Inpatient CBT Reduces Suicide and Readmissions After Discharge

Brief cognitive behavioral therapy (BCBT) sessions adapted for psychiatric inpatients reduced postdischarge suicide attempts and readmission rates, according to a randomized clinical trial.

In a trial of 200 participants at a private psychiatric hospital, providing up to four sessions of BCBT-inpatient (BCBT-I) treatment reduced the occurrence of suicide attempts by 60% compared with usual care (OR 0.40, 95% CI 0.20-0.80) in the 6 months following discharge, according to Gretchen Diefenbach, PhD, psychologist of the Anxiety Disorders Center at the Institute of Living in Hartford, Connecticut, and co-authors reporting in JAMA Psychiatry.

Meanwhile, the effect of such individual therapy sessions on readmission rates was moderated by substance use disorder (SUD): the rate of psychiatric readmissions was reduced by 71% (RR 0.29, 95% CI 0.09-0.90) in participants without a SUD, while it was not significantly changed for those with SUD (OR 1.02, 95% CI 0.46-2.24).

Notably, the number needed to treat was seven for suicide attempts and six for readmission rates after controlling for participants with SUD, the authors reported.

“These results highlight a path forward for the field to shift to a new inpatient suicide prevention treatment model,” Diefenbach told MedPage Today in an email, adding that the findings show that “improvements can be made to the current standard of care” and provide “support for [BCBT-I] as an efficacious inpatient suicide prevention treatment.”

The BCBT-I sessions tested included narrative assessment and review of suicide attempt stories, crisis response plan, inventorying reasons for living, creation of a hope kit, reducing access to lethal means, developing coping cards, and relapse prevention.

Diefenbach said her group was surprised to find that the treatment effect of BCBT-I on suicide attempts remained similar for participants diagnosed with SUD, which represented 60% of all trial participants. Participants with a SUD experienced double the rates of readmission and odds of suicide attempt compared to participants without the disorder, according to the investigators.

The present findings highlight the importance of suicide-specific inpatient treatments, commented psychologist Kelly Green, PhD, and two colleagues at the University of Pennsylvania, Philadelphia, in an accompanying editorial. Such treatment, they noted, “remains a first-line intervention for patients judged to be at high near-term risk for suicide” despite innovations in outpatient settings.

Green and coauthors also praised the implementation and testing of BCBT-I, a combination of BCBT and cognitive therapy for suicide prevention, which “addresses a critical chasm in suicide-specific inpatient care by evaluating its efficacy compared to inpatient treatment as usual,” they wrote. They also highlighted that the study’s findings show the potential of evidence-based suicide intervention “to prevent, rather than briefly delay, suicide.”

There are still gaps in the research for inpatient suicide intervention, Green’s group noted, including the need to ensure outcomes are scalable and treatments can be easily implemented.

Diefenbach and colleagues acknowledged that the treatment was delivered on an individual basis by PhD-level clinicians, so more research will be needed to understand the treatment’s effect when delivered through routine inpatient care.

To conduct the randomized clinical trial, Diefenbach’s group recruited adults ages 18-65 at a private psychiatric hospital in Connecticut. Eligibility criteria were either suicide attempt within 1 week of admission or ideation with plan on admission as well as suicide attempt within 2 years. Exclusion criteria included current mania, schizophrenia, intellectual disability, those unwilling or unable to follow study procedures, and non-fluency in English.

The authors compared participants in a treatment as usual group (n=106) to those with additional BCBT-I (n=94). Treatment as usual consisted of 24-hour multidisciplinary care based on a short-term stabilization model as well as safety planning and care connection calls, based on current guidelines.

Trial participants were enrolled from January 2020 through February 2023. They had a mean age of 32.8 years, and 117 of participants were women.

The effect of BCBT-I on suicidal ideation was less clear, but post hoc analyses indicated less severe suicidal ideation following BCBT-I at 1 and 2 months follow-up.

The authors conducted follow-up assessments monthly for 6 months following discharge and collected medical records data through 6-month follow-up. In total, 57% of participants completed all follow-up assessments.

Limitations of the study include the relatively high loss to follow-up and its conduct during the COVID-19 pandemic, which may have affected the trial in various ways.

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