Clinical assessment and treatment of suicidal risk: A critique of contemporary care and CAMS as a possible remedy.

Abstract

There is a significant need to improve clinical practices related to suicidal patients within contemporary mental health practice. It is argued that there is a general over-reliance on psychotropic medications and the use of inpatient psychiatric hospitalizations for suicidal risk. This reliance is puzzling given the lack of empirical support for these approaches; the evidence supporting the use of psychotropics is mixed and there are recent challenges to the routine use of inpatient care that tends not to be suicide-specific and may increase post-discharge risk. Importantly there are several psychological treatments proven effective in rigorous randomized controlled trials (RCTs). Of the replicated RCTs, dialectical behavior therapy (DBT), two forms of suicide-specific cognitive-behavioral therapy-cognitive therapy for suicide prevention (CT-SP) and brief cognitive behavioral therapy (BCBT)-and the collaborative assessment and management of suicidality (CAMS) have shown robust data for effectively treating suicidal risk. But despite the data these treatments are not widely used. Possible reasons for an inadequate professional response to suicidality may include: (a) countertransference, (b) fear of malpractice litigation, (c) lack of knowledge about suicide risk assessment, and (d) lack of knowledge about effective treatment for suicidal risk. CAMS is discussed as a possible remedy for the professional and clinical issues raised in this article. Clinical Impact StatementThis article critiques current contemporary practices related to suicidal patients with general suggestions for raising the standard of clinical care. Various evidence-based approaches to improving practices with suicidal patients are considered and the Collaborative Assessment and Management of Suicidality (CAMS) is discussed in depth.

One Size Does Not Fit All: A Comprehensive Clinical Approach to Reducing Suicidal Ideation, Attempts, and Deaths

“…Nevertheless, the previously discussed lack of suicide-specific evidence is rather striking. To this end, Jobes has argued that some contemporary providers may make assumptions about the presumed effectiveness of inpatient care and the use of medicine on suicidal risk [20]. Importantly, such presumptions can have a major impact on the patient’s clinical disposition, and even the course of their entire life.…”

“…As discussed elsewhere, there are over 80 randomized controlled trials (RCTs) of treatments where suicide-related outcomes are the primary focus [20,62]. Within clinical science, RCTs are the gold standard of what has proven effective in a causal manner because of their reliance on experimental designs and a-priori hypothesis testing.…”

Suicide in Transgender Veterans: Prevalence, Prevention, and Implications of Current Policy

“…There are currently no psychosocial interventions for STBs that have been subjected to a randomized control trial (RCT) in a sample of transgender adults or transgender veterans. This is not surprising given that few RCT studies regarding the reduction of STBs have been completed in the broader adult population (Brown & Jager-Hyman, 2014; Jobes, 2017). With accumulating evidence that internal, external, and structural stigma play a role in maintaining mental-health disparity in transgender adults, it is also concerning that no interventions or programs have been created and tested that seek to reduce broadly defined stigma experienced by transgender adults.…”

“…One way in which suicide-prevention efforts in the transgender veteran population may be enhanced is through the adaptation of suicide-specific psychological interventions. In the general population, variants of cognitive/cognitive-behavioral therapy (CBT) specific to suicide (Brown et al, 2005; Rudd et al, 2015), dialectical behavior therapy (Linehan, 2014), and the collaborative assessment and management of suicidality (CAMS; Jobes, 2017) have replicated RCT support for the reduction of STBs. Although suicide-specific interventions developed for and tested within a transgender veteran population are most conducive to the CBPR approach (Tebbe & Budge, 2016), adaptations to broader suicide-specific interventions may also be advantageous and can be guided by current research.…”

Prospective study of association of characteristics of hotline psychological intervention in 778 high-risk callers with subsequent suicidal act

“…Psychological interventions are important in suicide prevention, especially for psychiatric patients (Zalsman et al, 2016). Previous studies report that several interventions Australian & New Zealand Journal of Psychiatry,54(12) such as multisystemic therapy (Huey et al, 2004), cognitive therapy for suicide prevention (Brown et al, 2005) and collaborative assessment and management of suicidality (CAMS; Jobes, 2017) are effective in reducing suicidal behaviors. However, negative attitudes and the stigmatization of suicide (Reynders et al, 2014) combined with the limited availability and high costs of psychological services (Han et al, 2018) limit care-seeking among individuals at high risk of suicide.…”