A Novel Cognitive Reappraisal Intervention for Suicide Prevention

The goal of this project is to refine and test a novel emotion-regulation based psychosocial
intervention designed to reduce suicide risk in middle-aged and older adults (50-90 years
old) who have been discharged after a suicide-related hospitalization (i.e. for suicidal
ideation or suicide attempt). Suicide rates in this group are alarmingly high, and reducing
suicide rates in at-risk populations is a major NIMH priority.

The Investigators developed a novel psychosocial intervention called "Cognitive Reappraisal
Intervention for Suicide Prevention (CRISP)," which aims to improve cognitive reappraisal
ability (i.e. the ability to modify the appraisal of a situation to alter its emotional
significance) (target), and reduce suicide risk (outcome). The conceptual framework views
suicidal ideation and behavior as failed attempts to regulate negative emotions and by
improving cognitive reappraisal, an effective emotion regulation strategy, the investigators
expect to reduce suicide risk. This theory is supported by studies showing that unsuccessful
attempts to regulate negative emotions and decreased cognitive reappraisal are associated
with increased suicidal ideation and behavior.

The R61 phase is a proof-of-principle phase and its goals are to optimize CRISP and test its
engagement with cognitive reappraisal. Certified social workers will administer 12 weekly
sessions of CRISP to 40 middle-aged and older adults (50-90 years old) after a
suicide-related hospitalization. Research assistants, unaware of the study aims, will conduct
assessments at study entry (hospital admission), discharge, 6 and 12 weeks post-discharge.
Target engagement will be assessed with electrocortical measures (i.e. late positive
potential, LPP) during a standard pictured-based stimuli and our novel cognitive reappraisal
paradigm.

The R33 phase aims to provide further evidence of target engagement of the optimized CRISP in
a larger sample, evaluate the relationship of cognitive reappraisal with suicide risk as
measured with Columbia Suicide Severity Rating Scale-C-SSRS and estimate implementation
parameters for a large-scale clinical trial. A different sample of 90 middle-aged and older
adults (using the same inclusion/exclusion criteria as for the R61 phase) will be randomized
(3 to 1) to CRISP (N=60) or to Supportive Therapy (ST, a control treatment not designed to
improve emotion regulation) (N=30). Assessments will be conducted on admission, at discharge,
and at 6, 12 and 24 weeks post-discharge. Primary aims are: 1) CRISP participants will show
improvement in cognitive reappraisal ability from discharge to end of treatment; and 2)
improvement in cognitive reappraisal ability will be associated with suicide risk over 24
weeks.

Inclusion Criteria:

1. 50 years and older

2. Diagnosis (based on SCID-5 Clinical Trials Version to assess DSM-5 diagnoses): Any
DSM-5 depression or anxiety diagnosis, including major depressive disorder, bipolar
depression, depressive disorder Not Elsewhere Classified, anxiety disorder Not
Elsewhere Classified, adjustment disorder with anxiety and depressed mood (but without
any of the diagnoses shown under Exclusion Criteria)

3. Recent hospitalization for suicidal ideation or suicide attempt. At hospital
admission, Columbia Suicide Severity Rating Scale greater or equal to 3, "Active
Suicidal Ideation with any methods or a suicide attempt."

4. Patients with any degree of suicidal ideation at discharge (Columbia Suicide Severity
Rating greater or equal to 0) will be included.

5. We will also include patients on psychotropics and on after-care community
psychotherapy.

Exclusion Criteria:

1. History or current diagnosis of Psychotic Disorders; Current Diagnosis of Bipolar I or
Bipolar II, with current episode hypomanic, manic or mixed; Diagnosis of Dementia.

2. Cognitive Impairment: We will exclude participants with Mini Mental State Exam less
than 24.

3. Acute or severe medical illness (i.e. delirium; decompensated cardiac, liver, or
kidney failure; major surgery; stroke or myocardial infarction during the three months
prior to entry.

4. Aphasia, sensory problems, and/or inability to speak English.