Inpatient Post Admission Cognitive Therapy (PACT) for the Prevention of Suicide Attempts

Suicide remains a serious public health problem as the 4th leading cause of death among
individuals 15-44 years old and the 2nd leading cause of death in the military. Developing
effective interventions for suicide behavior has been a stated goal of the National Strategy
for Suicide Prevention. To date, only a limited number of controlled studies have examined
the efficacy of psychosocial interventions in reducing suicide behavior. Preliminary findings
from the University of Pennsylvania (Brown et al., 2005) indicate that outpatient cognitive
therapy reduces the likelihood of repeat suicide attempts by approximately 50%. Yet the
efficacy of this promising new intervention has not been tested in other medical settings or
in other specific at risk groups.

We propose an adaptation of Beck and colleagues cognitive therapy suicide protocol for
implementation, feasibility, and pilot testing at an inpatient psychiatry setting for
specific delivery to military service members and their family members with a recent suicide
attempt. Suicide attempt behavior is one of the most powerful risk factors for repeat suicide
behavior as well as eventual death by suicide. Delivering a brief and possibly potent
psychotherapeutic intervention during a patient's inpatient hospitalization aims to directly
target individuals at high risk for future suicide behavior, i.e., young adult, mostly males
with a recent suicide attempt, under direct stress of a military career. We expect that the
adapted intervention, titled Post Admission Cognitive Therapy (PACT), will show promise in
reducing the likelihood of post-hospitalization suicide attempt behavior as well as
psychological risk factors associated with suicide such as depression, hopelessness, suicide
ideation, and posttraumatic symptoms. Our proposed design is a randomized controlled pilot
trial with blinded outcome assessments.

Specific Aims: (1) To develop and evaluate a new manual of Post-Admission Cognitive Therapy
(PACT) as a targeted inpatient treatment for individuals admitted for a recent suicide
attempt to a military hospital. (2) To assess the feasibility of the study's assessment
procedures by monitoring the completion rate of outcome measures during face-to-face as well
as follow-up phone and web-based administrations. (3) To evaluate the degree of change and
variability of response to Post-Admission Cognitive Therapy in comparison to Enhanced Usual
Care at post-intervention and follow-up (1-, 2-, and 3-Month) on subsequent suicide attempt
behavior (primary outcome) as well as on levels of depression, hopelessness, and suicide
ideation (secondary outcomes). (4) To examine in a preliminary manner whether improvements on
primary and secondary outcome measures are associated with enhanced problem solving abilities
which is viewed as a potential mechanism of change in cognitive therapy for the reduction of
suicide behavior.

Study Design: We plan to randomize 24 patients hospitalized at the Walter Reed National
Military Medical Center for a recent suicide attempt to one of two conditions: (1)
Post-Admission Cognitive Therapy + Enhanced Usual Care (PACT+EUC) or (2) Enhanced Usual Care
(EUC). Individuals who are over the age of 18, able to communicate in English and willing to
provide informed consent will be recruited. The PACT+EUC condition will consist of six 60-90
minute individual cognitive therapy sessions administered preferably over 3 days. The EUC
condition will consist of the usual care patients receive at an inpatient facility during
their hospitalization in addition to assessment services provided by independent evaluators
who work directly with our research team. The primary outcome variable is the number of
subsequent suicide attempts. We expect that patients in the control condition will reattempt
suicide at an earlier date and at a higher frequency as compared to patients enrolled in the
intervention condition. Secondary outcome measures include the severity of depression,
hopelessness, and suicide ideation. Patients in both conditions will be assessed on the
dependent measures at baseline and at 1-, 2-, and 3- month follow-up intervals. Data analyses
will provide estimates of the statistical power of PACT relative to EUC over time via the
usage of repeated observation data. Our preliminary effect size estimates will be used for
future sample size calculations to conduct a larger randomized controlled trial to
definitively determine the efficacy of PACT.

Inclusion Criteria:

- Recent Suicide Attempt

- Baseline Completed Preferably within 48 Hours of Admission

- Over the Age of 18

- Provides Informed Consent

Exclusion Criteria:

- Self-Inflicted Harm with No Intent or Desire to Die

- Medical Incapacity to Participate

- Current State of Active Psychosis

- Expected Discharge within 72 Hours of Admission