a randomized controlled trial, ASSIP was highly effective in reducing the risk of suicide reattempts. The therapeutic elements in this treatment are described and possible implications for future directions in clinical suicide prevention discussed.

Suicide Ideation Is Related to Therapeutic Alliance in a Brief Therapy for Attempted Suicide.

The objective of this study was to investigate the role of therapeutic alliance on suicide ideation as outcome measure in a brief therapy for patients who attempted suicide. Sixty patients received the 3-session therapy supplemented by follow-up contact through regular letters. Therapeutic alliance was measured with the Helping Alliance Questionnaire (HAQ). Outcome at 6 and 12 months was measured with the Beck Scale for Suicide Ideation (BSS). Therapeutic alliance increased from session 1 to session 3. Higher alliance measures correlated with lower suicidal ideation at 12 months follow-up. A history of previous attempts and depression had a negative affect on therapeutic alliance. The results suggest that in the treatment of suicidal patients therapeutic alliance may be a moderating factor for reducing suicide ideation.

A Novel Brief Therapy for Patients Who Attempt Suicide: A 24-months Follow-Up Randomized Controlled Study of the Attempted Suicide Short Intervention Program (ASSIP).

BACKGROUND: Attempted suicide is the main risk factor for suicide and repeated suicide attempts. However, the evidence for follow-up treatments reducing suicidal behavior in these patients is limited. The objective of the present study was to evaluate the efficacy of the Attempted Suicide Short Intervention Program (ASSIP) in reducing suicidal behavior. ASSIP is a novel brief therapy based on a patient-centered model of suicidal behavior, with an emphasis on early therapeutic alliance. METHODS AND FINDINGS: Patients who had recently attempted suicide were randomly allocated to treatment as usual (n = 60) or treatment as usual plus ASSIP (n = 60). ASSIP participants received three therapy sessions followed by regular contact through personalized letters over 24 months. Participants considered to be at high risk of suicide were included, 63% were diagnosed with an affective disorder, and 50% had a history of prior suicide attempts. Clinical exclusion criteria were habitual self-harm, serious cognitive impairment, and psychotic disorder. Study participants completed a set of psychosocial and clinical questionnaires every 6 months over a 24-month follow-up period. The study represents a real-world clinical setting at an outpatient clinic of a university hospital of psychiatry. The primary outcome measure was repeat suicide attempts during the 24-month follow-up period. Secondary outcome measures were suicidal ideation, depression, and health-care utilization. Furthermore, effects of prior suicide attempts, depression at baseline, diagnosis, and therapeutic alliance on outcome were investigated. During the 24-month follow-up period, five repeat suicide attempts were recorded in the ASSIP group and 41 attempts in the control group. The rates of participants reattempting suicide at least once were 8.3% (n = 5) and 26.7% (n = 16). ASSIP was associated with an approximately 80% reduced risk of participants making at least one repeat suicide attempt (Wald χ21 = 13.1, 95% CI 12.4-13.7, p < 0.001). ASSIP participants spent 72% fewer days in the hospital during follow-up (ASSIP: 29 d; control group: 105 d; W = 94.5, p = 0.038). Higher scores of patient-rated therapeutic alliance in the ASSIP group were associated with a lower rate of repeat suicide attempts. Prior suicide attempts, depression, and a diagnosis of personality disorder at baseline did not significantly affect outcome. Participants with a diagnosis of borderline personality disorder (n = 20) had more previous suicide attempts and a higher number of reattempts. Key study limitations were missing data and dropout rates. Although both were generally low, they increased during follow-up. At 24 months, the group difference in dropout rate was significant: ASSIP, 7% (n = 4); control, 22% (n = 13). A further limitation is that we do not have detailed information of the co-active follow-up treatment apart from participant self-reports every 6 months on the setting and the duration of the co-active treatment. CONCLUSIONS: ASSIP, a manual-based brief therapy for patients who have recently attempted suicide, administered in addition to the usual clinical treatment, was efficacious in reducing suicidal behavior in a real-world clinical setting. ASSIP fulfills the need for an easy-to-administer low-cost intervention. Large pragmatic trials will be needed to conclusively establish the efficacy of ASSIP and replicate our findings in other clinical settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT02505373.

Gender differences in methods of suicide attempts and prevalence of previous suicide attempts.

OBJECTIVE: Suicide attempts are important predictors of completed suicide. Adolescents admitted to the emergency room of a large university hospital in Bern after a suicide attempt during the years 2004-2010 were prospectively assessed for methods of suicide attempt. METHOD: Adolescents (N = 257; 66.5% female; age 14-21 years), presenting after a suicide attempt, were assessed with the WHO/EURO Multicentre Study on Parasuicide assessment tool. RESULTS: Males more often used jumping from a high place (14% vs. 4.6% in females, p < .05) and less often intoxication (36% vs. 71.3%, p < .01). At least one previous suicide attempt was reported in 100 patients (44.4%; more females than males: Cramer-V = 0.21; p = .002). Of these, 35 adolescents did not present to this hospital or not at all for a previous suicide attempt. CONCLUSIONS: The present study is the first to examine methods of suicide attempts according to the ICD-10 X codes in this age group. Gender differences were observed. Because a relevant number of patients did not present to the same hospital or not at all for a previous suicide attempt, studies on pathways to care of adolescents after their first suicide attempt are important for early detection and intervention strategies.