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Erlangsen, A., Lind, B. D., Stuart, E. A., Qin, P., Stenager, E., Larsen, K. J., ... & Nordentoft, M. (2014). Short-term and long-term effects of psychosocial therapy for people after deliberate self-harm: A register-based, nationwide multicentre study using propensity score matching. The Lancet Psychiatry. Early Online Publication: doi:10.1016/S2215-0366(14)00083-2.

Between 9 million and 35 million suicide attempts occur yearly in the world, and suicide accounts for over 800,000 deaths every year worldwide. Suicide attempts are associated with future attempts and with mortality. Within the first year, 16% of people attempt suicide again. Despite the occurrence of suicide attempts and its effects, there has been inconclusive evidence of the effectiveness of interventions to reduce future attempts and death. That is why this Danish nationwide study by Erlangsen is so important. Another impressive aspect of this study is its size and scope. Since 1992, psychological therapies have been offered to people at risk of suicide in specialized clinics throughout Denmark. The aim of Erlangsen and colleagues’ study was to assess if those who received these psychological interventions had a reduced risk of suicidal behavior and mortality compared to people who did not receive the interventions. The authors collected data from 1992 to 2010 from Danish national health registries. This procedure was possible in Denmark because the health system is nationally coordinated and each individual has a traceable national health ID. In order to be included in the study, those who were offered specialized psychological interventions had to receive at least one session of treatment. Therapy included cognitive behavioral therapy, problem solving therapy, dialectical behavior therapy, psychodynamic therapy, systemic therapy and others. The interventions consisted of up to 8 to 10 individual outpatient sessions. The comparison group received “standard care” that consisted of admission to hospital, referral to a general practitioner, or discharge with no referral. The primary outcomes were: repeated self-harm, death by suicide, and death by any other cause. Of the people receiving psychotherapy, 5,678 had useable data. The “standard care” sample was much larger and consisted of 58,281 individuals who were matched to the psychological intervention group on many variables including sex, age, education, antidepressant medications, and psychiatric diagnosis. For those receiving psychotherapy, the rate of repeated suicide attempts in the first year was 6.7% and 15.5% at 10 years. For those receiving standard care, rate of repeated suicide attempts in the first year was 9.0% and 18.4% at 10 years. The odds of another suicide attempt one year post treatment was 73% lower among those receiving psychotherapy. Death by any other cause at the 10 year mark was also significantly lower in the psychological therapy group (5.3%) versus the no-therapy group (7.9%). The authors estimated that over the 20 year span of their data, psychological therapy: prevented repeated suicide attempts in 145 people, prevented deaths by any other cause in 153 people, and prevented 30 suicide deaths. Psychosocial interventions were associated with fewer repeated suicide attempts in women but not in men, and adolescents and young adults benefited most from psychological therapies.

Practice Implications

This is the largest long term follow up study ever of psychological interventions after a suicide attempt. Psychotherapy was associated with reduced risk of self-harm and mortality in the short and long term. This was especially true for women and in adolescents and young adults. Those receiving psychotherapy might have been a select group resulting in biased results. However, the extensive matching of the psychotherapy group to the no-therapy control group reduced the likelihood that factors other than psychotherapy influenced the findings. The study indicates strong support for providing psychological interventions to people at risk of suicide.

Fowler, J.C. (2012). Suicide risk assessment in clinical practice: Pragmatic guidelines for imperfect assessments. Psychotherapy, 49, 81-89.

The journal Psychotherapy regularly publishes Practice Reviews, which are clinician-friendly practical articles that are based on the best current evidence. Recently, James Fowler published a Practice Review on suicide risk assessment. The assessment, management, and treatment of suicidal patients are some of the most stressful events in clinical practice. However, there is very little that is clear in the evidence base to help clinicians to make accurate assessments about suicide risk. Assessing suicide risk factors tends to result in making an inordinate number of false-positive predictions (i.e., deciding that a patient will attempt suicide when in fact the patient will not attempt suicide). Making false positive suicide predictions might be seen by some as desirable because doing so represents a conservative course of action. However, a clinician acting as if a patient will suicide when he or she will not can lead to unintended negative consequences for the therapeutic alliance and for the patient’s future trust in health professionals. Fowler suggests an assessment approach in which efforts are made to enhance therapeutic alliance by negotiating a collaborative approach to assessing risk and understanding why thoughts of suicide are so compelling. The list of protective factors (e.g., supportive social contacts, religious beliefs, therapeutic contacts) and risk factors (e.g., past suicide attempts) based on the most current evidence are presented in the article in easy to read tables. Fowler also presents a list of clinician resources for suicide assessment and facts with handy web site addresses. For example, Fowler suggests the Suicide Assessment Five-step Evaluation and Triage (SAFE-T) that incorporates the risk and protective factors with the best evidence base.

Practice Implications

Most methods of predicting suicide risk result in false positives (i.e., predicting suicide when suicide will not occur). Though conservative, a false positive prediction of suicide risk can have a negative impact on therapeutic alliance and patients’ future trust in health care providers. Evidence-based assessments of risk and protective factors may help. A free SAFE-T pocket guide is available to download at the Substance Abuse and Mental Health Services Administration (SAMHSA) web site: http://store.samhsa.gov/product/SMA09-4432.

Author email: cfowler@menninger.edu