Cognitive behavioral therapy for suicidal behaviors: improving patient outcomes

Figures & data

Table 1 Overview of randomized controlled trials of CBT for adults (aged 18 years and older) that included suicide-related cognitions as an outcome measure

Reference	N	Main focus of intervention	Treatment group	Suicidal outcome posttreatment	Effect size posttreatment	Suicidal outcome follow-up	Effect size follow-up	Suicidal outcome follow-up	Effect size follow-up
de Groot et al^Citation29	122	Grief in people bereaved by suicide	1. Family-based CBT	Proportion reporting suicidal ideation: 18% (1) vs 17% (2)	10.5 months; 1 vs 2, d=0.04 (95% CI: −0.48 to 0.56)	–	–	–	–
			2. Usual care
Gandy et al^Citation30	45	Epilepsy	1. CBT	Score on the Neurological Depressive Disorders Inventory-Epilepsy suicide item:^Citation49 1.30 (1) vs 1.96 (2)	Posttreatment; 1 vs 2, d=−0.86 (95% CI: −1.46 to −0.23)	Score on the Neurological Depressive Disorders Inventory-Epilepsy suicide item: 1.47 (1) vs 1.69 (2)	3 months; 1 vs 2, d=−0.23 (95% CI: −0.84 to −0.38)	–	–
			2. Waitlist control
Morley et al^Citation31	185	Substance use and comorbid suicide risk	1. CBT + usual care	Score on the Beck Scale for Suicidal Ideation:^Citation50 5.82 (1) vs 6.00 (2)	6 months; 1 vs 2, d=−0.21 (95% CI: −0.74 to 0.30)	–	–	–	–
			2. Usual care
Rudd et al^Citation32	152	Suicide attempts in military sample	1. CBT + usual care	Score on the Beck Scale for Suicidal Ideation:^Citation50 2.71 (1) vs 3.39 (2)	18 months; 1 vs 2, d=0.06 (95% CI: −0.60 to 0.48)	–	–	–	–
			2. Usual care
Slee et al^Citation33	90	Self-harm	1. CBT + usual care	Score on the Suicide Cognitions Scale:^Citation51 46.63 (1) vs 59.70 (2)	3 months; 1 vs 2, d=−0.63 (95% CI: −1.08 to −0.17)	Score on the Suicide Cognitions Scale: 42.48 (1) vs 56.26 (2)	6 months; 1 vs 2, d=−0.65 (95% CI: −1.12 to −0.18)	Score on the Suicide Cognitions Scale: 36.60 (1) vs 54.88 (2)	9 months; 1 vs 2, d=−1.01 (95% CI −1.50 to −0.52)
			2. Usual care
Tarrier et al^Citation34	49	Suicidal behaviors in schizophrenia	1. CBT + usual care	Score on the Beck Scale for Suicidal Ideation:^Citation50 4.2 (1) vs 5.6 (2)	4 months; 1 vs 2, d=−0.18 (95% CI: −0.85 to 0.48)	Score on the Beck Scale for Suicidal Ideation: 4.1 (1) vs 5.1 (2)	6 months; 1 vs 2, d=−0.15 (95% CI: −0.81 to 0.52)	–	–
			2. Usual care
Van Spijker et al^Citation35	236	Suicidal ideation	1. Internet-delivered CBT	Score on the Beck Scale for Suicidal Ideation:^Citation50 4.47 (1) vs 3.30 (2)	6 weeks; 1 vs 2, d=−0.28 (95% CI: −0.54 to −0.03)	–	–	–	–
			2. Waitlist control
Wagner et al^Citation36	62	Depression	1. Internet-delivered CBT	Score on the Beck Scale for Suicidal Ideation:^Citation50 2.27 (1) vs 2.40 (2)	Posttreatment; 1 vs 2, d=0.02 (95% CI: −0.47 to 0.53)	–	–	–	–
			2. Face-to-face CBT
Weinberg et al^Citation38	30	Deliberate self-harm in borderline personality disorder	1. CBT + usual care	Score on the Suicide Behaviors Questionnaire:^Citation52 27.47 (1) vs 42.69 (2)	2 months; 1 vs 2, d=−0.62 (95% CI: not provided)	Score on the Suicide Behaviors Questionnaire: 37.96 (1) vs 45.69 (2)	8 months; 1 vs 2, d=−0.31 (95% CI: not provided)	–	–
			2. Usual care
Weitz et al^Citation37	146	Depression	1. CBT	Score on the Beck Depression Inventory suicide ideation item:^Citation53 0.67 (1) vs 0.49 (2), 0.65 (3), and 0.55 (4)	4 months; 1 vs 2, –d=0.24 (95% CI: −0.23 to 0.71); 1 vs 3, d=0.03 (95% CI: −0.44 to 0.50); 1 vs 4, d=0.16 (95% CI: −0.29 to 0.62)		–	–	–
			2. Interpersonal therapy
			3. Imipramine + clinical management
			4. Placebo + clinical management

Note: − means not applicable.

Abbreviation: CBT, cognitive behavioral therapy.

Table 2 Overview of randomized controlled trials of CBT for adults (aged 18 years and older) that included suicide-related behaviors as an outcome measure

Reference	N	Main focus of intervention	Treatment group	Suicidal outcome posttreatment	Effect size posttreatment	Suicidal outcome follow-up	Effect size follow-up	Suicidal outcome follow-up	Effect size follow-up
Barrowclough et al^Citation43	327	Psychosis with comorbid substance use disorder	1. CBT + motivational interviewing + usual care	Proportion reporting self-harm: 14.9% (1) vs 11.9% (2)	12 months; 1 vs 2, d=0.18 (95% CI: −0.24 to 0.60)	Proportion reporting self-harm: 9.5% (1) vs 6.8% (2)	24 months; 1 vs 2, d=0.22 (95% CI: −0.32 to 0.75)	–	–
			2. Usual care
Brown et al^Citation42	120	Suicide attempt	1. CBT + usual care	Proportion reporting suicide attempt: 24.1% (1) vs 41.6% (2)	18 months; 1 vs 2, d=−0.45 (95% CI: −0.88 to −0.01)	–	–	–	–
			2. Usual care
Cottraux et al^Citation41	65	Borderline Personality Disorder	1. CBT	Score on a clinician-administered self-harming behaviors checklist: 1.96 (1) vs 2.36 (2)	24 months; 1 vs 2, d=−0.48 (95% CI: −1.35 to 0.39)	–	–	–	–
			2. Rogerian supportive therapy
Davidson et al^Citation40	106	Borderline Personality Disorder	1. CBT + usual care	Mean number of suicide attempts: 0.69 (1) vs 1.22 (2)	12 months; 1 vs 2, d=−0.26 (95% CI: −0.71 to 0.20)	Mean reporting suicidal acts: 0.93 (1) vs 2.09 (2)	24 months; 1 vs 2, d=−0.42 (95% CI: −0.88 to 0.04)	Mean reporting suicidal acts: 1.88 (1) vs 3.03 (2)	6 years; 1 vs 2, d=−0.31 (95% CI −0.77 to 0.15)
			2. Usual care
Rudd et al^Citation32	152	Suicide attempts in military sample	1. CBT + usual care	Proportion reporting suicide attempt: 13.8% (1) vs 40.2% (2)	24 months; 1 vs 2, d=−0.79 (95% CI: −1.23 to −0.35)	–	–	–	–
			2. Usual care
Slee et al^Citation33	90	Self-harm	1. CBT + usual care	Mean number of self-harm episodes: 5.63 (1) vs 5.65 (2)	3 months; 1 vs 2, d=0.002 (95% CI: not calculable)	Mean number of self-harm episodes: 5.30 (1) vs 4.03 (2)	6 months; 1 vs 2, d=0.15 (95% CI: −0.31 to 0.60)	Mean number of self-harm episodes: 1.18 (1) vs 4.58 (2)	9 months; 1 vs 2, d=−0.51 (95% CI −0.98 to −0.04)
			2. Usual care
Tyrer et al^Citation39	480	Deliberate self-harm	1. CBT	Proportion reporting parasuicide events: 39% (1) vs 46% (2)	12 months; 1 vs 2, d=−0.14 (95% CI: −0.35 to 0.07)	–	–	–	–
			2. Usual care
Weinberg et al^Citation38	30	Deliberate self-harm in borderline personality disorder	1. CBT + usual care	Mean number of self-harm episodes: 0.60 (1) vs 3.63 (2)	2 months; 1 vs 2, d=−0.57 (95% CI: not provided)	Mean number of self-harm episodes: 1.98 (1) vs 6.69 (2)	8 months; 1 vs 2, d=−0.34 (95% CI: not provided)	–	–
			2. Usual care

Abbreviation: CBT, cognitive behavioral therapy.

Figure 1 Forest plot of the effect size (Cohen’s d) of CBT on suicidal cognitions compared to the control group at the first assessment posttreatment in nine randomized controlled trials.

Note: Only studies with both an effect size and associated confidence interval at posttreatment were included in this plot.
Abbreviation: CBT, cognitive behavioral therapy.

Figure 2 Forest plot of the effect size (Cohen’s d) of CBT on suicidal behaviors compared to the control group at the first assessment posttreatment in six randomized controlled trials.

Note: Only studies with both an effect size and associated confidence interval at posttreatment were included in this plot.
Abbreviation: CBT, cognitive behavioral therapy.

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