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Am Fam Physician. 2006;73(6):1088-1090

Persons who have attempted suicide are approximately 40 times more likely to commit suicide than those with no such history. In 2002, suicide was the fourth leading cause of death in adults 18 to 65 years of age. However, little is known about prevention. Studies have investigated a variety of interventions for persons who have attempted suicide, including cognitive behavior therapy. Brown and colleagues conducted a study to determine if using cognitive therapy reduced suicidal behaviors.

The study included 120 patients who had attempted suicide and were evaluated within 48 hours after the attempt. After an entry interview, each participant was randomized to usual care or a 10-session outpatient cognitive therapy intervention. No participants were asked to stop mental health or substance abuse treatment. At the end of therapy, participants were required to complete a relapse prevention task. Failure to demonstrate adaptive coping strategies during this task prompted additional sessions. Outcome measures included additional suicide attempts during the study, depression, hopelessness, and suicidal ideation as measured by rating scales.

Of the 120 participants, 77 percent had a major depressive disorder, and 68 percent had a substance use disorder. Ten percent dropped out of cognitive therapy, and 7 percent dropped out of the usual care group. At 18 months, the suicide reattempt rate was significantly lower in the cognitive therapy group than in the usual care group. The estimated attempt-free probability was 0.76 in the cognitive therapy group and 0.58 in the usual care group. Approximately 41 percent of the usual care group had at least one suicide attempt, compared with 24 percent in the cognitive therapy group. Benefits from cognitive therapy were noted only when adjusting for sex, age, and minority status.

When using one rating scale, depression severity was lower in the intervention group at all measured intervals; however, another scale showed a difference between groups only with an omnibus measure of depression and not at any one assessment point. Hopelessness was lower in the intervention group, but there was no difference in suicidal ideation between groups. Although one half of the patients assigned to cognitive therapy had more than 10 sessions, the number of sessions did not influence suicide attempts.

The authors conclude that cognitive therapy reduces the likelihood of repeat suicide attempts by one half. Depression and feelings of hopelessness were lower in the cognitive therapy group. The authors suggest that a relatively brief cognitive therapy intervention could be readily adapted to a real-life community mental health setting.

editor’s note: The U.S. Preventive Services Task Force1 recently stated that there was insufficient evidence to recommend for or against screening for suicide risk in the general population. Although the study strengthens the case for suicide prevention, its applicability to the primary care setting is limited. The problem is, how does a physician decide who is at risk for suicide? If this were possible, does intervention help? Attempted suicide, on which most intervention studies are based, is not the most common primary care risk factor for suicide. More common, alone or in combination, are psychiatric illness, substance abuse, demographics, stressors, and other potentiating factors such as having a gun in the home.2 Even so, only a small proportion of patients with these risk factors will actually attempt or commit suicide. There have been no studies showing that screening for these risk factors prevents suicide.—c.w.

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