A Cognitive Behavioral Approach to Suicide Prevention Among Adults with Psychosis: Stakeholder Involvement and an Open Pilot Trial in Community Mental Health

Background and Purpose: Suicide is among a leading cause of death for individuals with schizophrenia spectrum disorders (SSDs). Despite a growing body of literature documenting associations between psychosis symptoms, suicide ideation and attempt, evidence-informed interventions aiming to prevent suicide are lacking for individuals experiencing psychosis symptoms. Cognitive Behavioral Suicide Prevention for psychosis (CBSPp) is one of few suicide-focused interventions tailored for psychosis symptoms and was developed in the United Kingdom. To date, investigations of CBSPp have shown promising improvements in psychiatric outcomes and our team sought to modify the treatment for delivery in US community mental health (CMH) settings. This abstract presents on Aim 1 of a NIMH-funded pilot effectiveness clinical trial (R34) study, involving modifications to the treatment with use of stakeholder input and an open pilot trial for preliminary testing prior to a clinical trial.

Methods: A total of 25 adult stakeholders participated in the modification phase, including 6 clients with SSDs and recent suicide ideation or attempt, 7 peer advocates, and 12 mental health providers in CMH. All stakeholders attended a qualitative in-depth interview with research staff to explore perspectives about 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. Qualitative stakeholder findings were presented to a panel of scholarly experts in suicide and psychosis research, intervention research, and implementation science for additional feedback prior to finalizing a final list of modifications. Modifications were implemented systematically and preliminarily testing in an open pilot trial of 5 mental health providers and 5 clients with SSDs and recent suicide ideation or attempt. Clients received 10 individual therapy sessions across 10 weeks by trained CBSPp providers and completed clinical assessments at multiple timepoints (baseline, mid-treatment, post-treatment, and follow-up). In addition, participants attended a qualitative in-depth interview with research staff at post-treatment to explore CBSPp experiences and areas for further modification. Quantitative data were analyzed in SPSS28 and qualitative were coded in Dedoose, similar to methods of the stakeholder modification data.

Results: Emerging themes from stakeholders in the modification phase identified logistic, perceptual, and clinical challenges in introducing a treatment innovation. Final CBSPp modifications include tailoring CBSPp content and protocol for psychosis clients in CMH, increasing the feasibility of provider training, and enhancing client engagement to boost content and provide added support to clients. In the open pilot trial, clients made improvements in suicide ideation, depression, hopelessness, general symptoms of psychosis, entrapment, defeat, coping, psychological stress, and impulsivity from baseline to post-treatment.

Implications and Conclusions: Consistent with prior literature, buy-in and stakeholder support in the implementation of a treatment innovation emerged as important factors. Stakeholder involvement was essential in the modification process and open pilot findings reinforced the potential of CBSPp as a suicide prevention approach in CMH. A clinical trial is currently underway and future research will continue to examine the effectiveness and implementation of CBSPp on a larger scale and across various clinical settings.