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

Posttraumatische Belastungsstörung infolge eines Suizidversuchs

Zusammenfassung:Hintergrund: Erste Studien legen nahe, dass ein selbstdurchgeführter Suizidversuch überraschend häufig eine PTBS-Symptomatik verursachen könnte. Die berichteten Prävalenzangaben der Studien variieren jedoch erheblich. Methode: In der vorliegenden Online-Studie wurden N = 50 Suizidversuchsüberlebenden zu suizidversuchsbezogenen PTBS-Symptomen und gegenwärtigen Suizidgedanken befragt. Zur Falldefinition diente eine modifizierte Version der Posttraumatischen Checkliste für DSM-5 (PCL-5) entweder auf Basis eines Cut-off Wertes oder auf Syndrom-Basis. Ergebnisse: In Abhängigkeit von der Falldefinition wurden 52 % (n = 26) bzw. 42 % (n = 21) der Teilnehmenden als Personen identifiziert, welche potenziell die Diagnosekriterien einer PTBS infolge eines eigenen Suizidversuchs erfüllten. Teilnehmende mit suizidversuchsbezogener PTBS-Symptomatik berichteten teilweise über mehr gegenwärtige Suizidgedanken. Schlussfolgerung: Die Ergebnisse legen nahe, dass Personen nach einem selbstdurchgeführten Suizidversuch eine PTBS-Symptomatik entwickeln. Aufgrund der Relevanz dieser Ergebnisse für eine wirksame Behandlung von Suizidversuchsüberlebenden sind weitere Studien an größeren deutschen Stichproben und unter Nutzung klinischer Interviews zu empfehlen

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

Attempted Sucide Short Intervention Program

Suizidgedanken und suizidales Verhalten sind häufig auftretende Phänomene in der Bevölkerung. Die Arbeit mit dem suizidalen Patienten fällt jedoch vielen Klinikern schwer. Das vorliegende Manual stellt die Kurztherapie ASSIP (Attempted Suicide Short Intervention Program) vor, welche das Risiko für suizidale Handlungen nachweislich um annähernd 80% senkt und dabei kosteneffektiv die Anzahl stationärer Behandlungstage verringert. In den letzten Jahren hat ASSIP an internationaler Bedeutung gewonnen. Die Kurztherapie wurde in verschiedenen Gesundheitssystemen erfolgreich implementiert und erforscht. In dieser überarbeiteten Auflage werden zunächst die grundlegenden theoretischen Konzepte der Kurztherapie ASSIP vorgestellt. Danach kommen die einzelnen Elemente der patientenorientierten Behandlung, ergänzt durch aktuelle wissenschaftliche Ergebnisse und zusätzlichen Techniken, zur Sprache. Besonderes Augenmerk legt diese zweite Ausgabe auf internationale Entwicklungen und Perspektiven

Workshop: Half-day preconference Symposium. Brief therapy for patients with suicidal behavior

Suicide may appear as an option to escape from a subjectively unbearable life situation and may repeatedly emerge throughout life as a possible coping strategy when major life or identity goals are seriously threatened. Treatment of this high-risk group is challenging. The Attempted Suicide Short Intervention Program (ASSIP) is a three to four session brief therapy with an ongoing contact by semi-standardized letters, and has been found to be efficacious in reducing suicidal behavior. The brief intervention ASSIP emphasizes an early collaborative therapeutic alliance with the suicidal patient with the aim to reach a shared understanding of the suicidal crisis in a life-career (biographical) context. Meaningful preventive measures can then be developed. ASSIP is offered to suicide attempters in addition to treatment as usual and does not replace a long-term treatment. This workshop will introduce the main theoretical concepts and the practice of the brief therapy ASSIP. Workshop participants will be walked through the five ASSIP elements sessions step-by step. Video examples, role-play, and case discussions will be provided

Symposium: Psychotherapie nach dem Suizidversuch: neue Möglichkeiten der Intervention. Die Kurztherapie ASSIP zur Behandlung von Menschen mit suizidalem Verhalten

Das Attempted Suicide Short Intervention Program (ASSIP) ist eine Kurztherapie, die nachweislich das Risiko wiederholter Suizidversuche über einen Zeitraum von 24 Monaten um etwa 80 % reduziert (Wald χ21 = 13,1, 95 % CI 12,4–13,7, p < 0,001). ASSIP geht von der Annahme aus, dass suizidales Verhalten eine Handlung ist. Demnach kann Suizid als eine Option erscheinen, wenn wichtige Lebensziele oder Bedürfnisse bedroht sind. Ein Hauptziel von ASSIP ist der Aufbau einer frühen therapeutischen Beziehung, die durch Folgebriefe im Laufe von zwei Jahren aufrechterhalten wird. Innerhalb von drei bis vier Sitzungen zielt ASSIP darauf ab, ein gemeinsames Verständnis der individuellen Mechanismen, die zu suizidalem Verhalten führen, in einem biografischen Kontext zu erreichen, um spezifische Vulnerabilitäten und auslösende Ereignisse zu identifizieren. Wichtige individuelle Warnzeichen werden aufgedeckt, und es wird ein persönlicher Krisenplan entwickelt, um das Risiko eines zukünftigen Suizids zu verringern. Die erste Sitzung besteht aus einem narrativen Interview, das die Grundlage für eine therapeutische Allianz und ein Behandlungsengagement bildet (erste Sitzung, Median = 4,91, IQR = 4,3–5,2; dritte Sitzung, Median = 5,32, IQR = 4,9–5,6, W = 257,5, p < 0,001, Paartest). Das Video-Playback gibt den Patienten die Möglichkeit eines kontrollierten „Wiedereintauchens“ in den suizidalen Modus, ohne sich zu verlieren. Neuere Befunde weisen darauf hin, dass sowohl die Reduktion dysfunktionaler Bewältigung als auch die Entwicklung problemorientierter Bewältigungsstrategien für die Überwindung suizidaler Krisen wesentlich sind. Die ASSIP-Gruppe zeigte im Vergleich zur Kontrollgruppe 11 % weniger dysfunktionales Coping (ASSIP, Median = 1,83; CG, Median = 2,05, W = 1316, p = 0,011, r = 0,21) und 6 % mehr problemorientiertes Coping (ASSIP, Median = 2,83; CG, Median = 2,67, W = 2217, p = 0,029, r = 0,17) nach einem 24-monatigen Follow-up. In diesem Vortrag sollen die verschiedenen Elemente von ASSIP kurz skizziert und die entsprechenden Forschungsergebnisse beschrieben werden

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

Introduction: Clinical interventions for patients after a suicide attempt may focus on Reasons for Living (RFL) and/or Reasons for Dying (RFD). Aim: We examined the clinical implications of working with RFL and RFD of patients attending the Attempted Suicide Short Intervention Program (ASSIP), in comparison to a control group. Methods: In this secondary analysis of a 2-year randomized controlled study, the longitudinal development of RFL und RFD was examined. Participants (55% female; mean age of 36) with a history of suicide attempts therefore completed the Suicide Status Form II at baseline, 6-, 12-, 18-, and 24-months follow-up. Results: Differences in the longitudinal development of RFL and RFD were confirmed. The number of RFL did not change over time or between groups. In contrast, RFD decreased significantly over the 24-month period with a greater decrease in the ASSIP group (t1: 2.32 to t5: 0.51) compared to the control group (t1: 1.90 to t5: 1.04) (b=-0.02; p=.004). Furthermore, we identified three subgroups in the longitudinal development of RFD: a decreasing (n=77), a steady high (n=17) and a trajectory group with first increasing and then decreasing RFD (n=26). The proportion of ASSP patients was highest in the descending and lowest in the constant high group. Associations between RFD and suicidal ideation were found longitudinally (t1: p = .031 to t5: p < .000; beta between .193 and .539) and for suicidal behavior (t1: p = .051; OR = 1.25 to t5: p = .001, OR = 1.40). No associations were found for RFL. Patients in the steady high group were characterized by higher levels of suicidal ideation and more suicide reattempts throughout the 24-month period. Conclusion: The relevance of RFL as a protective factor was not confirmed. The results confirm the importance of RFD in the suicide process and show that patients whose RFD did not decrease over a long period of time are at particularly high risk for suicidal ideation and behavior. The number of RFD can be reduced over a 24-month period by brief interventions such as ASSIP. Clinical interventions should focus more on RFD, its aetiology, and maintenance