پیشگیری شناختی رفتاری از خودکشی در روانپریشی: یک کارآزمایی بالینی

Background Suicide behaviour in psychosis is a significant clinical and social problem. There is a dearth of evidence for psychological interventions designed to reduce suicide risk in this population. Aims To evaluate a novel, manualised, cognitive behavioural treatment protocol (CBSPp) based upon an empirically validated theoretical model. Methods A randomly controlled trial with independent and masked allocated and assessment of CBSPp with TAU (n = 25, 24 sessions) compared to TAU alone (n = 24) using standardised assessments. Measures of suicide probability, and suicidal ideation were the primary outcomes and measures of hopelessness, depression, psychotic symptoms, functioning, and self-esteem were the secondary outcomes, assessed at 4 and 6 months follow-up. Results The CBSPp group improved differentially to the TAU group on two out of three primary outcome measures of suicidal ideation and suicide probability, and on secondary outcomes of hopelessness related to suicide probability, depression, some psychotic symptoms and self-esteem. Conclusions CBSPp is a feasible intervention which has the potential to reduce proxy measures of suicide in psychotic patients.

Suicide and suicide behaviour are of substantial public and social concern. It is well established that risk of suicide is considerably elevated in those suffering from schizophrenia and psychotic disorders (Caldwell and Gottesman, 1990, Cohen et al., 1994, Hawton et al., 2005 and Bolton et al., 2007). Suicide ideation and suicide attempts are common with up to 50% of patients experiencing suicidal ideation at any point in time or having a history of previous attempts (Hawton et al., 2005 and Palmer et al., 2005). It is assumed that there is a progressive continuum from ideation, intent, action and completion (Bolton et al., 2007). Thus, suicidal ideation is a risk factor for self-harm and completed suicide and a legitimate clinical target in its own right. A meta-analysis of cognitive–behavioural interventions (CBT) to reduce suicide behaviour (Tarrier et al., 2008) demonstrated that individual, but not group, CBT, was effective in significantly reducing suicide behaviour in adults, although not adolescents, in the short and medium term. This result held despite considerable variability both in the target populations and in the CBT interventions. There is, however, a paucity of studies which have attempted to diminish suicide behaviour in psychosis, despite the well established high risk in this group. Cognitive behaviour therapy for psychosis (CBTp) reduces positive and negative symptoms of psychosis, depression, and anxiety but has less effect on hopelessness (Wykes et al., 2008) and suicidality (Tarrier et al., 2006). Psychological interventions are most likely to be successful when they are clearly derived from a theoretical understanding of underlying mechanisms (Bolton et al., 2007 and Johnson et al., 2008a). Advances in understanding the cognitive architecture underpinning suicidality have resulted in the development of empirically validated theoretical models, such as, the Schematic Appraisal Model of Suicide (SAMS) (Johnson et al., 2008a and Johnson et al., 2008b) which was modified from the Cry of Pain model (Williams, 1997). The SAMS has three core psychological components, namely, the presence of negative information processing biases, extensive ‘suicide schema’, and a negative and suicide focused appraisals system (Johnson et al., 2008a). To date, empirical evidence supports a multi-tiered appraisals system together with the operation of suicide schema in people experiencing suicidality, psychosis, and post traumatic stress disorder (Pratt et al., 2010, Taylor et al., 2010b, Taylor et al., 2010c and Panagioti et al., 2012c). The Cognitive Behavioural Prevention of Suicide in psychosis protocol (CBSPp) (Tarrier et al., 2008 and Tarrier et al., 2013) was founded on the SAMS. Thus, the specific cognitions targeted by CBSPp are information processing biases, and appraisals of defeat, entrapment, emotional dys-regulation, social isolation, and poor interpersonal problem solving (Tarrier et al., 2013). Although CBSPp arose from work with psychosis and post-traumatic stress disorder, it has the potential to be applied trans-diagnostically (Tarrier et al., 2013). The aim of this study was to evaluate the CBSPp protocol. As far as we are aware this is the first evaluation of a suicide prevention intervention that has been intentionally derived from an empirically validated theoretical model of suicide (Johnson et al., 2010a, Johnson et al., 2010b, Pratt et al., 2010, Taylor et al., 2010b, Taylor et al., 2010c, Johnson et al., 2011, Taylor et al., 2011, Panagioti et al., 2012a, Panagioti et al., 2012b and Panagioti et al., 2012c). Specifically, it was hypothesised that CBSPp in addition to Treatment As Usual (TAU) would have significant advantages over TAU alone in reducing 1) measures reflecting suicidal behaviour including hopelessness, and, 2) measures associated with other symptom clusters of psychosis including depression, thought disorder, and low self-esteem.