Adding Brief CBT to Inpatient’s Usual Treatment Reduces Suicide Reattempts

A recent study revealed adding brief cognitive behavioral therapy (CBT) to the usual treatment of an inpatient admitted for suicidal ideation or behavior reduced 6-month discharge suicide reattempts and the rate of readmissions.¹

“Results of this randomized clinical trial indicate that an expanded suicide-specific psychosocial intervention, specifically [brief] CBT-inpatient, can provide additional therapeutic value toward maintaining safety after discharge,” wrote investigators, led by Gretchen J. Diefenbach, PhD, from Yale University School of Medicine.

Patients discharged after being admitted to a psychiatric inpatient setting for suicidal ideation or behavior have an increased suicide risk, especially in the first 3 months post-discharge.² To prevent suicide reattempts, it is important inpatients receive suicide prevention treatments.

Investigators sought to determine whether adding a brief CBT for suicide prevention to usual treatment reduces post-discharge suicide attempts, suicidal ideation, and psychiatric readmissions.¹ The team also wanted to see if having a substance use disorder moderated the treatment effects.

The study followed inpatients at a private psychiatric hospital in Connecticut who were enrolled between January 2020 through February 2023. The study included inpatients who were admitted after a suicidal crisis, either a past-week suicide attempt or idea with a plan on admission and attempt within previous 2 years.

Among the 200 participants analyzed, the mean age was 32.8 years, and 117 participants were female. Patients were randomized to receive either treatment as usual (n = 106) or treatment as usual plus brief CBT (n = 94). Those who received brief behavioral therapy had ≤ 4 sessions.

In total, 114 of participants (57%) completed monthly follow-up assessments for 6 months post-discharge. Investigators obtained data on suicide attempts and readmissions through blind interviews and medical record review, respectively. Patients self-reported data on suicidal ideation.

Investigators found brief CBT among inpatients reduced the likelihood of suicide attempts over a 6-month discharge by 60% (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.20 – 0.80) and the rate of psychiatric readmissions by 71% (OR, 0.29; 95% CI, 0.09 – 0.90). The reduction of psychiatric readmissions on brief CBT was only seen in participants without a substance use disorder (SUD).

The effect of CBT on suicidal ideation was unclear. However, post hoc analyses showed less severe suicidal ideation after a brief CBT at 1 – 2 months post-discharge compared with those who only received the usual treatment.

Investigators noted the difficulties of implementing suicide prevention strategies in the inpatient setting.

“In addition to short lengths of stay, workflows can be chaotic, with frequent, often abrupt changes in schedules and discharge plans,” investigators wrote. “Burdensome workloads within the context of understaffing and high clinical acuity taxes personnel resources, and physical space is also often limited.”

The team added how it may not be possible to get a doctor with expertise in CBT and specialized training in brief CBT-inpatient to provide the brief CBT like it was done in this study, as it will be a substantial hospital investment. The current day-rate reimbursement structure of inpatient care does not allow for extra payments for these specialized services.

Investigators wrote how the findings were limited by patients having similar demographic and clinical profiles, all patients having prior suicide attempts, and many participants getting lost to follow-up. Other limitations impacting the findings included the fact the study was conducted during the COVID-19 pandemic and the unavailable death records making it impossible to determine the efficacy of brief CBT to prevent death by suicide.

“Given recent evidence that post-discharge suicide rates have not improved over the past 50 years, it is time for the field to shift to new treatment models for inpatient suicide prevention,” investigators wrote.

References

1. ^{Diefenbach GJ, Lord KA, Stubbing J, et al. Brief Cognitive Behavioral Therapy for Suicidal Inpatients: A Randomized Clinical Trial. JAMA Psychiatry. Published online September 11, 2024. doi:10.1001/jamapsychiatry.2024.2349}
2. ^{Chung DT, Ryan CJ, Hadzi-Pavlovic D, Singh SP, Stanton C, Large MM. Suicide Rates After Discharge From Psychiatric Facilities: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2017;74(7):694-702. doi:10.1001/jamapsychiatry.2017.1044}