COGNITIVE APPROACHES TO SUICIDE

Center for Disease Control and PreventionFebruary 6, 2004

Aaron T. Beck, M.D.

Gregory K. Brown, Ph.D.University of Pennsylvania

REVIEW OF STUDIES 1969-2004

I. CLASSIFICATION

NIMH TASK FORCE 1969

ATTEMPTED SUICIDE

1. Degree of Intent

2. Degree of Medical Lethality

SUICIDE IDEATION

1. Degree of Intent

2. Degree of Medical Lethality

COMPLETED SUICIDE

1. Degree of Intent

Definition of a Suicide Attempt

“a potentially self-injurious behavior with a nonfatal outcome, for which there is evidence (either explicit or implicit) that the person intended at some (nonzero) level to kill himself/herself.”

Source: O’Carroll, Berman, Maris, Moscicki, Tanney, & Silverman (1996)

 

Intentional Self-Injury Behavior 

SuicideIntent 

   

Definite 

 

Uncertain/ Potential

 

None 

 

Definite 

DefiniteSuicideAttempt (1)

PossibleSuicideAttempt (2)

SuicideIdeation

 

Uncertain 

PossibleSuicideAttempt (3)

PossibleSuicideAttempt (4)

MildSuicideIdeation

 

None 

Intentional Self-Injury Behavior without Suicide Intent (5)

Possible/PotentialSelf-Injury Behavior without Suicide Intent (6)

 

II. ASSESSMENT

INSTRUMENT DEVELOPMENT

1. MEDICAL LETHALITY (BIOLOGICAL DAMAGE) SCALE

2. SUICIDE INTENT SCALE (FOR ATTEMPTERS)

• POST-SUICIDE SCALEa. Psychological Autopsy

4. SUICIDE IDEATION SCALE

5. HOPELESNESS SCALE

6. SUICIDE IDEATION AT WORST POINT

7. WISH TO LIVE – WISH TO DIE SCALE

8. BECK DEPRESSION INVENTORY – SUICIDE ITEM

CONSTRUCT VALIDITY

1. DEPRESSION SCALE, SUICIDE INTENT

SCALE, POST SUICIDE INTENT SCALE,

AND HOPELESSNESS SCALE

CORRELATE SIGNIFICANTLY WITH

MEDICAL LETHALITY

2. HOPELESSNESS CORRELATES MORE

STRONGLY THAN DOES DEPRESSION

WITH LETHALITY (INCLUDING DEATH).

a. Hopelessness-intent correlation is high when depression is partialed out, but not vice-versa.

b. Hopelessness correlation persists across all

demographic and diagnostic groups.

c. Hopelessness as a mediator between stressors and suicide.

III. PREDICTION OF SUICIDE

Risk Factors for Psychiatric Patients 1975-2000

• Sampled 6,891 psychiatric outpatients

• Conducted National Death Index search

• Identified 49 suicide cases

• All patients received structured interviews and standardized assessment measures

Source: Brown, Beck, Steer, & Grisham (2000)

Predictive Validity

Measure Hazard Ratio

95% CI 2 p

BHS > 8 4.46 2.00- 9.94 13.32 0.001

BDI > 22 3.55 1.93- 6.55 16.53 0.001

SSI > 2 6.56 3.61-11.93 38.02 0.001

SSI-W > 14 13.84 5.64- 33.98 51.02 0.001

Source: Brown, Beck, Steer, & Grisham (2000)

Adjusted Hazard Ratios For Suicide with Psychiatric Outpatients

0

0.5

1

1.5

2

2.5

3

3.5

4

Hospi

taliz

atio

nSui

cide

Atte

mpts

Bipol

ar D

isord

erM

ajor

Dep

ress

ion

Suici

de Id

eatio

nUne

mpl

oyed

Age (Y

ears

)

Predictive Validity of Standardized Measures for Completed Suicide

with Psychiatric Outpatients

0

2

4

6

8

10

12

14

16

BDI BHS SSI (Current) SSI (Worst)

Odd

s R

atio

s

Measure:Cut-off Score: > 22 > 8 > 2 > 14

3.64.5

6.6

13.8

Wish to Die vs. Wish to Live and Completed Suicide with Psychiatric Outpatients

0

0.5

1

1.5

2

2.5

3

3.5

Wish to Die = > Wish to Live Wish to Live > Wish to Die

Pe

rce

nt

Wh

o C

om

mit

ted

Su

icid

e

N = 21 of 637 N = 23 of 5131

3.2%

.4%

Odds Ratio = 7.4 (95% CI: 4.0-13.4), p < .001

SUICIDE ATTEMPTERS

1970-1975

2000-2001

TENTATIVE CLASSIFICATION OF ATTEMPTERS

1. “PERSONALITY DISORDER” VS

“DEPRESSIVES” 1970-1975

2. “BORDERLINES” VS “NON-BORDERLINE DEPRESSIVES” 2000-2001

b. CLASSICAL DEPRESSIVE: - Attempt related to steady progression of depression

a. BORDERLINES:

- More repeats

- High degree of

reactivity

- Low control

CHARACTERISTICS OF ATTEMPTERS1970-1975

PERSONALITY DISORDERS ATTEMPT WHEN DISTRESSED

1. “Self-medicate” with drugs to relieve distress

2. Often feel shame, guilt, hopeless, after drug and then attempt

3. Low tolerance for frustration or distress

4. Poor problem solving

5. Defective self-control

6. More reality problems

DEPRESSIVE

(n = 109)

PERSONALITY DISORDER

(n = 182)

MALE 27.5% 53.3%

WHITE 53.2% 51.6%

AGE (YEARS) 30.7% 28.1%

MARRIED 24.8% 14.5%

SINGLE 34.9% 47.5%

WIDOWED 4.6% 2.8%

SEPARATED/

DIVORCED31.2% 27.9%

COHABITATING 4.6% 7.3%

SUICIDE AT 5 YR FOLLOW-UP 4.6% 8.2%

CHARACTERISTICS OF EPISODIC DEPRESSIVE ATTEMPTERS

ATTEMPT SUICIDE AT DEPTH OF

DEPRESSION (IF NOT RETARDED)

1. Profound hopelessness and generalized cognitive distortions

2. Suicide ideation only during episode

Odds Ratios for Suicide with Suicide Attempters

0

1

2

3

4

5

6

Alcohol problems *

Unemployed *

Wished Dead *

Single or Divorced

Precautions T

aken

*p < .05

Sensitivity of Reaction to Attempt for Completed Suicide

0

2

4

6

8

10

12

Glad Alive Ambivalent Wished Dead

Pe

rce

nt

Wh

o C

om

mit

ted

Su

icid

e

N = 9 of 176 N = 5 of 199 N = 10 of 101

5%2.5%

10%

Odds Ratio: 0.98 0.35 2.83

Wish to Die vs. Wish to Live and Completed Suicide with Psychiatric

Outpatients

0

0.5

1

1.5

2

2.5

3

3.5

Wish to Die = > Wish to Live Wish to Live > Wish to Die

Per

cent

Who

Com

mitt

ed S

uici

de

N = 21 of 637 N = 23 of 5131

3.2%

.4%

Odds Ratio = 7.4 (95% CI: 4.0-13.4), p < .001

IV: INTERVENTION

Cognitive Therapyfor Suicide Attempters

NIMH / CDC

Follow-upAssessm ents

1 ,3 ,6 ,12 ,18 ,24 m os

10 Sessionsof CT

Cognitive Therapy+ Enriched Care

Follow-upAssessm ents

1 ,3 ,6 ,12 ,18 ,24 m os

0 Sessionsof CT

Enriched Care

Random ization

Inform ed ConsentIntake Interview

Screened in EDor identified in PEEC logs by

study personnel

Study Design

Inclusion and Exclusion Criteria• Inclusion Criteria:

– Patient must be evaluated at the ED within 48 hours of attempting suicide

– Patient must complete a full baseline assessment within 3 weeks of making the attempt

– Age 16 or older – Patient must have at least two verifiable contacts with

telephone numbers– Must be able to provide informed consent

• Exclusion Criteria:– A severe incapacitating medical disorder that would

prevent participation in psychotherapy

Recruitment

538 Patients Referred186 were unable to be contacted

164 were excluded (not true attempters)

Of the 188 Eligible Patients Contacted68 (36%) refused

120 Baselines Completed

with 60 Patients assigned to CT+ECand 60 Patients assigned to EC

Sample Description

Age and Gender

Gender

43%

57%

Male Female

Mean Age

33.2 years

SD = 9.7

27.5

63.4

10.1

0

10

20

30

40

50

60

70

CaucasianAfrican AmericanOther

Ethnicity

%

Marital Status

64%11%

11%

7%7%

Single Divorced Married Separated Widowed

7%

0

10

20

30

40

50

60

<$8,000

$8-14,000

$14-20,000

>$20,000

Yearly Income66% Unemployed or Disabled

Method of Suicide Attempt

Overdose

58%Cut17%

Jump13%

Hang6%

Traffic3%

CO23%

Type of Drug Used in Overdose

52%

15%

13%

20%

Prescription

Over Counter

I llicit

Combination

Psychiatric Diagnoses

0

10

20

30

40

50

60

70

MDD Bipolar Substance Anxiety

• Mean Number of Axis I Diagnoses was 3• Most Patients had Major Depression with

Co-Morbid Substance Use Disorder

Substance Use Diagnoses

30

23

17

8

1

8

0

5

10

15

20

25

30

35

Alco

hol

Coca

ine

Opioid

Cann

abis

Amph

ePo

ly

Participation Bias

0.32, 3.64

1.0955 Other (n = 13)

0.22,0.68

0.396644 African American (n = 151)

1.49, 4.54

2.602951 Caucasian (n = 89)

CI (95%)ORYes % (n=180)

No % (n=112)

Ethnicity

Consent