Suicide & CBT - from Marsha Linehan's presidential address at AABT 2001

Marsha Linehan has been a leading suicide researcher for decades. Her presidential address at the 2001 convention of the Association for Advancement of Behavior Therapy, “The Status of Suicide Research and the Future of Behavior Therapy,” summarized what we currently know about treating suicidal individuals and what we need to learn.

Suicide is a leading cause of death throughout much of the world. Psychotherapy has not had an overall effect on suicide thus far. Suicide rates have not declined with the growth of psychotherapy and suicide attempts and self-injury rates are high as well. Suicide is a major public health problem.

Many people who commit suicide are in mental health treatment at the time (and yet go ahead and kill themselves). Individuals who are referred for treatment following a suicide attempt actually have a higher rate of suicide completion when they receive treatment than when they do not. This is probably because the most suicidal patients are the ones who follow through on treatment.

Treating the individual’s disorder is not treating their suicidality. Antidepressant therapy for depression does not decrease the rate of suicide or suicide attempts as compared with placebo control groups. Similarly, antipsychotic medication for schizophrenia can be very helpful but it does not reduce the rate of suicide. We do not have any data on whether non-pharmacological treatments for disorders associated with suicide reduces the risk of suicide or not.

There have been many studies of behavioral (i.e. non-biological) treatments for disorders such as major depression but much less data on the efficacy of these treatments for suicidal behavior. There have only been 25-30 studies of non-pharmacological treatments for suicidal patients.

The current standard of care is to hospitalize suicidal patients but the available data shows no decrease in suicide rates when suicidal patients are hospitalized. Actually, we may have things structured to encourage the problem we’re trying to solve. Often, threatening to kill yourself is the only way to get mental health services and get relief from the suffering in your daily life. When people have the option of going into the ER or hospital at will without having to threaten suicide, rates of suicide attempts drop (2 studies).

Continuity of care also sometimes is advocated as a standard of care but, when “continuity of care” means continuing with the same care rather than being referred to a crisis intervention specialist, it actually produces worse results.

Brief (up to 6 session) problem-solving interventions result in fewer suicide attempts in 5 out of 6 studies. More intensive intervention plus outreach also result in fewer suicide attempts, however intensive intervention has not been superior to brief intervention in the research that has been done thus far.

We’ve done much less research on the treatment of suicidality than on the treatment of depression. Is it that we think we already know what to do and/or are afraid to try anything new with suicidal patients?

We need to do more research and do better quality research. We need to include high-risk patients in research trials rather than excluding them from clinical trials. If we continue to exclude them, we will never discover what works. We need to develop new treatment approaches. We have been very successful at developing effective treatments but we have not done much work on treatments for suicide.

The desire to die is about the absence of options. No matter why someone commits suicide, it is because they do not see another option open to them. Our job is to join the individual in their life and help them find other options, to enable them to have a life worth living.

A belief that life is worth living and that one can cope has a big impact on suicidality. We cannot eliminate misery and suffering from life. We need to help people have a life worth living (and help them bear the suffering which is a part of life). Simply maintaining contact with someone who cares reduces suicidality.

Replies:

Suggestions for handling suicidal crises (largely from Marsha Linehan), by Jim Pretzer, 11/24/01

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