Marjan Ghahramanlou Holloway Gregory K Brown Aaron T Beck

Suicide is the 11th leading cause of death in the United States, with a rate of one completed suicide every 17 minutes (Hoyert, Kung, & Smith, 2005). Among individuals 15-24 years old, suicide is the third leading cause of death after accidents and homicide; among individuals 25-44 years old, suicide is the fourth leading cause of death after accidents, malignant tumors, and heart disease (Hoyert et al., 2005). Approximately 20% of all U.S. suicides occur in elderly persons; firearms account for up to 80% of these suicides (Oslin et al., 2004). Suicide ideation has been estimated in 2.3% of U.S. residents ages 18-54 within the past 12 months; within this group, 28.6% made a plan to kill themselves, and 32.8% of these individuals carried out a serious attempt to commit suicide (Cole & Glass, 2005).

Suicide among individuals with depression is a major public health problem. The lifetime risk of suicide for individuals with major depressive disorder (MDD) has been estimated to be 15% among psychiatric inpatients (Guze & Robins, 1970). Recent epidemiological data have suggested that the risk of suicide for individuals with MDD is approximately 3.4%, with males having a 7% risk and females having a 1% risk (Blair-West, Cantor, Mellsop, & Eyeson-Annan, 1999). An overall 6% risk of completed suicide for affective disorders has been reported in a recent meta-analysis (Inskip, Harris, & Barraclough, 1998). The National Comorbidity Survey indicates that individuals with MDD have odds ratios of 11.0 for suicide ideation and 9.6 for suicide planning (Kessler, Borges, & Walters, 1999). Yet few individuals with MDD receive adequate treatment for depression before and after a suicide attempt.

Most individuals with MDD are at the highest risk for suicide during the early years within the course of illness (Vieta, Nieto, Gasto, & Cirera, 1992); those who attempt suicide often do so in the first 3 months of a depressive episode and within 5 years of the onset of their depression (Malone, Haas, Sweeney, & Mann, 1995). Anxiety increases the risk of early suicide in the course of major depression, whereas stable levels of hopelessness increase long-term risk (Placidi et al., 2000). Together, these findings suggest that depressed individuals, especially those with suicide ideation or suicide attempts, constitute a high-risk group for suicide.

The National Strategy for Suicide Prevention identifies suicide as a "public health problem that is preventable," and one of its goals is the development and implementation of suicide prevention programs (U.S. Public Health Service, 2001, p. 46). Consequently, adequate training of mental health providers in assessment and treatment of depressed patients with suicide behavior is an important step in reducing subsequent suicide attempts. Interventions that target suicide attempters and achieve a 25% reduction in suicide attempts have been estimated to lead to a 2.6 reduction in the population rate of suicide (Lewis, Hawton, & Jones, 1997). Using national annual rates of suicide, approximately 1,000 deaths can be prevented each year.

Our primary objective in this chapter is to educate clinicians in empirically based strategies for the assessment and treatment of depressed individuals with suicide behavior. The first section addresses the relation between suicide behavior and psychotherapy outcome. The second section familiarizes the reader with assessment procedures to be utilized for depressed individuals with suicide behavior. The third section outlines the major components of an empirically based cognitive treatment protocol for adult depressed patients with recent suicide behavior.

SUICIDE BEHAVIOR AND PSYCHOTHERAPY OUTCOME

Few studies have examined the relation between treatment response and completed suicide. In general, individuals who have committed suicide are expected to demonstrate a history of poorer treatment outcomes compared to individuals who have not committed suicide. For instance, Motto,

Heilbron, andJuster (1985) found that in a sample of 2,753 inpatients, negative or variable results of previous efforts to obtain help predicted suicide risk. Modestin, Schwarzenbach, and Wurmle (1992) found that therapist experience was the most significant psychotherapy factor contributing to different outcome in a sample of suicide completers compared to matched controls. Goldstein, Black, Nasrallah, and Winokur (1991) found that a favorable outcome at discharge was a protective factor for suicide in a prospective study of 1,906 inpatients with affective disorders. Additionally, Borg and Stahl (1982) reported that patient dropout from treatment was a risk factor for suicide.

There is a paucity of studies that have examined patient response to cognitive therapy (CT) and completed suicide. Dahlsgaard, Beck, and Brown (1998) investigated response to CT as a predictor of suicide completion in a group of psychiatric outpatients. In this matched cohort study, suicide completers attended significantly fewer psychotherapy sessions and had a significantly higher rate of premature termination of therapy, as well as significantly higher hopelessness scores as compared to controls. Overall, the study suggested that nonresponsiveness to psychotherapy, as measured by the number of sessions attended; level of hopelessness; and premature termination serves as an important risk factor for suicide.

ASSESSMENT OF SUICIDE IDEATION AND BEHAVIOR

Comprehensive evaluations of past and current suicide behavior prior to and during treatment are needed for risk management and treatment planning. The ongoing assessment of a patient's risk for suicide cannot, at any time, rely solely on a single indicator. All available information should be used collectively by the clinician to identify potential risk factors, to address immediate safety concerns, and to consider appropriate approaches to ongoing risk management.

Comprehensive Assessment of Suicide

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