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.
Below: Survival curves.
Suicide-attempt-free survival of participants who attempted
suicide at least once during the 24-month follow-up period. (A) All
participants (n = 120). (B) Participants without BPD (n =
100).
By:
Anja Gysin-Maillart, Konrad Michel
Outpatient Department, University Hospital of Psychiatry, University of Bern,
Bern, Switzerland
Simon
Schwab, Leila Soravia
Translational Research Center, University Hospital of Psychiatry, University of
Bern, Bern, Switzerland
Millie
Megert
Psychiatric Department, General Hospital, Thun, Switzerland
1 and Lourens Schlebusch2
