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Ellis Et Al., 2015 Suicide and Life-Threatening Behavior 1 © 2015 The American Association of Suicidology DOI: 10.1111/sltb.12151 Impact of a Suicide-Specific Intervention within Inpatient Psychiatric Care: The Collaborative Assessment and Management of Suicidality THOMAS E. ELLIS,PSYD, KATRINA A. RUFINO,PHD, JON G. ALLEN,PHD, JAMES C. FOWLER,PHD, AND DAVID A. JOBES,PHD A growing body of literature indicates that suicidal patients differ from other psychiatric patients with respect to specific psychological vulnerabilities and that suicide-specific interventions may offer benefits beyond conventional care. This naturalistic controlled-comparison trial (n = 52) examined outcomes of intensive psychiatric hospital treatment (mean length of stay 58.8 days), com- paring suicidal patients who received individual therapy from clinicians utilizing the Collaborative Assessment and Management of Suicidality (CAMS) to patients whose individual therapists did not utilize CAMS. Propensity score matching was used to control for potential confounds, including age, sex, treatment unit, and severity of depression and suicidality. Results showed that both groups improved significantly over the course of hospitalization; however, the group receiving CAMS showed significantly greater improvement on measures specific to suicidal ideation and suicidal cognition. Results are discussed in terms of the potential advantages of treating suicide risk with a suicide-specific intervention to make inpatient psychiatric treatment more effective in reducing risk for future suicidal crises. Although various authors have rightly 2012). These studies have demonstrated the commented on the paucity of evidence for effectiveness in reducing suicidality with therapeutic interventions for suicidal dialectical behavior therapy (DBT; Linehan patients (Leenaars, 2011; Linehan, 2000), et al., 2006), cognitive therapy (CT; Brown the evidence base has shown accelerating et al., 2005), and mentalization-based ther- growth in recent years (Ellis & Goldston, apy (MBT; Bateman & Fonagy, 2008, 2009), among others. THOMAS E. ELLIS,KATRINA A. RUFINO, The Collaborative Assessment and JON G. ALLEN, and JAMES C. FOWLER, The Management of Suicidality (CAMS), in Menninger Clinic and Baylor College of Medi- development over the past two decades (e.g., cine, Houston, TX, USA; DAVID A. JOBES, The Jobes, 2006, 2012), is not considered a brand Catholic University of America, Washington, DC, USA. of psychotherapy, but rather is a collabora- The authors thank the Brown Foundation tive framework for working with suicidal and the Bernice Peltier Huber Charitable Trust patients, independent of therapeutic orienta- for their generous support of this research. tion. Research evidence thus far suggests Address correspondence to Thomas E. Ellis, The Menninger Clinic, 12301 Main St., promise. For example, in one nonrandom- Houston, TX 77035; E-mail: tellis@menninger. ized control comparison study, CAMS was edu associated with rapid reductions in suicidal 2SUICIDE-SPECIFIC INPATIENT TREATMENT ideation in comparison with usual treatment those already obtained from intensive, (Jobes et al., 2005). Moreover, compared to psychotherapeutic, milieu-based inpatient usual care, CAMS was also significantly treatment. This multimodal inpatient treat- linked to decreases in primary care and emer- ment has been shown to be highly effective gency department utilization room settings in reducing depression severity over a in the 6-month follow-up. Additional sup- hospital course of 4 to 6 weeks (Clapp port for the impact of CAMS was demon- et al., 2013). In the current investigation, strated in a recent randomized clinical trial because randomization of patients to condi- (Comtois et al., 2011) which showed that tions is not possible due to the nature of patients who received a fairly brief course of the treatment setting, we used propensity outpatient CAMS care had significant reduc- score matching (Austin, 2011; Rosenbaum tions in suicidal thinking and overall & Rubin, 1983) to create a comparable symptom distress, with increased hope and control sample of patients matched on vari- reasons for living at 12-month follow-up in ables related to suicide risk and treatment comparison with enhanced care as usual response. This methodology enabled us to patients. In addition, CAMS patients were approximate many of the virtues of a ran- significantly more satisfied with their care in domized control trial design by statistically comparison with usual care and showed managing a range of possible “third vari- better overall retention to treatment. ables” that could cloud understanding of In a related development, our team the causal impact of the treatment condi- has modified CAMS for a unique form of tions (i.e., the differential impact of CAMS- inpatient suicide-specific care (see Ellis, informed care in comparison with existing Allen, Woodson, Frueh, & Jobes, 2009; care). Ellis, Daza et al., 2012; and Ellis, Green et al., 2012 for descriptions of the modifica- tions, implementation, and protocol). In an METHOD open pilot trial with 20 patients (Ellis, Daza et al., 2012; Ellis, Green et al., 2012), we Setting demonstrated safety and feasibility of this approach within an inpatient environment, The Menninger Clinic is a private, acceptability by patients and staff, and sig- not-for-profit, 120-bed psychiatric hospital nificant symptom improvement among par- in Houston, Texas. Patients typically mani- ticipants. Treatment effect sizes were large: fest multiple comorbid conditions, promi- 2.28, 0.92, and 1.38 for depression, hope- nently mood disorders, anxiety disorders, lessness, and suicidal ideation, respectively. substance-related disorders, and personality Because the lack of a comparison disorders. Most patients are referred follow- group precluded attributing causation to ing unsatisfactory response to prior medical CAMS, the current study was designed to and/or psychological treatments. Approxi- replicate and extend the pilot findings, con- mately 60% of patients are from outside of sistent with Rounsaville’s stage model of Texas. Typical lengths of stay in the hospi- treatment research development (Rounsaville, tal range from 4 to 8 weeks. The treatment Carroll, & Onken, 2001). In this model, program includes general medical care, treatment research progresses from feasibil- pharmacotherapy, physical activities (as ity testing (open trial), to “tinkered” pilot tolerated by the individual), twice weekly testing, to larger randomized efficacy trials. individual and twice weekly group psycho- In the current study, we sought specifically therapy, daily psychoeducational groups, to address the question of whether the use family work, and leisure-time social/recreational of CAMS with suicidal psychiatric activities. These interventions are employed inpatients would meaningfully supplement in the context of a therapeutic milieu that the therapeutic benefits above and beyond includes continuous nursing care as well as ELLIS ET AL. 3 patient government and ample opportunity Kroenke et al., 2004; Lowe,€ Unutzer€ et al., for spontaneous interactions among patients. 2004; Lowe,€ Gr€afe et al., 2004). Data for this study were aggregated for three The Beck Scale for Suicide Ideation adult treatment programs, including one for (BSS; Beck & Steer, 1991) is a self-report young adults (Compass), one for profession- instrument consisting of 21 sets of state- als in crisis (PIC), and one for adults with rel- ments containing content such as wish to atively chronic disorders (HOPE). live, wish to die, frequency of ideation, perceived capability to carry out an attempt, Participants and extent of actual preparation. Statements within each item are graded according to This study included 52 participants severity and scored from 0 to 2. Possible ranging from 18 to 68 years of age (M = scores range from 0 to 38 (a sum of the 19 32.87, SD = 13.57). Most participants items included in the total). The BSS is (69.2%) were female, and a large majority widely used in suicide research and has (92.3%) were Caucasian. The greatest num- demonstrated predictive validity for suicide ber of participants reported completing a attempts and deaths by suicide (Brown, Jeg- Bachelor’s degree (38.5%) followed by lic, Henriques, & Beck, 2006). some college (30.8%) and a professional The Beck Hopelessness Scale (BHS; degree (13.5%). The average length of stay Beck & Steer, 1993) is a 20-item self-report for the present sample was 58.8 days. All instrument intended to measure negative individuals in the current study reported future thinking. Items are rated as true or some form of suicidality (ideation or false, with approximately half of the items attempts) within weeks of admission. reverse coded. Hopelessness as measured by The number of reported lifetime suicide the BHS has been shown to be a key medi- attempts ranged from zero to seven (M = ator between depression and suicidal idea- 1.81, SD = 1.71). Fourteen participants tion and has proven predictive validity for (26.9%) reported no lifetime attempts, 12 deaths by suicide (Brown et al., 2006). (23.1%) reported one attempt, and 26 The Suicide Cognitions Scale (SCS; (50.0%) reported multiple attempts. Bryan et al., 2014) is a self-report instru- ment consisting of 18 items that are rated Measures on a 5-point scale according to strength of belief. The items were constructed to be The Columbia-Suicide Severity Rating consistent with the suicidal schemas of Scale (C-SSRS; Posner et al., 2011) is a unbearability (e.g., “I can’t stand this
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