Talk Therapy May Prevent Suicide in High-Risk Patients

Deborah Brauser

November 25, 2014

Talk therapy may decrease risk for future suicide attempts and completions in patients who have already made a previous attempt, new research suggests.

A matched cohort study showed that a group of more than 5000 individuals in Denmark who voluntarily underwent 6 to 10 sessions of psychosocial counseling after deliberate self-harm had 27% fewer suicide attempts and 38% fewer deaths in the following year than those who received treatment as usual or no treatment at all.

In addition, these benefits remained. They had 26% fewer suicide completions 5 years after receiving short-term talk therapy than the subgroup that did not receive the treatment.

"We have evidence that psychosocial treatment ― which provides support, not medication ― is able to prevent suicide in a group at high risk of dying by suicide," lead author Annette Erlangsen, DPH, adjunct associate professor in the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, said in a release.

The investigators noted in the same release that "it might be valuable to broadly implement therapy programs for [all] people who have attempted suicide in the past."

The study was published online November 24 in Lancet Psychiatry.

Repeated Self-Harm Prevented

The researchers examined health data for more than 65,000 Danish citizens who attempted suicide between January 1992 and December 2010. Of these, 5678 (69.1% women) received psychosocial therapy at 1 of 7 "suicide prevention clinics."

Denmark provides free healthcare and opened the first of these types of clinics in 1992 before opening them nationwide in 2007. They were specifically built to help individuals at risk for suicide but not deemed in need of hospitalization.

Data on the patients receiving psychosocial therapy (PT) were compared with those of 17,034 individuals (69% women) who also attempted suicide but who did not receive this type of treatment.

Results showed that 937 of the participants receiving PT (16.5%) had at least one other suicide attempt during 20 years of follow-up vs 19.1% of those receiving no treatment. In addition, 391 of the PT group died from any cause, and 93 died by suicide.

During the first year, 382 of the PT participants had a repeated self-harm episode (6.7%) vs 1536 of the nontreated participants (9.0%). This corresponded to 7095 per 100,000 vs 9712 per 100,000, respectively (P < .0001).

The PT group also had a significantly lower risk for self-harm (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.65 - 0.82) than the group not receiving PT. The absolute risk reduction (ARR) was 2.3%, and the number needed to treat (NNT) was 44.

"If we apply this NNT to our cohort of 5678 recipients of psychosocial therapy, it implies that repeated self-harm was prevented in 129 people," write the investigators.

In addition, the PT group had a significantly lower risk for death by any cause (OR, 0.62; 95% CI, 0.47 - 0.82; ARR, 0.7; NNT, 153), "resulting in 37 avoided deaths within the first year."

There were no significant between-group differences in suicide completions during that period.

However, the death by suicide rate after 5 years was 299 per 100,000 person-years for the PT group vs 396 per 100,000 for the nontreated group (P = .03); and at the 10-year follow-up, it was 229 per 100,000 vs 314 per 100,000, respectively (P = .01).

At the 20-year point, the OR for repeated self-harm in the treatment group vs the nontreated group was 0.84 (95% CI, 0.77 – 0.91), with an ARR of 2.6% and an NNT of 39. This suggested that 145 repeat episodes were avoided. The OR for suicide was 0.75 (95% CI, 0.60 - 0.94), with an ARR of 0.5% and an NNT of 188, "equivalent to 30 prevented suicide deaths."

Finally, the investigators found that women, individuals between the ages of 10 and 24 years, and those who only had one episode of self-harm benefited most from PT.

"Our findings provide a solid basis for recommending that this type of therapy be considered for populations at risk for suicide," coinvestigator Elizabeth A. Stuart, PhD, also from Johns Hopkins' Department of Mental Health, said in the release.

The investigators note that because the types of interventions varied widely, they are not sure what exactly helped to guard against future suicide attempts.

"While it is possible that it was simply the provision of a safe, confidential place to talk," the researchers said in the release that they hope to further examine which types of therapy work better ― and why.

"For the evidence to be conclusive the intervention needs to be assessed in a randomised controlled trial; however, these findings might be the best evidence available and provide a sound basis for policy makers who wish to limit suicidal behaviour and fatal events," they write.

Great Clinical Utility

In an accompanying editorial, Maria A. Oquendo, MD, from the New York State Psychiatric Institute and Columbia University in New York City, and Philippe Courtet, MD, PhD, from the Department of Emergency Psychiatry at CHRU of Montpellier, France, write that the search for effective interventions in this high-risk population has been "hampered" by the rarity of suicide's occurrence.

They applaud the current investigators for using observational data and propensity scoring to test hypotheses in a big, real-world sample covering a long period.

"Although randomized controlled trials remain the gold standard for assessment of interventions, propensity scoring of observational treatment data can be of great utility," they write.

However, they note several study limitations. As mentioned by the authors, the editorialists point out that disparate types of PT were used, "begging the question of what the so-called active ingredient is."

Dr Oquendo and Dr Courtet add that the term "deliberate self-harm" is also controversial because a person's intent is not always easy to establish.

"Thus, use of suicide intent to distinguish suicide attempters...from those with non-suicidal self-injury...will at times need clinical judgment, which might lead to misclassification," they write.

"Ultimately, progress will build on clear-cut, precise definitions to classify self-injury, permitting delineation of the probable disparate clinical strategies effective in addressing two distinct types of self-injury, with or without suicide intent."

The study authors and Dr Courtet have reported no relevant financial relationships. Dr Oquendo reports receiving royalties for the commercial use of the Columbia-Suicide Severity Rating Scale and that her family owns stock in Bristol-Myers Squibb.

Lancet Psychiatry. Published online November 24, 2014. Abstract, Editorial


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