Phone Calls May Help Keep Suicide at Bay in Bipolar Disorder

Fran Lowry

June 18, 2013

MIAMI — A novel telephone-based intervention to help ease the transition from inpatient to outpatient after a suicide attempt is showing definite promise as an effective suicide prevention strategy for people with bipolar disorder.

Dubbed the Coping Long-Term with Active Suicide Program for Bipolar Disorder, or CLASP-BD, the intervention was found to be feasible and acceptable to patients to reduce their risk for suicide in the 12 months following hospitalization for bipolar depression.

"Suicide risk in bipolar disorder is extremely high, arguably the highest amongst all the psychiatric disorders," Lauren Weinstock, PhD, from Brown University, Providence, Rhode Island, told Medscape Medical News.

"We feel, from a clinical perspective, that we really need to develop interventions that target suicide specifically if we are going to reduce this risk," Dr. Weinstock said here at the 10th International Conference on Bipolar Disorders (ICBD).

Suicide Risk Forgotten After Hospital Discharge

As she was developing CLASP, Dr. Weinstock said she discovered that once patients were discharged from the hospital, the fact that they remained at risk for suicide was forgotten.

Dr. Lauren Weinstock

"We found this anecdotally, and it is actually quite alarming. After a suicide crisis, patients often go back to their community providers, and the providers may pay some attention to the suicide attempt immediately after the hospitalization, but in the months that follow, it doesn't come up again in treatment. But the fact is, we need to continue to pay close attention to suicide risk, which remains very high in the first 12 months after hospitalization."

The CLASP-BD program consists of 3 individual therapy sessions while the patient is in hospital, as well as 1 family meeting, which can take place while the patient is in the hospital or shortly after discharge, followed by 13 telephone calls to both the patient and to a family member over a 6-month period once the patient has gone home.

"This is not meant to be a replacement for community treatment but to be an adjunct to treatment that we can deliver to people as they are making the transition from inpatient to outpatient," Dr. Weinstock explained.

"We review the factors that contributed to the hospitalization, what things may have influenced their suicidal ideation, and then we shift gears and talk with them about what is important to them, their values, and so on. The idea is to help motivate them and help bring their actions back in line with their values and goals."

In this small pilot trial, Dr. Weinstock and her team recruited 21 patients with bipolar depression who were psychiatry inpatients hospitalized for attempted suicide or because they had a definite plan to commit suicide.

The patients were randomly assigned either to the CLASP-BD intervention (n = 11 patients) or to enhanced treatment as usual (E-TAU; n = 10).

E-TAU consisted of treatment as usual in the community but was enhanced with letters to the community care providers at baseline, 3 months, and 6 months, summarizing the patient's risk, symptoms, and hospital course. "We are trying to encourage continuity of care, but E-TAU is really our control condition," Dr. Weinstock explained.

The patients were similar in age (mean age, 48 years in the CLASP group, 43 years in the E-TAU group; P = .21); most were white (10 in the CLASP group and 9 in the E-TAU group; P = .94), and they were similar in disability status.

Patients in both groups had similar lifetime history of suicide attempts (8 in CLASP and 8 in E-TAU) and suicide behavior (9 in CLASP and 10 in E-TAU). More patients randomly assigned to E-TAU had a history of nonsuicidal self-injury (5 patients vs 2 patients randomly assigned to CLASP), although this was not statistically significant.

No Completed Suicides

After 6 months posthospitalization, there were significant differences in rates of suicide attempts between the 2 groups.

There were no completed suicides during the 6 months of the study. However, there were significant differences in rates of suicide behavior and suicidal rehospitalization between the 2 groups.

There were 3 suicide attempts among the 10 patients who were randomly assigned to E-TAU, vs 0 suicide attempts in patients who received CLASP (P = .02), 1 patient in the CLASP group exhibited suicide behavior compared with 5 in the E-TAU group (P = .04), and 1 patient in the CLASP group was rehospitalized for suicidal behavior compared with 5 in the E-TAU group (P = .03).

"The numbers here are similar for suicide behavior and rehospitalization, but the P values are different because we had some missing data. Also it is important to remember that this is a very small feasibility study, and we did not set out to show statistical significance," Dr. Weinstock said.

The CLASP group also had greater reduction in their intensity of suicidal ideation, as measured on the Columbia Suicide Severity Rating Scale (C-SSRS), as well as greater reduction in depression, as measured on the Quick Inventory of Depressive Symptomatology, Clinician Rating (QIDS-C) scale, and in feelings of hopelessness, as measured on the Beck Hopelessness Scale (BHS).

Table. Suicide Intensity, Depression, and Hopelessness Before and After Intervention

Measure CLASP-BD Pretreatment CLASP-BD Post-treatment E-TAU


E-TAU Post-treatment P Value Cohen's d Effect Size
C-SSRS 19.11 3.75 18.40 9.17 .15 0.73
QIDS-C 22.36 8.25 22.70 15.67 .04 1.08
BHS 11.79 6.94 13.29 14.00 .12 0.86


"We were really encouraged by the results because it was a small pilot, and to see the difference was proof that this intervention is not only feasible but has a positive effect," Dr. Weinstock said. "We are feeling very optimistic moving forward and will be looking at CLASP in a much larger trial."

Commenting on this report for Medscape Medical News, Barbara L. Gracious, MD, from the Research Institute at Nationwide Children's Hospital in Columbus, Ohio, said that she was impressed by the good effect the CLASP intervention had, adding that such outreach used to be usual care years ago.

Dr. Barbara Gracious

"This poster shows that a simple, cost-effective intervention that is supportive in nature, simply calling a patient after they've been discharged, seems to have a powerful effect on subsequent behavior, which includes suicide behaviors and need for rehospitalization," Dr. Gracious, who was not part of the study, said.

"This used to be standard of care a long time ago, and I think it's fallen out of favor over the years, but this kind of thing used to happen back when there were more case managers in hospitals. This seems to provide evidence that moving back in that direction, towards having individuals who are case managers either at the insurance level or at the hospital level working with clinicians, could be an incredibly powerful and life-saving intervention."

This study was funded by an American Foundation for Suicide Prevention Young Investigator Award to Dr. Weinstock. Dr. Weinstock and Dr. Gracious report no relevant financial relationships.

10th International Conference on Bipolar Disorders (ICBD). Abstract 115. Presented June 15, 2013.


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