PORTLAND, ORE. – Collaborative Assessment and Management of Suicidality significantly helped depressed, hopeless, and suicidal psychiatric inpatients in a small case series at the Menninger Clinic in Houston.
It was an open study with no control group, but also the first study to show the technique – which previously has been proven to help military, college, and other outpatients – helps hospitalized people, too.
Sixteen women and five men aged 18-55 years reported significant drops in suicidality after an average of about 11 sessions of CAMS, as the technique is known, over 6 weeks.
At the heart of CAMS is a strong, trusting bond – or collaboration – between patients and therapists. CAMS also tackles suicidality as a problem in itself, not merely as a symptom of a disorder, said lead investigator Thomas E. Ellis, Psy.D. "So often when you view suicidality as a symptom and you treat the disorder, you anticipate that as the person feels better, the suicide problem is eliminated. Research is not consistent with that model. We view suicidal ideation and behavior as a target," said Dr. Ellis, director of psychology at the Menninger Clinic. "We address the disorder, but at the same time, we don’t assume suicidality will be eliminated just because the disorder’s been treated."
At the outset, CAMS patients are assured that they will not be judged, and the therapist empathizes with their suicidal wish. The basic assumption is that the patient "is doing the best they can under the circumstances, and that the suicidality is there simply for lack of better coping behavior," Dr. Ellis said.
The therapeutic bond leads to accurate risk assessment plus identification and treatment of suicide drivers, such as emotional pain, stress, agitation, hopelessness, and self-hate. Patients were asked to rate their levels of those things – plus suicidal intent – throughout the study.
All were admitted with significant suicidal ideation and past attempts. Mood disorders were the primary diagnoses, often comorbid with anxiety disorders, substance abuse, and personality disorders. Patients often had been to an acute care facility first. It took a week or two to enroll them in the study once they got to Menninger, "so they had some time to stabilize a bit," said Dr. Ellis, also professor of psychiatry in the Menninger department of psychiatry and behavioral sciences at the Baylor College of Medicine.
At the outset, the patients’ mean Beck Depression Inventory-II score was 38.8, indicating severe depression. At the end of the study, it was 11.9, indicating minimal depression. Beck Hopelessness Scale scores dropped from a mean of 9.4 to 5.8, an improvement from moderate to mild hopelessness. Beck Scale for Suicide Ideation scores dropped from a mean of 10.8 to 3.9. The findings were statistically significant, with robust effects sizes of at least 0.68.
Patients also reported steady improvements in various suicide drivers, with effect sizes greater than 1. The average length of hospitalization in the trial was 52 days.
During treatment, patients were taught problem solving skills, distraction techniques, emotion regulation skills, self-compassion, or whatever else was appropriate. Future trigger events also were anticipated and addressed.
Perfectionism "is often a major issue" with self-hate. Also, "many times we review relationships in the past where a person may have been emotionally or verbally abused, and they picked up those attitudes and continue to beat up on themselves," Dr. Ellis said.
It’s up to the therapist to determine which approach to take with such issues, be it cognitive-behavioral therapy, psychodynamic therapy, or some other method. The process might or might not include pharmacotherapy and group therapy.
CAMS does not advocate any one way. "It’s not specific to a single theoretical orientation. We think of it as a platform a little bit like how Windows runs a variety of different [computer] programs," Dr. Ellis said.
The next step is to analyze the data to figure out whether patients got better because their particular drivers were addressed, or because of the bond they developed with their therapists.
But Dr. Ellis does not expect a randomized trial. "We would have a difficult time randomizing [patients] to the non-CAMS condition, because the hospital is a small world and the word gets around we have this exciting new thing," he said.
Dr. Ellis reported no disclosures.