Can Follow-Up Interventions Improve Outcomes for Those Hospitalized for Suicidal Ideation and Behavior?

BACKGROUND

The six months following discharge from a psychiatric inpatient stay are a time of increased risk for suicidal ideation and behavior. However, health care systems often don’t offer any follow-up contact or interventions aimed at reducing suicide risk during this critical period.

It is not clear which interventions work best to reduce suicidal ideation and behavior. Cognitive-focused treatments emphasize improving the symptoms of depression by improving cognitive functions, such as memory. Alternatively, some of the least examined treatments are based on positive psychology, which focus on feelings of gratitude, optimism, and charitable acts.

Dr. Jeffrey Huffman of Massachusetts General Hospital compared the effects of a positive psychological intervention with that of a cognitive-focused comparison intervention. This was the first randomized controlled trial of the effect of positive psychology compared with an alternative intervention on individuals with major depressive disorder at risk for suicide.

QUESTION

During the high-risk period after hospitalization, will a follow-up intervention based on positive psychology work better than a cognitive-focused intervention to address suicide risk?

STUDY

Sixty-five individuals receiving inpatient treatment for Major Depressive Disorder (MDD) and suicidal ideation or a recent suicide attempt participated in the study. Once recruited, the participants were randomly assigned to one of two treatment groups: the positive psychological intervention group or the cognitive-focused comparison intervention group, each to be administered in addition to any other usual treatments. The purpose of these interventions was to reduce suicide risk, as well as symptoms associated with MDD such as hopelessness and suicidal ideation and behavior. Through this research, Dr. Huffman also sought to determine if these interventions could feasibly be delivered by phone to this population.

The positive psychological intervention was focused on promoting optimism, gratitude, altruism, and personal strengths. Each week for six weeks, the participants would complete an exercise associated with one of these constructs. For example, a participant could be asked to write a letter of gratitude after recalling three positive life events from the past week. The first exercise was assigned and completed during the participant’s hospital stay. It was then reviewed the next day by a member of the research team who then assigned the second exercise, which was to be completed at home. For exercises three through six, the person administering the treatment would conduct a telephone follow-up with the participant to review the week’s exercise, identify thoughts and feelings associated with the completion of the exercise (especially positive ones), and discuss ways in which the participant could use this information in daily life.

In contrast, the cognitive-focused comparison intervention focused on recalling memories in a neutral way to promote memory recall, organization, and concentration. For the first exercise, each participant was instructed to list three events from their week which were neither positive nor negative. Follow-up over the next five weeks was completed in the same fashion as the positive psychological intervention with a member of the research team conducting a telephone interview to review each exercise, though the exercises to be completed were different. In addition, each week’s exercise differed in respect to the type of events to be recalled. For example, week one was focused on daily events, while week two was focused on medical events.

Study interventionists conducted two follow-up assessments to evaluate intervention effectiveness at six and 12 weeks after the interventions.

RESULTS

Of the original 65 participants, 58 completed all six study exercises. Of those 58 participants, 52 participants completed the 12-week follow-up.

While both groups had a reduction in depressive symptoms and suicidal ideation, the cognitive focused intervention led to greater reductions. At six weeks, the cognitive focused intervention was also more effective than the positive psychology intervention at reducing hopelessness, though this difference was not significant at 12 weeks. The cognitive focused intervention was also associated with greater increases in optimism and gratitude. However, neither intervention was found to promote greater improvements in positive affect at either six weeks or 12 weeks.

Three participants from each group were hospitalized by the 12-week follow-up. Additionally, four participants from the positive psychology intervention group and two from the cognitive focused intervention group had engaged in non-suicidal self-injury. One participant from the positive psychology intervention group reported a suicide attempt at the 12-week follow-up.

TAKEAWAY

-Although both positive psychology interventions and cognitive-focused interventions reduced suicidal ideation and symptoms of depression, it was found that cognitive-focused interventions may be more effective

-Post-discharge interventions can feasibly be delivered by phone

-Continued efforts are needed to further develop post-hospital discharge interventions to reduce suicidal ideation and behavior


Jeffrey Huffman
Associate Professor of Psychiatry and Physiology and Director of the Cardiac Psychiatry Research Program
Massachusetts General Hospital
Grant Title: Developing a Positive Psychology Intervention to Reduce Suicide Risk
2013 Standard Research Grant

Grant-Related Publications:

Celano, C. M., Beale, E. E., Mastromauro, C. A., Stewart, J. G., Millstein, R. A., Auerbach, R. P., & Huffman, J. C. (2017). Psychological interventions to reduce suicidality in high-risk patients with major depression: a randomized controlled trial. Psychological Medicine, 47(5), 810–821. https://doi.org/10.1017/S0033291716002798

Click here to read more about Dr. Huffman’s Standard Research Grant.

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