Client, Peer, and Provider Stakeholder Input on the Modification of a Cognitive Behavioral Suicide Prevention Treatment for Adults with Psychosis

Background and Purpose: Suicide is among the leading causes of death for adults with schizophrenia spectrum and other psychotic disorders (SSPDs) with suicide risk estimates being over eight times greater than among the general population. There is a paucity of evidence-based interventions to reduce suicide among adults with SSPDs and our study sought to modify and evaluate the acceptability and preliminary effectiveness of Cognitive Behavioral Suicide Prevention for psychosis (CBSPp) for a community mental health (CMH) setting. This paper presents on Aim 1 qualitative data of the NIMH-funded pilot effectiveness clinical trial (R34) to gain input from stakeholders to inform treatment modifications prior to testing in a randomized controlled trial (Aim 2).

Methods: A total of 26 adult stakeholders participated in Aim 1 of the study, including 6 clients with SSPDs and recent suicide ideation or attempt, 7 peers, and 12 providers in CMH. Peers and providers were recruited by research staff attending virtual staff meetings and clients were recruited by providers who attended staff meetings. Interested clients were screened to confirm recent ideation or attempt and SSPD diagnosis. All stakeholders attended a 1-hour virtual qualitative in-depth interview with research staff to explore perspectives on the need for CBSPp, treatment barriers, sustainability facilitators, and areas for improvements. Qualitative interviews were transcribed, coded in Dedoose using an open-coding technique to generate themes across questions, and analyzed using grounded theory methods.

Results: Clients, peers, and providers agreed there was a need for CBSPp in CMH, clients indicated they would want the treatment, and providers expressed interest in being trained to deliver the treatment. The following 3 treatment barrier themes emerged across participant groups: 1) logistic (e.g., technology barriers if virtual, provider training and delivery time), 2) client perceptions (e.g., readiness and motivation for treatment), and 3) co-occurring disorders (e.g., substance abuse). The following 4 sustainability facilitator themes emerged across participant groups: 1) buy-in (e.g., client, provider, agency buy-in to the utility of CBSPp), 2) client outcome data (e.g., CBSPp efficacy and client endorsement of helpfulness, 3) provider support (e.g., supervision, ongoing training, and inclusion of CBSPp into workload), and 4) treatment team collaboration. The following 3 areas for improvement themes emerged across participant groups: 1) increase self-esteem, 2) bolster social support, and 3) add tailoring options in the treatment manual (e.g., for trauma; per providers).

Implications and Conclusions: Study findings highlight the logistic, perceptual, and clinical challenges perceived by clients, peers, and providers in the process of introducing CBSPp in a CMH setting. Consistent with prior literature, buy-in and support for the delivery of a new treatment emerged as important factors for sustainability and scalability over time. Findings were subsequently presented to a panel of scholarly experts in the fields of suicide and psychosis research, intervention research, and implementation science for additional feedback and to inform modification decisions. Stakeholder perspectives using community based participatory research approaches are essential to problem-solve challenges and barriers of new treatment delivery with an overall goal of improving access, feasibility, and quality of suicide prevention interventions.