Intervention

There are two broad strategies of intervening in suicide. One approach is to treat suicidal behaviour indirectly by treating any accompanying psychiatric disorder, of which the main candidate would be depression. The second approach is to develop treatments that focus specifically on tackling suicidal ideation and behaviour. Due to the clear discordance between depression and suicidal behaviour, even a highly effective treatment for depression is unlikely to be an effective treatment for suicidal behaviour. A recent review by Khan et al. (2000) illustrates the point. These authors reviewed suicide rates in documented trials of new antidepressants over a 10-year period in the USA. Data from almost 20000 patients were included. The overall rate of suicidal behaviour was low—just less than 1% committed suicide and almost 3% attempted suicide. Importantly for the argument here, the active treatments produced depressive symptom reduction of 41% compared to 31% for placebo, but the groups did not differ in rates of suicide. There are some limitations to generalising from these findings. The trials were very brief—4-8 weeks—and the patients in the trials were not typical in that they were not actively suicidal and not comorbid (Hirschfeld, 2000). However, the data demonstrate that reductions in depression can take place without accompanying reductions in suicidality. Studies of recovery also show that improvements in depression, hopelessness, and psychosocial function can all occur without any reduction in repetition of suicidal behaviour (Townsend et al., 2001). One possible exception to this is the use of lithium to treat bipolar disorder in particular. There is evidence from epidemiological studies that patients taking lithium have reduced suicide risk. However, this is mainly based on naturalistic studies of those attending lithium clinics (Verkes & Cowen, 2000). Clearly, there may be selection factors operating in that those motivated and able to adhere to a lithium regimen might be at lower risk to start with.

There is a wide range of psychological treatments aimed specifically at reducing suicidal behaviour. Treatments tend to focus on preventing repetition of parasuicide, partly because of the near impossibility of demonstrating treatment effectiveness in such a rare behaviour as completed suicide. On the whole, treatments show limited effectiveness, many studies finding no difference in parasuicide rates in those given a specific treatment and those given standard treatment (Hawton et al., 1998; Heard, 2000). The difficulty in demonstrating effectiveness of treatment is undoubtedly influenced by the relative rarity of suicidal behaviour. An additional major factor, increasingly recognised, is the heterogeneity of those who engage in suicidal behaviour. The only thing that these individuals necessarily have in common is a single behavioural act.

Some studies have shown positive results. There is no really clear pattern to those studies: they include brief treatments as well as longer-term treatments, and treatments based on psychodynamic principles as well as those based on broadly cognitive-behavioural principles. Linehan reported significantly lower rates of self-harm in borderline personality disorder patients given dialectical behaviour therapy (DBT) (Linehan et al., 1991). DBT is an intensive intervention, with weekly individual and group session for about 1 year. The group sessions aim to teach skills, such as interpersonal problem-solving skills, strategies for regulating emotions, and ways of tolerating distress, and the individual sessions focus on understanding suicidal episodes and dealing with issues of adherence to treatment. Bate-man and Fonagy (1999) also reported a statistically significant reduction in self-harm rates along with other outcome measures in borderline personality disorder patients, this time those receiving psychoanalytically oriented partial hospitalisation (maximum 18 months), compared to those receiving standard psychiatric treatment. In both of these cases, benefits were maintained at follow-up (Bateman & Fonagy, 2001; Linehan et al., 1993).

Brief treatments with unselected samples have also shown evidence of effectiveness. Salkovskis et al. (1990) employed a brief (five sessions) home-based, problem-solving approach with patients who had a history of self-harm. The sessions covered standard problem-solving training, such as help with identifying problems, generating solutions, and implementing solutions, all applied flexibly to the individual's situation. Compared to a treatment-as-usual group, those receiving the intervention showed reduced depression, hopelessness, and suicide ideation and also significantly lower repetition rates at 6 months, although at 18-month follow-up the groups were no longer significantly different on repetition. Guthrie et al. (2001) found that recent suicide attempters given four sessions of home-based brief psychodynamic interpersonal therapy aimed at resolving interpersonal problems showed lower parasuicide rates at 6-month follow-up than those receiving treatment as usual.

It is difficult to say why some studies have found a positive effect against a background of most showing no difference between a targeted intervention and treatment as usual. The Linehan et al. (1991) and Bateman and Fonagy (1999) studies focus on a particular subset of attempters—those meeting criteria for borderline personality disorder—thus reducing the heterogeneity of the sample and also targeting a group with higher rates of self-harm. The Salkovskis study may have accommodated heterogeneity, as the authors emphasised the flexible application of the treatment to individual cases. In contrast, a group intervention that included problem solving reported by Rudd et al. (1996) found no significant benefit over and above treatment as usual. The problem-solving intervention in the Rudd et al. study was implemented in groups of 12-14, thus necessarily limiting the extent to which treatment could be tailored to the individual. These explanations are post hoc, but it is clear that the heterogeneity of patients, as well as low base rates, represent major obstacles to successful intervention.

BiPolar Explained

BiPolar Explained

Bipolar is a condition that wreaks havoc on those that it affects. If you suffer from Bipolar, chances are that your family suffers right with you. No matter if you are that family member trying to learn to cope or you are the person that has been diagnosed, there is hope out there.

Get My Free Ebook


Post a comment