with Kelly L. Green, PhD, and Dr. Sidney Zisook, MD

New treatments to help individuals struggling with suicidal ideation and behavior continue to emerge. Psychopharmacologic and behavioral approaches often work most effectively in combination. Here, two clinicians share their approach.

How Effective is Cognitive Therapy for Suicide Prevention?

Kelly L. Green, PhD, a senior research investigator at the University of Pennsylvania’s Penn Center for the Prevention of Suicide, addressed cognitive therapy as a treatment for suicide prevention during her Psych Congress 2020 talk.  Cognitive therapy for suicide prevention (CT-SP), she explained, is specifically developed for those who have recently attempted suicide or experienced acute suicidal ideation and is founded on the premise that suicide is a problematic coping behavior for overwhelming pain and hopelessness. Suicidal behavior is viewed as the primary problem and not the manifestation of another disorder.

CT-SP is one of several interventions that clinicians can use in patients exhibiting suicidal behavior. Prevention can also include pharmacologic treatment, marriage counseling, and treatment for substance abuse. As a technique, CT-SP is brief and focused, and generally includes 10 to 16 sessions.

In a study aimed at determining the effectiveness of a 10-session cognitive therapy intervention for adults who recently attempted suicide, Gregory Brown, PhD, and colleagues found that CT-SP reduced repeat suicide attempts by 50% after 18 months of follow-up.1

These results also applied to military personnel with suicidal ideation or a recent suicide attempt. At 2-year follow-up, soldiers receiving brief cognitive behavioral therapy (CBT) in addition to usual treatment were 60% less likely to make another suicide attempt than soldiers receiving just the usual treatment.2

Based on CBT, CT-SP is delivered in three phases. In the initial phase, the therapist assesses the patient’s risk for suicide; the intermediate phase consists of developing cognitive and behavioral coping strategies; and the final phase includes consolidation of skills and can be thought of as a dress rehearsal for handling future crises.

Treatment starts with narrative interviewing to encourage patients to tell their story in detail. The interview provides a basis for case conceptualization and builds a collaborative approach to addressing problems. “The goal is to listen how suicidal behavior makes sense for that person,” said Dr. Greene. “Seeing the steps that led to the suicide can lead to areas to intervene.”

Once those steps are identified, treatment involves focusing on the thoughts, beliefs, and behaviors most closely related to the suicidal crisis and selecting interventions perceived by both the clinician and the individual to be the most helpful in preventing a future suicidal act. Therapy also includes identifying and discussing reasons for dying and reasons for living, the latter of which may involve creating a Hope Kit of items that represent reasons for living, such as pictures, letters, poetry, and meaningful mementos.

During the intermediate phase, therapists apply cognitive therapy strategies to help patients acquire skills that reduce the likelihood of future suicidal behavior. These might include:

  • Activity monitoring and scheduling to increase meaningful or purpose-driven activities, strengthen or enhance reasons for living, and increase social connectedness
  • Cognitive restructuring to help individuals identify and evaluate thoughts specific to suicidal crises and increase cognitive flexibility
  • Evaluating pros and cons to help individuals resolve ambivalence and make important decisions
  • Problem-solving to help individuals brainstorm and evaluate potential solutions to solve problems without resorting to suicide
  • Coping cards to remind individuals of important conclusions from therapy that can be used in a crisis

Dr. Greene concluded her presentation with case management recommendations for professionals working with suicidal patients. She advised therapists to reach out to patients through reminder and check-in calls, providing emotional support, sending birthday/holiday cards and other caring points of contact, and offering referrals as indicated. She also advises that clinicians discuss cases in regular team meetings to receive support and consultation.

Pharmacologic Interventions for Suicide Prevention

In a separate but related Psych Congress 2020 session, Sidney Zisook, MD, a distinguished professor of psychiatry at the University of California, San Diego, posed the question: “Do antidepressants cause suicide?” His talk included a review of the events leading up to the FDA’s recent Boxed Warnings of suicidality in children and adolescents exposed to antidepressants.

Until 2003, there were no such warnings, but the question asked by Dr. Zisook created a great deal of public discussion. In response, FDA published a Public Health Advisory warning of suicidality in children and adolescents exposed to antidepressants, and by 2004, Boxed Warnings appeared on the package inserts for all antidepressants indicated for this patient population.

“It was not clear that data supported those warnings,” however said Dr. Zisook. “The data showed suicidal ideation, but no actual suicide.” In 2006, an FDA advisory board re-examined the data and extended the warnings for adults aged ≤25 years.

“Again, the warnings were based on suicidal ideation and suicide attempts, but not actual suicides,” he clarified. “Antidepressant treatment is effective at decreasing suicidality, but there were unintended consequences of the warnings that make the diagnosing of mood disorders less common and treatment less available. Because of the Black Box Warning, clinicians may be reluctant to diagnose depression and treat aggressively and may help cause increased rates of suicide.”

Before and after the warnings, numerous studies suggested a strong association between increased antidepressant use and decreased rates of suicide, according to Dr. Zisook. The research showed that antidepressants likely decrease the risk for suicide by reducing the intensity and recurrence of depressive episodes, and not through a direct anti-suicide effect. The pattern of suicide attempts – highest in the month before treatment, next highest in the month after treatment, and declining thereafter – was similar whether the patient was prescribed antidepressants or receiving psychotherapy.3

Treating major depressive disorder (MDD) is one of the most effective strategies clinicians can take to prevent suicide in their patients. Effective treatment of MDD reduces suicidal thoughts, plans, and intent, thereby having an indirect effect on preventing suicide. Antidepressants and other evidence-based treatments for MDD likely decrease a patient’s risk for suicide as well by reducing the intensity and recurrence of depressive episodes.

The bottom line: “Antidepressants have not been shown to increase actual deaths by suicide in any age group,” emphasized Dr. Zisook.

Pharmacotherapy, Suicidal Behavior, and the Patient with Schizophrenia

Dr. Zisook also presented results of studies of FDA-approved and non-approved, evidence-informed medications that support his recommendations for pharmacotherapy to decrease the risk of suicide in certain patient groups. Among patients with schizophrenia, for example, suicide is the leading cause of premature death.

He shared with Psych Congress the findings of a study comparing clozapine and olanzapine for their ability to reduce suicidal behaviors in 980 patients with schizophrenia or schizoaffective disorder.4 Fewer clozapine-treated patients had suicidal ideation, attempted suicide, or required hospitalization, antidepressant use, and rescue interventions to prevent suicide.

Similarly, in those with unipolar and bipolar mood disorders, lithium reduced the risk of suicide, possibly by decreasing aggression and impulsivity, and showed statistically significant less deliberate self-harm than patients treated with carbamazepine.5

In another study, the effects of a single dose of IV ketamine on suicidal ideation were studied in patients with MDD. Compared to placebo and midazolam, ketamine reduced suicidal thoughts within 1 day and for up to 1 week.6 However, Dr. Zisook noted that additional research on ketamine’s long-term safety and efficacy in reducing suicide risk is needed before clinical implementation.

Intranasal esketamine demonstrated efficacy in improving suicidal thoughts within 4 hours after the first dose. This medication (Spravato) was FDA approved in August 2020 for the indication of MDD treatment-resistant depression with acute suicidal ideation or behavior (more on esketamine in Psycom Pro’s weekly news roundup); however, its effectiveness to prevent suicide or reduce suicidal thoughts and behaviors has not been demonstrated.

Treating Associated Conditions

“It is important to recognize that MDD is a chronic and recurrent illness, and that suicide risk waxes and wanes in intensity over time,” advised Dr. Zisook. There are no hard core data on the effectiveness of treating depression to prevent suicide. Most studies are observational. After antidepressant treatment is initiated or the dose changed, it is important to monitor patients for changes in thoughts of suicide or suicidal behaviors.

Enhanced medical management of these patients might include:

  • developing a collaborative plan with the patient’s family
  • utilizing a team approach
  • performing ongoing assessment
  • monitoring and developing a safety plan that includes means restriction and firearms safety.

See also, other clinical treatment challenges in schizophrenia, such as medication adherence, metabolic effects, and comorbid mood disorders.


Last Updated: Oct 1, 2021