Patient Involvement Key to Prevention Strategy’s Success

One of the most delicate tasks in psychiatry is evaluating a new patient who has attempted or is thinking about suicide.

“Suicide is a loaded topic for both clinicians and patients,” said Thomas Ellis, Ph.D., director of psychology at the Menninger Clinic in Houston and a professor of psychiatry at Baylor College of Medicine.

“The clinician fears the patient will die, and patients fear involuntary commitment or the like if they open up,” said Ellis in an interview with Psychiatric News. “So assessment becomes an adversarial process: the therapist needs information that the patient is afraid to give.”

A way to navigate that apparent impasse is to use an engagement strategy that goes beyond a one-shot safety plan.

One such strategy is the Collaborative Assessment and Management of Suicidality, or CAMS, an outpatient approach pioneered by David Jobes, Ph.D., a professor of psychology at Catholic University in Washington, D.C., and used in a modified form for inpatients by Ellis and colleagues at Menninger.

“CAMS is a therapeutic framework used to collaboratively assess suicidal risk and set in motion a suicide-specific intervention to keep highly suicidal people out of inpatient settings,” said Jobes. “It’s a way to stratify risk.”

And CAMS is also part of a trend that focuses first on suicidality, said Barbara Stanley, Ph.D., a lecturer in psychiatry at Columbia University College of Physicians and Surgeons and director of the Suicide Intervention Center at the New York State Psychiatric Institute.

Reverses Traditional Approach

The traditional view was “treat the disorder and the suicidality will go away,” said Stanley in an interview. More recent research suggests that better results come from initial use of a suicide-specific approach (like CAMS), followed by treatment for depression, anxiety, or other diagnoses.

“First get the suicidality under control then, if there’s a lot of anxiety or depression, treat that, so that they don’t hurt themselves when under stress,” said Stanley, who is not involved with Jobes’ research.

The core of CAMS is the Suicide Status Form (SSF), which is more than a simple checklist of symptoms. Developed originally by Jobes as an assessment tool, it now serves to elucidate both quantitative and qualitative aspects of suicidality.

CAMS is not a new psychotherapy, Jobes emphasized.

“We have plenty of those,” he said. “With CAMS, clinicians use their experience and knowledge but within a framework that advances a suicide-specific agenda that identifies, targets, and treats suicide drivers.”

At first, the SSF helps establish a relationship between patient and therapist. “With permission, the therapist sits next to the patient and helps the patient fill out the form in his or her own hand,” he explained.

The form asks patients to rate their psychological pain, stress, agitation, hopelessness, self-hate, and overall risk of suicide. Next, they list their five most significant reasons for living and for dying.

In that side-by-side collaboration, the patient becomes the expert on his or her case, said Ellis.

“We were concerned that patients wouldn’t want to talk about suicidality or that it would take several sessions before that would come out,” he said. “But to the contrary, using the SSF, we found that patients are eager to talk when suicidality is approached objectively, in a nonjudgmental manner.”

Collaboration Is Foundation

In fact, CAMS’ strength lies in its collaborative nature, said Stanley.

“You’re not preaching to the patient and not leaving it to the patient to figure out what the problem is,” she said. “You’re working together.”

The SSF also helps patient and therapist understand those drivers of suicide. They may not be diagnosable mental disorders, however.

“As clinicians, we want to think that psychopathology trumps everything, but for patients, that may not be the first thing that comes to mind,” said Jobes. Patients may see relationship, marriage, or work problems causing their depression, rather than their depression affecting their functioning.

The SSF guides not only assessment but can help direct treatment and measure outcomes.

CAMS also begins the process of helping patients develop new skills to cope with their suicide drivers. Broadly speaking, that means finding ways other than the wish to die as a way of coping with stressors.

“Patients see suicide as a way to relieve their suffering,” said Ellis. “CAMS keeps the suicide issue front and center in treatment sessions as they identify other ways to obtain that relief.”

To test those new coping skills, the “final exam” at Menninger prior to discharge involves asking patients to imagine a challenging moment that would have once triggered suicidality and then having them practice walking through that situation successfully.

Research into the effects of CAMS has moved slowly but steadily, said Jobes. Ellis and colleagues have published results of an open trial of 24 Menninger Clinic patients that recorded pre- to post-treatment improvements in Beck Scale for Suicide Ideation scores and SSF suicide drivers, as well as on the Suicide Cognition Scale.

Katherine Comtois, Ph.D., M.P.H., of the Harborview Medical Center in Seattle, and colleagues published a study of 32 outpatients randomly assigned to CAMS versus “enhanced care as usual” and found that CAMS was “effective in treating suicidal ideation, distress, and hopelessness” over the course of 12 months.

Jobes was a coauthor on both papers. Independently, Danish researchers are conducting a “well-powered, randomized, controlled trial of dialectical behavioral therapy and CAMS,” and another study is under way at the U.S. Army’s Fort Stewart in Georgia.

For the moment, CAMS provides a way to engage patients on the brink of suicide and follow them through treatment.

“We understand that patients can kill themselves in or out of treatment, in or out of a hospital,” said Jobes. “We don’t debate that, but we give the patient a second chance. Clinicians can win the battle by getting the patient into the hospital for a day or two, but you’re not going to win the war that way because the patient has to not want to kill themselves—not because the judge orders it or their wife threatens to leave them, or because that’s what the clinician wants for them, but because the patient wants to live.”

The Web site for the Suicide Prevention Lab at Catholic University is https://sites.google.com/site/cuajsplab/home.