Augmenting Massed Cognitive Processing Therapy to Prevent Suicide Risk Among Patients With PTSD

Aim

Determine if the addition of Crisis Response Planning to massed Cognitive Processing Therapy for PTSD reduces suicide attempts among military personnel with diagnosed or subthreshold PTSD and suicide ideation; identify early markers of treatment response and relapse of suicide risk; and identify treatment content and design features that influence treatment effectiveness and acceptability.

With its rising rates over the past 20 years, suicide tragically has become one of the top two causes of death among U.S. service members. For military veterans, the risk of death by suicide is 1.5 times that of civilians, among whom suicide rates have risen by 30% since 1999, placing suicide in the top 10 causes of death in the United States.

This has made suicide prevention efforts a top priority for the Department of Defense. One intervention specifically identified as warranting further research is Crisis Response Planning, or CRP. In CRP, the patient and therapist sit down together and, in less than 30 minutes, develop a plan to help the patient identify when they are in crisis and how to effectively reduce their distress. The plan, which fits on a notecard they can keep in their pocket, identifies warning signs, self-regulatory strategies, reasons for living, sources of social support, and professional and crisis services.

CRP shows great potential to help save lives. Research has found that rapid reductions in suicidal thoughts during treatment are associated with reduced risk for suicide attempts. Relatedly, a randomized clinical trial (RCT) led by Craig Bryan, PsyD, ABPP, of The Ohio State University showed that acutely suicidal military personnel who received CRP showed significantly faster reductions in suicidal ideation (or suicidal thoughts) during the following month than those who received treatment as usual, and they were 76% less likely to attempt suicide. In further research, Dr. Bryan showed that CRP reduces suicidal thoughts within hours of the intervention.

Moving the research forward

These findings are highly encouraging and provide empirical support for CRP’s efficacy in reducing suicidal thoughts and behaviors. However, more studies are needed to confirm the effectiveness of CRP in different clinical settings and with different groups of military personnel. In this effort, Dr. Bryan is leading a STRONG STAR-affiliated RCT at Fort Cavazos in Central Texas to examine the impact of adding CRP to an evidence-based PTSD therapy for military personnel with PTSD and recent suicidal thoughts and/or behavior.

It is important to look at this population because PTSD is a signature wound of post-9/11 military conflicts and a significant risk factor for suicide. In fact, it is one of the few psychiatric conditions that distinguishes people who have attempted suicide from those who have only thought about it, suggesting that PTSD facilitates the transition from suicidal thought to action.

The trauma-focused PTSD treatment used in this study, Cognitive Processing Therapy (CPT), has been shown to produce large reductions in PTSD symptoms and in suicidal ideation. Dr. Bryan’s research also found that CPT’s effects on reducing suicidal ideation are accelerated when therapy sessions are delivered daily for two weeks (called “massed” CPT) versus the typical schedule of weekly sessions over several months.

Researchers believe that combining the two treatments could have a positive compounding effect, as some previous research suggests. In a pilot study of Dr. Bryan’s, adding CRP to CPT led to faster and larger reductions in suicidal ideation among military and veterans with PTSD as well as reductions in suicide attempts during follow-up. Research by the study team suggests that rapid reductions in suicidal ideation may also be important for PTSD recovery.

How the study works, and what investigators aim to determine

In this study, 150 military personnel with PTSD or subthreshold PTSD, meaning they have most but not all symptoms of PTSD, will be randomly assigned to one of two study arms: (1) massed CPT plus CRP or (2) massed CPT coupled with typical suicide risk management strategies, referred to as “usual care.”

Researchers will follow study participants for up to one year to assess for suicidal ideation and monitor for suicidal attempts. Analyses with these data will be used to address the primary aim of the study, which is to determine if adding CRP to CPT effectively reduces suicidal behavior.

During treatment, participants also will be asked to wear a Fitbit device and complete surveys on their smartphone multiple times per day to track their physical activity level, sleep quality, and mood in real-time. Researchers will analyze these data to identify early indicators of recovery or treatment nonresponse, which they will use to develop new guidelines to help clinicians decide if their patients are getting better or are at risk for attempting suicide during or after treatment.

Finally, researchers will conduct qualitative interviews with participants to collect their feedback about what they found to be the most – and least – useful parts of treatment. This information will provide clues for further improving and refining treatments to prevent suicide and promote recovery from PTSD.

The ultimate benefit is expected to be improved methods for preventing suicidal attempts and saving lives, for the benefit of our military service members and veterans and their families, with implications for suicide prevention in the larger global community.

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