A Cognitive-Behavioral Approach to Suicide Prevention Among Adults with Schizophrenia Spectrum Disorders

Background: Individuals with schizophrenia spectrum disorders (SSDs) are at elevated risk for suicide with data indicating a lifetime rate of suicide death. In addition to well-documented risk factors of hopelessness, depression, age, gender, substance use, previous suicide attempt, clinical insight, lethality of means, and longer duration of untreated psychosis, there has been growing evidence of SSD symptomatology, such as hallucinations and delusions, contributing to suicide thoughts and behaviors. Despite high suicide rates and specific symptom-level risk factors, there is a paucity of therapeutic suicide prevention approaches with tailoring suicide risk in relation to symptoms among individuals with SSDs. 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. Our team modified a CBSPp for adult clients in a community mental health (CMH) setting with stakeholder input and conducted a pilot clinical trial to examine preliminary effectiveness, feasibility, and acceptability.

Methods: This study involved a single-site randomized pilot trial with a planned enrollment of 60 adults meeting criteria for having a SSD and recent suicide ideation and/or attempt. Participants were randomized to either receive CBSPp or services as usual (SAU). A 4-wave design was used for clinical and cognitive assessments and qualitative interviews were conducted post-treatment with participants in the CBSPp group. Our primary objective was to determine whether CBSPp is feasible and acceptable, involving examinations of recruitment rate, treatment engagement and adherence, retention and completion rates, and experiences in the CBSPp treatment and overall study. Our secondary objective was to preliminarily evaluate whether modified CBSPp is associated with reductions in clinical (suicide ideation, suicide attempt, symptoms of psychosis, depression, and emergency/hospital service, hopelessness, defeat, and entrapment) and cognitive (information processing biases, appraisals, and schemas) outcomes in comparison to SAU from baseline to post-treatment assessment.

Results: Final CBSPp modifications included 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 significant improvements in suicide ideation, depression, hopelessness, general symptoms of psychosis, entrapment, defeat, coping, psychological stress, and impulsivity from baseline to post-treatment. Clinical trial results are forthcoming as a step beyond the open pilot trial.

Discussion: This randomized pilot trial provides clinically relevant information about whether CBSPp can improve SI/A, depression, and psychosis among adults with SSDs. In addition to increasing the existence of tailored behavioral interventions aiming to prevent suicide among individuals with SSDs , it is essential that more interventions are developed for and with Community Mental Health (CMH) settings given they are among the largest mental health service providers in the United States and deliver the majority of SSD care. Testing this modified cognitive-behavioral suicide prevention-focused intervention has potential for public health impact by increasing the intervention’s utility and usability in CMH and ultimately working towards reductions in premature suicide death.