The Influence of Treatment Latency on Suicide-Specific Treatment Outcomes

Introduction The Attempted Suicude Short Intervention Program (ASSIP) provides an effective and cost-effective treatment option for people who have attempted suicide. Studies suggest that longer treatment latency is associated with poorer response to therapy, more severe symptomatology, and more suicide attempts This study examined the influence of treatment latency (time between suicide attempt and initiation of therapy) on the number of suicide attempts over the long-term course of ASSIP and the influence of treatment relationship on the extent of suicidal ideation. Method Survival and regression analyses were performed on 60 participants who had recently attempted suicide and received ASSIP at an outpatient psychiatric clinic. 60% were women and 40% were men. Results The results found no significant association between treatment outcome in ASSIP and treatment latency (HR = 1.06; 95% CI: 0.92- 1.21, p = .44). Treatment relationship significantly influenced suicidal ideation at time t4 (B = − .35, t(55) = −3.21, p = .002), but treatment latency was not significantly associated with suicidal ideation (B = .02, t(55) = 0.87, p = .39). Conclusion No relationship between treatment latency and treatment outcome could be found, suggesting that ASSIP can be implemented at any time after the last suicide attempt. In contrast, the treatment relationship plays a central role in ASSIP

Longitudinal Development of Reasons for Living and Dying With Suicide Attempters: A 2-Year Follow-Up Study

Background: Clinical interventions for patients after a suicide attempt might include a focus on Reasons for Living (RFL) and/or Reasons for Dying (RFD). The present study examined the longitudinal development of RFL and RFD in patients with and without a suicide-specific intervention - the Attempted Suicide Short Intervention Program (ASSIP). Methods: In this secondary analysis of a 2-year follow-up randomized controlled study, participants completed the Suicide Status Form II to assess RFL and RFD, at baseline, as well as at 6-, 12-, 18-, and 24-months follow-up. Growth models and latent class analysis were used to investigate longitudinal developments in RFL and RFD. Regression models were used to test the association between RFL, RFD and suicidal reattempts and ideation. Results: Cross-sectionally and longitudinally, RFD, but not RFL, were associated with suicide reattempts and suicidal ideation. The number of RFD decreased significantly across the 24 month period (from 1.90 at t1 to 1.04 at t5 in the control group and from 2.32 at t1 to 0.51 at t5 in the intervention group), and this decrease was stronger (b = −0.02; p = 0.004) in the ASSIP group than in the control group. There was no overall change in RFL. Three latent trajectories of RFD were identified: a decreasing (n = 77), a steady high (n = 17) and a trajectory with first increasing and then decreasing RFD (n = 26). The proportion of patients in the ASSIP intervention was highest in the decreasing trajectory and lowest in the steady high trajectory. Patients in the steady high trajectory were characterized by worse mental health and fewer social obligations (partner, children) at baseline. Conclusion: The results confirm the importance of RFD within the suicidal process and show that the number of RFD can be further reduced over the period of 24 months with short interventions such as ASSIP. The relevance of number of RFL in the suicidal process, as protective factor, was not confirmed. In the subgroup of patients whose RFD did not decrease over a long period of time, there is a particularly high risk of suicidal ideation/behavior. Clinical interventions should focus more closely on RFD, their etiology and maintenance

Cost-effectiveness of a brief structured intervention program aimed at preventing repeat suicide attempts among those who previously attempted suicide: a secondary analysis of the ASSIP randomized clinical trial

IMPORTANCE: This is the first cost-effectiveness analysis of a brief therapy, the Attempted Suicide Short Intervention Program (ASSIP), for individuals who attempt suicide. OBJECTIVE: To explore the cost-effectiveness of the ASSIP intervention in the context of the Swiss health care system. DESIGN, SETTING, AND PARTICIPANTS: In this economic evaluation, the cost-effectiveness analysis was performed from a health care perspective between January 2017 and April 2018 using data from a randomized clinical trial conducted between June 2009 and December 2014. Participants were individuals who had attempted suicide and were receiving treatment at a psychiatric university hospital in Switzerland that provides inpatient and outpatient services for suicide attempters referred from an emergency department of a general hospital. INTERVENTIONS: The intervention group received 3 manual-based therapy sessions followed by regular personalized letters over 24 months. The control group was offered a single suicide risk assessment. MAIN OUTCOMES AND MEASURES: The main economic analysis explored cost per suicide attempt avoided expressed in 2015 Swiss francs (CHF). Cost-effectiveness planes were plotted and cost-effectiveness acceptability curves calculated. RESULTS: One hundred twenty participants (mean [SD] age, 37.8 [14.4] years; 66 [55%] women and 54 [45%] men) were assigned to an intervention group or a control group, each with 60 participants. At 24 months of follow-up, 5 suicide attempts were reported in the ASSIP group among 59 participants with follow-up data available, and 41 were reported in the control group among 53 participants with follow-up data available. The ASSIP group had higher intervention costs, with CHF 1323 vs CHF 441 for the control group. At 24 months of follow-up, psychiatric hospital costs were lower in the ASSIP group than in the control group, although this difference was not significant (mean [SD], CHF 20 559 [38 676] vs CHF 45 488 [73 306]; mean difference, CHF -16 081; 95% CI, CHF -34 717 to 1536; P = .11). General hospital costs were significantly lower for the ASSIP group. Total health care costs were also lower, but the difference was not significant (mean [SD], CHF 21 302 [38 819] vs 41 287 [74 310]; difference, CHF -12 604; 95% CI, CHF -29 837 to 625; P = .14). In a base-case analysis, ASSIP was dominant, with significantly fewer reattempts at lower overall cost. The intervention had a 96% chance of being less costly and more effective. A sensitivity analysis showed a 96% and 95% chance of ASSIP being more effective and less costly at willingness-to-pay levels of CHF 0 and CHF 30 000, respectively. CONCLUSIONS AND RELEVANCE: The ASSIP intervention is a cost-saving treatment for individuals who attempt suicide. The findings support the use of ASSIP as a treatment for suicide attempters. Further studies are needed to determine cost-effectiveness in other contexts. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02505373

Reasons for Living and Dying in Suicide Attempters: A Two-year Prospective Study

Background: The aim of this study was to explore Reasons for Living (RFL) and Reasons for Dying (RFD) of suicide attempters and their association with current and future suicidal ideation and behavior. Method: The sample consisted of 60 patients who were admitted at a psychiatric emergency unit in Switzerland following an attempted suicide. They received treatment as usual, participated in an assessment interview and completed self-report questionnaires including written RFL and RFD responses, depressive symptoms, and suicide ideation at baseline and 6, 12 and 24 months follow-ups. Outcome measures were suicide ideation and repeated suicide attempts. Multiple imputations were used in order to address missing data. Results: The number of RFD responses was the strongest predictor for increased suicide ideation at baseline. The number of RFL responses was not associated with suicide ideation and reattempts. RFD, depressive symptoms, and baseline suicide ideation predicted subsequent suicide reattempt up to 12 months later in simple regression analyses. Mediation analyses suggested that RFD mediated the effect of depressive symptoms at baseline on suicide ideation at 12-months follow-up. Conclusion: RFL were unrelated to the mental health of study participants and did not function as protective factor against suicide risk. RFD may be an important motivational driver in the suicidal process. Clinical interventions should focus more on the reduction of RFD than on RFL in suicidal individuals

ASSIP : nouvelle modalité thérapeutique après un geste suicidaire [ASSIP: A new therapy following suicide attempt]

Although patients attempting suicide represent a highly vulnerable population, are often reluctant to care and at high risk of repetition, no specific therapy exist for them in French-speaking Switzerland. ASSIP <sup>®</sup> (Attempted Suicide Short Intervention Program) fills in this gap. It is a short therapy developed in Bern and being currently implemented in French-speaking Switzerland with the support of the Foundation « Promotion santé suisse » (Swiss health care promotion). ASSIP <sup>®</sup> intervention is patient-centered and based on a narrative and behavioral approach and reduces suicide reattempts. It aims to jointly understand patient's suicidal process and to help him/her developing personal strategies to prevent repetition and manage future suicidal crisis

The Role of Self-Organization in the Suicidal Process

This article describes the application of a dual-regulation model to a case example of a female suicide attempter. The model complements the traditional goal-and-feedback view with self-organizing processes, which may help to better understand the suicidal process. From this view, impulsive suicidal behavior can be interpreted as a dysfunctional pattern by which high-internal tension is reduced through self-organized processes. High tension might result from intrapersonal factors and adverse life conditions, by which self-regulation is depleted. Also concepts from social psychology (i.e., ego depletion, self-regulation failure) are consistent with this view and are discussed in context of a suicidal crisis. Identifying dysfunctional self-organization processes and acquiring strategies to strengthen self-regulation might, therefore, be important for suicide prevention