Treating Veterans at Risk for Suicide: An Examination of the Safety, Tolerability, and Outcomes of Cognitive Processing Therapy

Abstract

Individuals with posttraumatic stress disorder (PTSD) are at increased risk for suicidal thoughts and behaviors; however, clinicians often report apprehension about recommending trauma‐focused therapy to patients with an increased risk of suicide. The present study aimed to evaluate the safety, tolerability, and response to cognitive processing therapy (CPT) among a sample of military veterans with PTSD and increased suicide risk. A secondary aim was to provide a clinically useful definition of high suicide risk. Chart review was used to classify the suicide risk level of 290 veterans who participated in CPT at a Veterans Affairs clinic. Treatment outcomes in veterans with different suicide risk levels were also gathered and compared. Over 50% (n = 155) of the sample demonstrated increased suicide risk, and 1.0% (n = 3) engaged in suicidal behavior after initiating treatment. To date, hospital records show no suicide deaths since 2016 among clinic patients who received CPT. Suicide risk level was not associated with CPT tolerability, and PTSD symptom change was equivalent across groups, ps = .085–.976. Veterans across groups reported clinically significant reductions in PTSD symptoms. The tested suicide risk categorization schemes performed similarly in differentiating the odds of CPT completion and PTSD symptom reduction. These results suggest that veterans with PTSD and an increased risk of suicide, including those with previous suicide attempts and current ideation, can tolerate and benefit from CPT. Additional variables must be considered to truly determine the acute and imminent suicide risk that would deem CPT to be contraindicated.

Addressing co‐occurring suicidal thoughts and behaviors and posttraumatic stress disorder in evidence‐based psychotherapies for adults: A systematic review

“…There were 11 studies that included CPT. Eight studies examined CPT only (Blain et al., 2020; Bryan et al., 2018; Resick et al., 2017; Stayton et al., 2019; Johnson et al., in press; Holliday et al., 2018; Horwitz et al., 2018; Roberge et al., 2021) and three studies compared CPT to another EBT (Bryan et al., 2016; Gradus et al., 2013; Post et al., in press; Resick et al., 2015). Ten CPT studies showed reductions in both PTSD‐ and suicide‐related outcomes, with the majority reporting significant reductions and, generally, few or no reports of suicidal ideation or behaviors at posttreatment or follow‐up assessments.…”

“…Ten CPT studies showed reductions in both PTSD‐ and suicide‐related outcomes, with the majority reporting significant reductions and, generally, few or no reports of suicidal ideation or behaviors at posttreatment or follow‐up assessments. Although one study reported suicide attempts by two participants approximately 7 months following treatment and one suicide attempt from a participant who completed just one session (i.e., combined 1% of the sample), the results showed that CPT significantly reduced PTSD symptoms regardless of patients’ baseline level of suicide risk (Roberge et al., 2021). For all studies that compared CPT to other EBTs, both EBTs resulted in improvement in PTSD and suicide outcomes.…”

Fluid vulnerability theory as a framework for understanding the association between posttraumatic stress disorder and suicide: A narrative review

“…Undoubtedly, these associations are multidirectional and intertwined, but targeting the most impaired dimension may reduce suicide risk most effectively. Finally, although suicide risk has been used as an exclusionary criterion for PTSD treatment, emerging research suggests that both conditions can safely be treated concurrently (Roberge et al., 2021; Rozek et al., in press). This means that clinicians are able to target the most impaired domain of functioning across both conditions (i.e., PTSD and suicide), more efficiently.…”

Introduction to the Special Issue on Posttraumatic Stress and Suicide

“…Finally, Roberge and colleagues (2021) dug even more deeply into the question of whether CPT is safe, tolerable, and effective for treating traumatized veterans with both PTSD and suicidal risk. Using a chart review of 290 veterans who participated in CPT at a Veteran's Affairs hospital, the investigators found that over half of the participants reported risk of suicide at intake, as measured by a history of previous suicide attempts or current suicidal ideation.…”