58 The psychological and behavioural treatment of suicidal behaviour: What are the common elements of treatments that work?

Chowdhury et al. 1973

E: 113

C: 84

Inclusion: repeat suicide attempters admitted to poisoning treatment centre

Exclusion: individuals at high risk of parasuicide to present ethnical concern

6

E 17 (24) _p  *

C 19 (23) _p  *

Termansen and Bywater 1975

E ₁: 57 (12)

E ₂: 57 (24)

E ₃: 50 (18)

C: 38 (20)

Inclusion: attempted suicide admissions, with suicide defined as ‘any act of self-injury, regardless of its seriousness, which was motivated by self-destructive tendencies’

Exclusion: patients with no initial or final assessment

3

E ₁: 1 **

E ₂: 2 **

E ₃: 7 **

C: 2 **

Welu 1977

E 63 (1)

C 57

Inclusion: suicide attempters, defined by any non-fatal act of self-damage inflicted with self-destructive intention, however vague and ambiguous; residing in catchment area for community mental health centre; brought to the hospital emergency room

Exclusion: under 16 years of age; students living in college or university housing; persons with usual residence of care-giving institution; individuals institutionalized at the time of the suicide attempt

4

E 3 *

C 9 *

Gibbons et al. 1978

E 200 (19 per cent)

C 200 (22 per cent)

Inclusion: at least 17 years of age; episode of deliberate self-poisoning; defined geographical area

Exclusion: formal psychiatric illness requiring immediate psychiatric treatment; immediate suicide risk; continuing treatment with psychiatrist or social worker seen within 2 weeks

12

E (13.5)*  _p

C (14.5)*  _p

Hawton et al. 1981

E: 48 (5)

C: 48 (15)

Inclusion: 16 or older; giving informed consent; registered with general practitioner; live within 15 miles of hospital; suitable for outpatient care; admitted to Oxford following an overdose; not in need of formal psychiatric or specialist facilities (i.e., inpatient care or rehabilitation) care; not in current care (social work, probation, psychologist, or other professional); agreeable and willing to receive care

12

E (10) _SH  **

C (15) _SH  **

Liberman and Eckman 1981

E: 12

C: 12

Inclusion: repeated suicide attempters (at least one previous attempt in preceding 2 years); referred to 10-day inpatient programme by psychiatric emergency team, local community mental health services, or hospital emergency room physician

Exclusion: psychotic patients; organic brain syndrome; currently addicted to alcohol or drugs

24

E: 2 *

C: 5 *

11 total attempts

Patsiokas and Clum 1985

E 1: 5

E 2: 5

C: 5

Inclusion: patients in psychiatric inpatient ward; admitted for suicide attempt

Exclusion: diagnosis of psychosis, alcoholism, or drug abuse

none

Not specified

Hawton et al. 1987

E 41 (11)

C 39 4)

Inclusion: episode of overdose; at least 16 years of age; give informed consent; registered with GP; living within 15 miles of the hospital; suitable for outpatient counselling (as determined by hospital counsellors)—continuing problems willing to tackle with help of counsellors; not in need of formal psychiatric care or specialist facilities; not in current care of psychiatric services, social worker, probation officer, psychologist, or professional agency; agreeable to assessment with counsellors; willing to accept after care

9

E 3 (7.3)*

C 6 (15.4) *

Torhorst et al. 1988

E 1: 40

E 2: 40

Inclusion: suicide attempt by intoxication; first parasuicide; repeated parasuicide

Exclusion: psychosis; continuing psychotherapeutic treatment elsewhere; inpatient psychiatric therapy of non-psychotic condition; drug overdose; lack of understanding of language; too long a travel time to outpatient centre

3, 12

E 1: (22.5) **

E 2: (22.5) **

Only 2 attempts after 3 months, varies by treatment compliance

Lerner and Clum 1990

E: 9

C: 9

Inclusion/Exclusion: aged 18–24; currently experiencing ‘clinically significant’ suicide ideations, as defined as a score of 11 or more on Modified Scale for Suicidal Ideations (MSSI); no signs of psychosis or substance abuse

3

Not specified

Salkovskis et al. 1990

E 12 (0)

C 8 (0)

Inclusion: aged 16–65; fixed abode within hospital boundary; not in need of immediate psychiatric treatment; not psychotic of suffering from organic illness; meet two or more of the following: previous suicide attempts; antidepressants taken as overdose; score of 4 or higher on Bugless and Horton (1974) risk of repetition scale

12

E 0

C 3 *

4 **

Waterhouse and Platt 1990

E 27

C 25

Inclusion: parasuicides, defined as non-fatal act in which an individual deliberately ingests a substance in excess of any prescribed or generally recognized therapeutic dosage, with no immediate medical or psychiatric treatment needs

Exclusion: parasuicides using methods other than self-poisoning; under 16 years of age; no fixed abode; living further than 16 miles from city; current psychiatric inpatient; self-discharges from hospital; direct referral to medical ward/bypassing casualty department

16 weeks

Not specified

Linehan et al. 1991

E 32 (10)

C 31 (9)

Inclusion: score of 7 on Diagnostic Interview for Borderlines; meet criteria for DSM-III diagnosis of BPD; at least 2 incidents of parasuicide in past 5 years, with at least one occurring within the past 8 weeks; aged 15–45; agreed to study conditions

Exclusion: meet DSM-III criteria for schizophrenia, bipolar disorder, substance dependence, or mental retardation

12

E (63.6) _p  *

C (95.5) _p  *

Allard et al. 1992

E 76 (13)

C 74 (11)

Inclusion: seen by emergency department after concrete suicide attempt; residing within psychiatric catchment area; speak French or English

Exclusion: no fixed address or expecting to move; already in the care of institution responsible for follow-up; physical handicap preventing attendance; inability for informed consent; sociopathy with physical threat to hospital personnel; attempt not occurring within one week

24

E 22 (35)*

C 19 (30)*

Klingman and Hochdorf 1993

E 116

C 121

Inclusion: 8th grade students

12 weeks

Not specified

Morgan et al. 1993

E 101 (0)

C 111 (0)

Inclusion: reside within hospital catchment area; no previous history of non-fatal deliberate self-harm

12

E: 5 (4.95) _SH* 7 **

C: 12 (10.81) _SH* 15 **

McLeavey et al. 1994

E 19 (2)

C 20 (4)

Inclusion: aged 15–45; no history of psychosis, mental retardation, or organic cognitive impairment; engaged in intentional self-poisoning; not in need of inpatient or day-patient car for psychiatric illness and/or suicidal risk; IQ of at least 80 on Mill Hill Vocabulary Scale

12

E (10.5) _SH  *

C (25) _SH  *

Cotgrove et al. 1995

E 47

C 58

Inclusion: aged 16 or below; suicide attempt, including deliberate self-injury and deliberate-self poisoning

12

E 3 (6)*

C 7 (12)*

van Heeringen et al. 1995

E 258 (62)

C 258 (63)

Inclusion: at least 15 years of age; live in Gent or suburbs; suicide attempters defined as deliberate self-poisoning and deliberate self-injury

Exclusion: patients in need of inpatient medical treatment

12

E 21(10.7) *

C 34 (17.4) *

Rudd et al. 1996

E 181 (38)

C 121

Inclusion: individuals who made an attempt precipitating referral; individuals with mood disorder and concurrent ideation, to include mixed symptomatology and adjustment disorder diagnoses; those abusing alcohol episodically with concurrent ideation

Exclusion: substance dependence or chronic abuse requiring separate treatment; psychotic component to presentation; diagnosable thought disorder; personality disorder diagnosis making outpatient group participation ineffective, disruptive, or inappropriate

24

Not specified

van der Sande et al. 1997

E 140 (33 per cent)

C 134 (63 per cent)

Inclusion: at least 15 years of age; attending Utrecht University Hospital for somatic treatment following suicide attempt

Exclusion: habitual self-harm activities (e.g., wrist-cutting or using excessive amounts of substances); accidental overdose; inability to understand and write Dutch; reside outside of hospital catchment area; psychiatric hospitalization; imprisonment; acute psychosis; drug or alcohol addiction; recurrent consultations with liaison psychiatrist; suicide attempters receiving experimental treatment during pilot phase

12

E 24 **

C 20 **

Harrington et al. 1998

E 85

C 77

(33 total)

Inclusion: age 16 or younger; diagnosed with deliberate self-poisoning; consent from legal guardian

Exclusion: other forms of self-harm (e.g., cutting or attempted hanging); social situations precluding family intervention; clinical or psychiatric contraindication; cases in which it was not clear if deliberate

6

Not specified

Evans et al. 1999

E 417

C 410

Inclusion: adult inpatients following deliberate self-harm; referred for routine psychiatric evaluation

Exclusion: individuals normally residing outside of catchment area; individuals who met the following clinical criteria meaning they were unlikely to use the intervention appropriately, placing themselves or others at risk; 3 or more contacts in past 6 months but failing to engage with psychiatric services; presenting unacceptable type or degree of aggression within previous 6 months; individuals inappropriately using alcohol or drugs leading to repetitive presentation in intoxicated state resulting in aggression or inability to engage in treatment

6

0 DSH repeats:

E: 347

C: 351

1 DSH repeats:

E: 46

C: 32

2 or more DSH repeats:

E: 24

C: 27

2 suicides in experimental

group

3 suicides in control group

Evans et al. 1999

E 18 (0)

C 16 (2)

Inclusion: episode of deliberate self harm; aged 16–50; personality disturbance within flamboyant personality cluster; histrionic or emotionally unstable; at least one previous episode of deliberate self-harm within previous year

Exclusion: primary ICD-10 diagnosis within the organic, alcohol or drug dependence, or schizophrenia groups

6

E 10 (56) *

C 10 (71) *

Linehan et al. 1999

E 12 (5)

C 16 (8)

Inclusion: women aged 15–45; met criteria for BPD on both PDE and SCID-II; met criteria for substance use disorder for opiates, cocaine, amphetamines, sedatives, hypnotics, anxiolytics, or polysubstance use disorder on SCID

Exclusion: met criteria for schizophrenia; another psychotic disorder, or bipolar mood disorder on SCID; mental retardation as assessed by Peabody Picture Vocabulary Test-Revised

16

Not specified

Turner 2000

E 12 (4)

C 12 (6)

Inclusion: patients initially treated in local hospital emergency services for suicide attempts; meet diagnostic criteria for BPD; not meet exclusionary diagnosis; give written informed consent; accept random assignment to treatment

Exclusion: schizophrenia; schizoaffective disorder; bipolar disorder; organic mental disorders; mental retardation; in need of inpatient drug or alcohol treatment

12

Not specified

Koons et al. 2001

E 14 (4)

C 14 (4)

Inclusion: honourably discharged women veterans; met criteria for DMS-III-R BPD

Exclusion: schizophrenia; bipolar disorder; substance dependence; antisocial personality disorder

6

E: (10)*  _SH, including suicide

C: (20)*  _SH, including suicide

Guthrie et al. 2001

E 58 (11)

C 61 (13)

Inclusion: presenting with episode of deliberate self-poisoning; able to read and write English; live within hospital catchment area; registered with a GP; not in need of inpatient treatment

Exclusion: living outside catchment area; not approached by emergency staff; discharged self without being seen; too physically/psychiatrically unwell; no fixed abode; not registered with GP

6

E 5 (9)_SH  *

C 17 (28)_SH  *

Wood et al. 2001

E 32 (1)

C 31 (0)

Inclusion: aged 12–16; referred to child and adolescent mental health service following deliberate self-harm incident; incident of deliberate self-harm at least once over the previous year; deliberate self-harm defined as any intentional self-inflicted injury, irrespective of the apparent purpose of the act

Exclusion: accidental overdose of recreational drugs or alcohol; judged as too suicidal for ambulatory care; could not attend groups given current situation (e.g., incarceration); psychiatric diagnosis; unlikely to benefit from group intervention (e.g., learning problems)

6

E 50 _SH  **

C 47 _SH  **

Motto and Bostrom 2001

E 389

C 454

Inclusion: Patients admitted to psychiatric inpatient unit following depressive or suicidal state

15 years

E 25 (death by suicide)

C 27 (death by suicide)

Raj et al. 2001

E: 20

C: 20

Inclusion: individuals with first or second attempted suicide by overdose of drugs or pesticides; aged 16–50; anxiety, depression (without psychotic symptoms), or adjustment disorder

Exclusion: score of less than 20 on MMSE; psychosis; dysthymia; bipolar affective disorder; obsessive–compulsive disorder; eating disorder; alcohol dependence or abusing other psychoactive substances; personality disorders; previous psychological intervention

3

E: 0

C: 1*

Wood et al. 2001

E: 32 (1)

C: 31 (0)

Inclusion: aged 12–16; referred for treatment following incident of deliberate self-harm, defined as any intentional self-inflicted injury, irrespective of the apparent purpose of the act; at least one other deliberate self-harm incident during previous year

Exclusion: judged to be too suicidal for ambulatory care; current situation meant they could not attend groups (e.g., incarcerated); psychotic disorder; unlikely to benefit from group intervention (e.g., learning problems)

7

E: 2 (6)*  _SH

C: 10 (32)*  _SH

Bennewith et al. 2002

E 964

C 968

Inclusion: patients with episode of self-harm; self-harm defined as deliberate and non-fatal act done in the knowledge that it is potentially harmful/excessive (as in drug overdose)

Exclusion: alcohol overdose (unless act of self-harm or suicide); illicit drug overdose (unless act of self-harm or suicide); less than 16 years of age; no fixed abode; imprisoned request for no one to be informed of the episode; deliberate self-harm in response to psychotic hallucination or delusion; managed entirely by primary care

12

E 211 (21.9) _SH  *

C 189 (19.5) _SH  *

Cedereke et al. 2002

E 107 (18)

C 109 (20)

Inclusion: suicide attempt; living within hospital catchment area

12

E 14 (17) *

26 **

C 15 (17) *

27 **

Clarke et al. 2002

E 220

C 247

Inclusion: episode of deliberate self-harm; deliberate self-harm defined as non-fatal act in which an individual deliberately causes self-injury or ingests a substance in excess of the therapeutic dose; adult residents of geographical area

Exclusion: less than 16 years of age; individuals aged 16–19 in full-time secondary education; overdose from recreational or problematic alcohol and/or drug use

12

E 19 (9) _SH readmission *

C 25 (10) _SH readmission *

Nordentoft et al. 2002

E: 156 (35)

C: 148 (42)

Inclusion/Exclusion: aged 18 to 45; legal residence in catchment area; diagnosis of schizophrenia, schizotypal disorder, delusional disorder, acute or transient psychosis, schizoaffective psychosis, induced psychosis, or unspecified non-organic psychosis according to ICD-10; exposure to antipsychotic medication never exceeding 12 weeks of continuous medication in antipsychotic dosage; absence of mental retardation (learning disability), organic mental disorder, and psychotic condition because of acute poisoning or a withdrawal state; familiarity with Danish language; written informed consent

12

E: 1 suicide

E: 18 (12) *

C: 13 (10.4)*

Rathus and Miller 2002

E: 29

C: 82

Inclusion: adolescent outpatient admissions; inclusion for DBT (must have both): suicide attempt within last 16 weeks (defined as self-harm with the intent to die); diagnosis of borderline personality disorder or minimum of 3 borderline personality features

Inclusion to TAU: those meeting either criteria A or B for DBT, but not both

Spirito et al. 2002

E 36 (7)

C 40 (6)

Inclusion: aged 12–18; receiving medical care at children's hospital following suicide attempt; suicide attempt defined as any intentional self-injury, regardless of lethality, as attempt to harm or kill oneself

3

Not specified

Meltzer et al. 2003

E 490 (192)

C 490 (187)

Inclusion: women; aged 18–65; DSM-IV diagnosis of schizophrenia or schizoaffective disorder; considered to be at high risk for committing suicide, defined as any one of the following: history of previous attempts or hospitalizations in previous 3 years; moderate to severe current suicidal ideation with depressive symptoms; command hallucinations for self-harm within 1 week

12

E: 34

C: 55

Power et al. 2003

E 31 (10)

C 25 (4)

Inclusion: acutely suicidal youth with severe mental illness; score between 4 and 7 on Expanded Version 4 of Brief Psychiatric Rating Scale (BPRS) suicidality subscore, with 4 equating a ‘suicidal thoughts frequent, without intent or plan’ and 7 equating ‘a specific suicidal plan and intent or suicide attempt’; agreement to participate

Exclusion: attended service for more than 1 year

6

E: 1 suicide

C: 1 suicide

Tyrer et al. 2003

E 239 (40)

C 241(38)

Inclusion: episode of self-harm; previous episode; informed written consent; do not require in-patient psychiatric treatment

Exclusion: psychotic disorder; bipolar disorder; primary diagnosis of substance dependence

12

E (39) _p

C (46) _p

Verheul et al. 2003

E 27 (3)

C 31 (8)

Inclusion: women aged 18–70; borderline personality disorder; no restriction on referral source; were able to find or had a referral source willing to provide 12 months treatment

Exclusion: DSM-IV diagnosis of bipolar disorder or chronic psychotic disorder; insufficient command of Dutch language; severe cognitive impairments

12

E: 2 (7) *

C: 8 (26) *

Self-mutilation

E: 8 (35) *

C: 13 (57) *

Katz et al. 2004

E: 32 (6)

C: 30 (3)

Inclusion: aged 14–17; suicide attempt or suicidal ideation severe enough to warrant psychiatric admission; adolescent agreed to stay in the hospital for brief treatment

Exclusion: mental retardation; psychosis; bipolar affective disorder; severe learning disabilities

12

Total hospitalizations

E: 6

C: 6

Total ER visits

E: 8

C: 14

Total incidents in hospital

E: 2

C: 10

March et al. 2004

E₁ 109 (18)

E₂ 111 (24)

E₃ 107 (17)

C 112 (23)

Inclusion: aged 12–17; ability to receive care as outpatient; primary DSM-IV diagnosis of MDD; written consent from patient and at least one parent; Children's Depression Rating Scale-Revised (CDRS-R) total score of 45 or higher; not taking antidepressants; depressive mood in at least 2 of 3 contexts (home, school, among peers) for at least 6 weeks prior

Exclusion: ccurrent or past diagnosis of bipolar disorder, severe conduct disorder, current substance abuse or dependence, pervasive developmental disorder(s), thought disorder; concurrent treatment with psychotropic medication or psychotherapy outside study; 2 failed SSRI trials; poor response to clinical treatment containing CBT for depression; intolerance of fluoxetine; confounding medical condition; non-English speaking patient or parent; pregnancy or refusal to use birth control; hospitalization for dangerousness to self or others within 3 months of consent; deemed ‘high risk’ because of a suicide attempt requiring medical attention within 6 months, clear intent or an active plan to commit suicide, or suicidal ideation with disorganized family unable to guarantee adequate safety monitoring

12 weeks

Total adverse events: 33 (7.5)*

E₁: 13 (11.9)

E₂: 5 (4.5)

E₃: 107 (8.4)

C: 6 (5.4)

Total suicide-related adverse events: 24 (5.5)*

E₁: 9 *8.26)

E₂: 5 (4.50)

E₃: 6 (5.61)

C: 4 (3.57)

Brown et al. 2005

E 60 (15)

C 60 (20)

Inclusion: suicide attempt, defined as a potentially self-injurious behavior with a non-fatal outcome for which there is evidence, either explicit or implicit, that the individual intended to kill himself or herself, within 48 hours prior to evaluation in emergency department; age 16 or older; English-speaking; able to complete baseline assessment; able to provide at least 2 verifiable contacts for tracking; ability to give informed consent

Exclusion: medical disorder preventing outpatient treatment

18

E 13 (24.1)*

C 23 (41.6)*

Donaldson et al. 2005

E 15

C 16

(8 total)

Inclusion: adolescents aged 12–17; admitted to emergency department or inpatient unit following suicide attempt; suicide identified as any intentional, non-fatal self-injury, regardless of medical lethality with intent to die

Exclusion: primary inclusion other than English; psychosis indicated on mental status examination; intellectual functioning precluding outpatient psychotherapy

6

E 4 (26.7) *

C 2 (12.5) *

Evans et al. 2005

E 417

C 410

Inclusion: patients admitted to hospital for self-harm

12

E 90 (21.6) _SH  *

C 77 (18.8) _SH  *

Nordentoft et al. 2005

E: 362 (149)

C: 39 (19)

Inclusion: inhabitants in Copenhagen or Frederiksberg municipality; aged 16–40; severe suicidal thoughts or incidents of attempted suicide; understand and willing to give informed consent

Exclusion: psychotic illness; intravenous drug abuse

12

3 suicides in experimental group

E: 213 (7)*

C: 21 (33.3)*

Rhee et al. 2005

E₁ (16, 50 per cent)

E₂ (10, 37 per cent)

C (15 per cent)

Total: 85

Inclusion: callers from telephone crisis hotline; currently not in therapy; currently at no or low risk for suicide; no indications for psychiatric referral due to severe impairment of functioning or psychotic symptoms; no indications for hospitalization or police intervention; expressed interest in beginning psychotherapy

Exclusion: medium or high risk for suicide

6 weeks

Not specified

van den Bosch et al. 2005

E 27

C 31

Inclusion: female; aged 18–65; DSM-IV diagnosis of BPD according to SCID-II

Exclusion: DSM-IV diagnosis of bipolar disorder or chronic psychotic disorder; insufficient command of Dutch language; severe cognitive impairments

18

During 12-month study

E: (7)*

C: (26)*

During 26-week follow-up

E: 1 (4)*

C: 6 (19)*

Linehan et al. 2006

E: 52 (16)

C: 49 (35)

Inclusion: women; aged 18–45; met criteria for BPD; current and past suicidal behaviour defined as at least 2 suicide attempts or self-injuries in the past 5 years, with at least 1 in the past 8 weeks

Exclusion: lifetime diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, psychotic disorder NOS, or mental retardation; seizure requiring medication; mandate to treatment; need for primary treatment for another debilitating condition

24

E: (23.1) **

C: (46)**

Tarrier et al. 2006

Inclusion/Exclusion: either first or second admission (within 2 years of a first admission) to inpatient or day patient unit for treatment of psychosis; DSM-IV criteria of schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, or psychosis NOS; Positive psychotic symptoms for 4 weeks or more; score of 4 or more (moderate to extreme) on PANSS target item for either delusions or hallucination; no substance misuse; psychotic symptoms not caused by organic disorder

18

E: 0

C: 3 deaths by suicide

Weinberg et al. 2006

E: 15

C: 15

Inclusion: females; borderline personality disorder; aged 18–40; history of repetitive DSH, with at least one episode during past month

Exclusion: comorbid psychotic disorder; bipolar I disorder; substance dependence score of 9 or higher on Beck Hopelessness Scale describing concrete immediate suicide plan

8

Frequency

E: 1.98 _SH

C: 6.69 _SH