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Attempted suicide is the main risk factor for suicide and repeated suicide attempts. However, the evidence for follow-up treatments reducing suicidal behavior in these patients is limited. The objective of the present study was to evaluate the efficacy of the Attempted Suicide Short Intervention Program (ASSIP) in reducing suicidal behavior. ASSIP is a novel brief therapy based on a patient-centered model of suicidal behavior, with an emphasis on early therapeutic alliance. Patients who had recently attempted suicide were randomly allocated to treatment as usual (n = 60) or treatment as usual plus ASSIP (n = 60). ASSIP participants received three therapy sessions followed by regular contact through personalized letters over 24 months. Participants considered to be at high risk of suicide were included, 63% were diagnosed with an affective disorder, and 50% had a history of prior suicide attempts. Clinical exclusion criteria were habitual self-harm, serious cognitive impairment, and psychotic disorder. Study participants completed a set of psychosocial and clinical questionnaires every 6 months over a 24-month follow-up period. The study represents a real-world clinical setting at an outpatient clinic of a university hospital of psychiatry. The primary outcome measure was repeat suicide attempts during the 24-month follow-up period. Secondary outcome measures were suicidal ideation, depression, and health-care utilization. Furthermore, effects of prior suicide attempts, depression at baseline, diagnosis, and therapeutic alliance on outcome were investigated. During the 24-month follow-up period, five repeat suicide attempts were recorded in the ASSIP group and 41 attempts in the control group. The rates of participants reattempting suicide at least once were 8.3% (n = 5) and 26.7% (n = 16). ASSIP was associated with an approximately 80% reduced risk of participants making at least one repeat suicide attempt (Wald χ21 = 13.1, 95% CI 12.4-13.7, p < 0.001). ASSIP participants spent 72% fewer days in the hospital during follow-up (ASSIP: 29 d; control group: 105 d; W = 94.5, p = 0.038). Higher scores of patient-rated therapeutic alliance in the ASSIP group were associated with a lower rate of repeat suicide attempts. Prior suicide attempts, depression, and a diagnosis of personality disorder at baseline did not significantly affect outcome. Participants with a diagnosis of borderline personality disorder (n = 20) had more previous suicide attempts and a higher number of reattempts. Key study limitations were missing data and dropout rates. Although both were generally low, they increased during follow-up. At 24 months, the group difference in dropout rate was significant: ASSIP, 7% (n = 4); control, 22% (n = 13). A further limitation is that we do not have detailed information of the co-active follow-up treatment apart from participant self-reports every 6 months on the setting and the duration of the co-active treatment. ASSIP, a manual-based brief therapy for patients who have recently attempted suicide, administered in addition to the usual clinical treatment, was efficacious in reducing suicidal behavior in a real-world clinical setting. ASSIP fulfills the need for an easy-to-administer low-cost intervention. Large pragmatic trials will be needed to conclusively establish the efficacy of ASSIP and replicate our findings in other clinical settings. ClinicalTrials.gov NCT02505373.

Background Older adults are underrepresented in suicide prevention research, even though suicide rates are higher in this age group (65+) than in any other age group in many countries worldwide. There are few clinical intervention studies that target this age group. A promising preventive intervention is the Attempted Suicide Short Intervention Program (ASSIP). Given differences in suicidal behaviour between older and younger adults, there is a need for suicide prevention intervention models that are adaptable to the heterogenic needs of older adults. This study protocol outlines the design of our upcoming study, which aims to evaluate a modified version of the Attempted Suicide Short Intervention Program (ASSIP) specifically adapted for older adults (65+), ASSIP for Older Adults (ASSIP-OA), as add-on to Treatment as Usual (TAU) and compared to TAU only. Methods A multicentre two-group parallel randomised controlled trial will be conducted to compare TAU to ASSIP-OA (3–5 sessions) and standardized letters for 2 years as an add-on to treatment as usual. The trial, which is open labelled, will recruit 132 participants (65+) within psychiatric services in Sweden after a suicide attempt or hospitalisation for serious suicidal plans. The main modifications in comparison with the original ASSIP include (a) flexibility in treatment delivery (offering home visits, breaks and shorter/longer sessions as needed), (b) an additional session together with relatives or other support person(s), and (c) age-specific linguistic and content-wise adaptation of homework, letters, and case conceptualization. The primary outcome is a suicidal episode (fatal or non-fatal). Secondary outcomes include psychiatric symptoms, severity of suicidal ideation, coping style and quality of life. The trial also includes measures of feasibility, health-care utilization and negative effects of treatment. Discussion This study has the potential to inform the development and implementation of a more person-centred care for suicidal older adults. Trial registration ClinicalTrials.gov: NCT06831942. Registered February 21, 2025, revised May 21, 2025.

This study examined two Death-Implicit Association Test versions targeting associations between the self-concept (standard identity D-IAT; iD-IAT) and internal versus external control (adapted control D-IAT; cD-IAT) and death among suicide attempters. Additionally, correlations with explicit psychological variables and psychometrics were explored. 116 psychiatric inpatients (58.1 % female; age M = 33.6, SD = 12.4) were classified as single versus multiple and recent versus lifetime suicide attempters. Implicit associations were measured using the iD-IAT and cD-IAT. Self-report measures included constructs relevant to suicidal behaviour. Recent attempters showed weaker self-life (t(114) = 2.18, p = .016) and internal control-life (t(114) = 2.26, p = .013) associations than lifetime attempters. Multiple attempters exhibited weaker internal control-life associations than single attempters (t(114) = 2.25, p = .007). The iD-IAT correlated with suicidal ideation (rs(114) = 0.20, p = .032), depression (rs(114) = 0.20, p = .033) and external control (rs(114) = 0.21, p = .021), the cD-IAT with suicidal ideation (rs(114) = 0.25, p = .006) and depression (rs(114) = 0.26, p = .006). The cD-IAT predicted multiple attempts (χ2(1116) = 3.88, p = .049), showed higher internal consistency (rsb =. 31, p = .001) and predictive validity in detecting multiple (AUC = 0.64; p = .013) and recent (AUC = 0.62; p = .028) attempters than the iD-IAT. The cD-IAT shows preliminary potential to differentiate suicidal behaviour based on recency and frequency, offering a tentative step toward understanding cognitive vulnerabilities of at-risk subgroups, warranting further refinement, validation and prospective analyses. •First implicit measure that captures control biases relevant to suicidal behaviour.•Implicit control biases differentiate recency and frequency of suicide attempts.•Recent attempters show weaker self-life and internal control-life associations.•The control D-IAT's D-value statistically predicts multiple attempts.•The control D-IAT shows higher validity than the well-established identity D-IAT.

Background The internal suicide debate hypothesis assumes that in a suicidal crisis, individuals are involved in an internal struggle over whether to live or die. Reasons for living (RFL) and Reasons for dying (RFD) are important individual reasons for staying alive (e.g. family) or wanting to die (e.g. hopelessness) and reflect this internal motivational conflict of the suicidal mind. The aim of this study was to explore the association between RFL and RFD of suicide attempters and current and future suicide ideation and behavior. Method The sample consisted of 60 patients who were admitted at a psychiatric emergency unit in Switzerland following an attempted suicide. They received treatment as usual, participated in an assessment interview and completed self-report questionnaires. Additionally, they were instructed to write down up to five individual RFL and RFD. The number of RFL and RFD responses, depressive symptoms, and suicide ideation were assessed at baseline and 6, 12, and 24 months follow-up. Outcome measures were suicide ideation and repeated suicide attempts. Multiple imputations were used in order to address missing data. Results The number of RFD responses was the strongest predictor for increased suicide ideation at baseline. The number of RFL responses was not associated with suicide ideation and reattempts. RFD, depressive symptoms, and baseline suicide ideation predicted subsequent suicide reattempt up to 12 months later in simple regression analyses. Mediation analyses suggested that RFD mediated the effect of depressive symptoms at baseline on suicide ideation at 12-months follow-up. Conclusion RFL were unrelated to the mental health of study participants and did not function as protective factor against suicide risk. RFD may be an important motivational driver in the suicidal process. Clinical interventions should focus more on the reduction of RFD than on RFL in suicidal individuals.

The Attempted Suicide Short Intervention Program (ASSIP) is a brief therapy aimed at preventing repeat suicide attempts by addressing the underlying backgrounds and vulnerabilities associated with suicidal behaviour. In Switzerland, ASSIP demonstrated an 80% reduction in long-term risk of repeat suicide attempts, but a description of the implementation and effects in a Swedish context is lacking. This pilot study, as part of a larger feasibility study preparing for a future RCT, examines the clinical characteristics of individuals receiving ASSIP in Sweden, focusing on gender differences and initial outcomes. One hundred individuals who had attempted suicide were recruited from psychiatric facilities across Sweden. Demographic and clinical data were collected, including diagnostic information and details about suicide attempt methods. Suicidal intent at index suicide attempt was assessed by the Suicide Intent Scale (SIS). Attitude towards suicide, suicide ideation and behaviour and other suicide-related symptoms were measured using the Suicide Assessment Scale Self-rate (SUAS-S) at baseline and after three sessions of ASSIP, and changes in SUAS-S scores were used to assess initial outcomes. Almost half of the cohort had a mood disorder and 39% had an anxiety disorder. Men were more likely than women to use violent methods in their suicide attempts. The mean SIS score was 17.6. SUAS-S scores had decreased significantly by the third session. The findings of this pilot study showed reduced self-rated scores on SUAS among high-risk individuals after three sessions of ASSIP treatment, suggesting the potential relevance brief, targeted interventions in suicide prevention. Except for the attempt method, no gender differences were found. Almost half of the cohort had a mood disorder and 39% had an anxiety disorder Mean SIS scores revealed high initial suicidal intent in the study population Immediate reduction noted in SUAS-S scores after ASSIP

This is the first cost-effectiveness analysis of a brief therapy, the Attempted Suicide Short Intervention Program (ASSIP), for individuals who attempt suicide. To explore the cost-effectiveness of the ASSIP intervention in the context of the Swiss health care system. In this economic evaluation, the cost-effectiveness analysis was performed from a health care perspective between January 2017 and April 2018 using data from a randomized clinical trial conducted between June 2009 and December 2014. Participants were individuals who had attempted suicide and were receiving treatment at a psychiatric university hospital in Switzerland that provides inpatient and outpatient services for suicide attempters referred from an emergency department of a general hospital. The intervention group received 3 manual-based therapy sessions followed by regular personalized letters over 24 months. The control group was offered a single suicide risk assessment. The main economic analysis explored cost per suicide attempt avoided expressed in 2015 Swiss francs (CHF). Cost-effectiveness planes were plotted and cost-effectiveness acceptability curves calculated. One hundred twenty participants (mean [SD] age, 37.8 [14.4] years; 66 [55%] women and 54 [45%] men) were assigned to an intervention group or a control group, each with 60 participants. At 24 months of follow-up, 5 suicide attempts were reported in the ASSIP group among 59 participants with follow-up data available, and 41 were reported in the control group among 53 participants with follow-up data available. The ASSIP group had higher intervention costs, with CHF 1323 vs CHF 441 for the control group. At 24 months of follow-up, psychiatric hospital costs were lower in the ASSIP group than in the control group, although this difference was not significant (mean [SD], CHF 20 559 [38 676] vs CHF 45 488 [73 306]; mean difference, CHF -16 081; 95% CI, CHF -34 717 to 1536; P = .11). General hospital costs were significantly lower for the ASSIP group. Total health care costs were also lower, but the difference was not significant (mean [SD], CHF 21 302 [38 819] vs 41 287 [74 310]; difference, CHF -12 604; 95% CI, CHF -29 837 to 625; P = .14). In a base-case analysis, ASSIP was dominant, with significantly fewer reattempts at lower overall cost. The intervention had a 96% chance of being less costly and more effective. A sensitivity analysis showed a 96% and 95% chance of ASSIP being more effective and less costly at willingness-to-pay levels of CHF 0 and CHF 30 000, respectively. The ASSIP intervention is a cost-saving treatment for individuals who attempt suicide. The findings support the use of ASSIP as a treatment for suicide attempters. Further studies are needed to determine cost-effectiveness in other contexts. ClinicalTrials.gov Identifier: NCT02505373.

This paper presents a model of suicidal behaviour based on suicide as a goal-directed action, and its implications. An action theoretical model has guided the authors in the development of a brief therapy for individuals who attempt suicide (ASSIP—Attempted Suicide Short Intervention Program). Key elements are an early therapeutic alliance, narrative interviewing, psychoeducation, a joint case conceptualization, safety planning, and regular letters over 24 months. In a randomized controlled trial, ASSIP was highly effective in reducing the risk of suicide reattempts. The therapeutic elements in this treatment are described and possible implications for future directions in clinical suicide prevention discussed.