A single 3-hour-long group psychosocial intervention designed specifically for patients in intensive outpatient programs for addiction treatment to prevent future suicide resulted in significantly improved knowledge and attitudes regarding suicide that persisted at 6 months of follow-up in a large multicenter randomized effectiveness study, reported Richard K. Ries, MD.
There is an enormous unmet need for evidence-based strategies for preventing addiction-related suicide, since people with substance use disorders have a 10-fold increased risk of suicide. Based upon these new study findings, the Preventing Addiction Related Suicide (PARS) program can now be considered the first such evidence-based intervention for this extremely high-risk population, Dr. Ries said at the virtual annual meeting of the American Association of Suicidology.
“We’ve shown that suicide prevention in intensive outpatient program addiction groups is feasible, easy to train, and highly rated by counselors, and I’d say it’s very adaptable, easy to go national in almost any addiction treatment program, right out of the box,” said Dr. Ries, professor of psychiatry at the University of Washington, Seattle, and director of outpatient psychiatry as well as the psychiatry addiction division at Harborview Medical Center.
The workbook-based PARS program developed by Dr. Ries and colleagues adapted empirically supported suicide prevention best practices from other settings for use in group-based intensive outpatient addiction treatment, which is the most common form of treatment for chemical dependency in the United States. Dr. Ries recognized the need for a program such as PARS because addiction counselors often feel out of their depth regarding suicide-related issues.
he explained. “We designed the PARS intervention to be integrated right into the counselors’ workflow. They get trained right in their setting in a one-shot deal that takes 2-3 hours. The training was highly rated by counselors as acceptable and effective in their day-to-day work, not ivory tower-type stuff.”
Once the counselors were trained in PARS, they then trained their alcohol- and drug-addicted patients. Elements of the PARS program include information on suicide risk and protective factors, myths and facts about suicide, action steps to take when warning signs of suicide are observed, and local crisis resources.
The effectiveness study was a randomized, stepped-wedge cluster design intervention that included 905 patients in 15 busy community group–based intensive outpatient addiction treatment programs in Western Washington. Patients were randomized to counselor-delivered PARS or treatment as usual, with follow-up assessments at 2 weeks and 1, 3, and 6 months.
There was no attempt to enrich the study population for suicidality by prescreening potential enrollees, since participation in a drug and alcohol treatment program already places an individual in a high-risk group. For example, 74% of study participants indicated they had thought of suicide at least once in the past year, compared with a background rate of 4% in the U.S. general population. And 29% of study participants reported a lifetime history of one or more suicide attempts, versus roughly 5% in the general population.
Dr. Ries’ coinvestigator, Katherine Anne Comtois, PhD, MPH, presented the study results. The three key outcomes were improvement on structured measures of suicide knowledge, attitudes, and help-seeking behavior. The PARS recipients showed statistically significant improvement compared with baseline on two of the three: they displayed greater knowledge about suicide and its close relationship with addiction, and less stigmatization and other maladaptive attitudes toward suicide. Scores on all three measures remained unchanged over time in the control group.
“Overall, we had small to medium effect sizes, comparable to what you might see in studies measuring antidepressant effect sizes. I think these were meaningful improvements in knowledge and attitudes,” said Dr. Comtois of the University of Washington.
The PARS group showed a small increase in the third endpoint – willingness to seek professional help for themselves, friends, or family if depressed or suicidal, but this didn’t achieve statistical significance. However, Dr. Comtois noted that the study outcomes were assessed per protocol using an intent-to-treat analysis. This likely underestimated the true effectiveness of the PARS intervention, given that 40% of patients randomized to PARS didn’t actually attend the intervention session.
“People with drug and alcohol problems have complicated lives,” she said by way of explanation for the high no-show rate.
The investigators are now performing a per-protocol analysis of the data, restricted to those subjects who actually attended their session. A long-term look at suicide events and outcomes in the study population is planned.
Dr. Ries and Dr. Comtois reported having no financial conflicts regarding the study, which was funded by a multiyear grant from the National Institute on Drug Abuse.