The increased risk for suicide in those experiencing from PTSD is well known. For example, Gradus et al., 2010 studied of a large sample of the Danish population (n = 208,918). They reported persons with PTSD had 5.3 times the rate of death from suicide than persons without PTSD. This included after adjustment for gender, age, marital status, income, and pre-existing depression diagnoses. Similarly, several others have noted an elevated suicide risk in those experiencing chronic PTSD; Tarrier & Gregg (2004), Krysinska & Lester (2010), Pompili et al., (2013).

Many clinicians fear that by treating PTSD they may push a client too far and trigger strong emotional reactions that lead to suicidal ideation, and an attempt. But what does the research say?

This blog will review some of the research related to CPT for PTSD and suicidal ideation.

2017

In her study of Effect of Group vs Individual Cognitive Processing Therapy in Active-Duty Military Seeking Treatment for Posttraumatic Stress Disorder Resick et al. (2017) also assessed suicidal ideation. Her team’s study had an exclusion criterion that consisted of suicidal or homicidal intent or psychosis. They measured suicidal ideation using the Beck Scale for Suicidal Ideation (BSSI). The BSSI is purported to measure three factors:

1. Active Suicidal Desire
2. Specific Plans for Suicide
3. Passive Suicidal Desire

Resick et al. (2017) reported that the proportions of suicidality as measured by the BSSI dropped in both group and individual treatment arms during treatment (overall effect of time, χ2  2 = 13.0; P = .002).

Resick et al. (2017) study also reported on adverse events. Seventeen psychological events were judged by the participants to be at least possibly related to the study, and these occurred because of increased symptoms evoked by baseline assessment procedures (4 patients) or the trauma focus of therapy (7 patients in group CPT and 6 patients in individual CPT).  Resick et al. (2017) described that most of the psychiatric adverse events were common symptoms of PTSD observed in the study population (military with PTSD).

During the study, two unsuccessful suicide attempts occurred in patients randomized to group CPT (one before the start of treatment and one during treatment); neither was judged to be study related as per participant report.

Resick et al. (2017) summarised that Cognitive Processing Therapy did not increase suicidal ideation on the BSSI or reported adverse effects despite the trauma focus. In fact, they observed a significant and steady decrease in suicidal ideation in both treatment formats.

2018

Holliday et al. (2018) completed a preliminary examination of decreases in suicide cognitions after Cognitive Processing Therapy among veterans with posttraumatic stress disorder due to military sexual trauma ( see below for more info on MST).

The study had some limitations due to a small sample size. Holliday et al. (2018) had 32 participants in their sample, 22 (68.8%) completed all 12 sessions of CPT, with an average of 9.94 (SD = 3.27) CPT sessions completed.

They used the Suicide Cognitions Scale (SCS). This measure is an 18-item self-report questionnaire composed of three latent factors of suicide-specific beliefs:

1. unbearability (e.g., “I can’t stand this pain anymore”)
2. unlovability (e.g., “I am completely unworthy of love”)
3. unsolvability (e.g., “suicide is the only way to solve my problems”)

Participants were administered the SCS at 1 week, 2 months, 4 months, and 6 months posttreatment. During CPT and posttreatment participants experienced a significant reduction in beliefs regarding:

• unbearability (b = −3.15, t[31] = −4.72[.67], p < 0.001)
• unlovability (b = −2.20, t[31] = −4.05[.54], p < 0.001)
• unsolvability (b = −1.22, t[31] = −2.49[.49], p = 0.019)

The study had limitations due to the small sample size. However, the authors concluded:

“These findings provide preliminary evidence that a standard course of CPT may have the potential to reduce suicide specific beliefs in veterans with MST-related PTSD.” pg 577

2021

Roberge et al. (2021) examined the effect of using CPT to treat veterans experiencing PTSD and suicidal ideation. The participants in her groups study screened well above the PCL-5 threshold (33) for PTSD, with a mean PCL-5 score of 50.70 (SD = 13.77).

The sample characteristics included:

• 42% current suicidal ideation
• 5% history of attempted suicide
• 46% low risk
• 10% acute risk of suicide

Roberge and colleagues 2021 also used two different categorisations methods to define elevated and low risk. These methods considered combinations of the following factors:

• history of suicide attempts
• absence of attempt
• recent and/or current suicidal ideation
• absence of recent and/or current suicidal ideation

They determined that most veterans who engaged in CPT were at increased risk for suicide as determined by these clinical factors. Given a picture says a thousand words this graph from the study shows the effects of CPT treatment for the various groups over a course of CPT for PTSD

Other important finding that Roberge and colleagues 2021 reported included;

• High risk veterans were just as likely to complete treatment as low risk veterans.
• Suicide risk groups experienced similar levels and rate of PTSD symptom change over the course of treatment.
• On average, veterans reported clinically significant reduction of PTSD symptoms.

Of particular interest to clinicians concerned about risk is Roberge and colleagues’ statement about treatment safety.

“Three veterans (1.0%) engaged in suicidal behaviour (i.e., suicide attempt) between treatment initiation and the chart review process (i.e., August 2020). Of these veterans, all endorsed suicidal ideation at the time of treatment initiation, and two had prior histories of suicide attempts. Two veterans’ attempts occurred approximately seven months after CPT, whereas the other veteran’s attempt occurred in the month following their first and only CPT session. According to local records, to date, no veterans who engaged in CPT between 2016 and 2018 have died by suicide.” (p.4)

Summary

CPT for PTSD can be safely and effectively delivered to individuals with increased risk for suicide and appears to result in a reduction in ideation as well as PTSD symptoms.

What is Military Sexual Trauma (MST)

Survivors of MST often work alongside their perpetrators and the can have the experience that the military does not take action. There can be negative consequences for reporting MST and stigma. MST happens in the context of the military hierarchy. MST can happen in the context of operations where fellow soldiers are protecting each other’s lives when in danger.

References

Holliday, R., Holder, N., Monteith, L. L., & Surís, A. (2018). Decreases in suicide cognitions after cognitive processing therapy among veterans with posttraumatic stress disorder due to military sexual trauma: A preliminary examination. Journal of Nervous and Mental Disease, 206(7), 575–578. https://doi.org/10.1097/NMD.0000000000000840

Jaimie L. Gradus, Ping Qin, Alisa K. Lincoln, Matthew Miller, Elizabeth Lawler, Henrik Toft Sørensen, Timothy L. Lash, Posttraumatic Stress Disorder and Completed Suicide, American Journal of Epidemiology, Volume 171, Issue 6, 15 March 2010, Pages 721–727, https://doi.org/10.1093/aje/kwp456

Krysinska, K., & Lester, D. (2010). Post-traumatic stress disorder and suicide risk: a systematic review. Archives of suicide research : official journal of the International Academy for Suicide Research, 14(1), 1–23. https://doi.org/10.1080/13811110903478997

Pompili, M., Sher, L., Serafini, G., Forte, A., Innamorati, M., Dominici, G., Lester, D., Amore, M., & Girardi, P. (2013). Posttraumatic stress disorder and suicide risk among veterans: A literature review. Journal of Nervous and Mental Disease, 201(9), 802–812. https://doi.org/10.1097/NMD.0b013e3182a21458

Resick, P. A., Wachen, J. S., Dondanville, K. A., Pruiksma, K. E., Yarvis, J. S., Peterson, A. L., & Mintz, J. (2017). Effect of group vs. individual cognitive processing therapy in active-duty military seeking treatment for posttraumatic stress disorder: A randomized clinical trial. JAMA Psychiatry, 74(1), 28–36. https://doi.org/10.1001/jamapsychiatry.2016.2729

Roberge, E.M., Harris, J.A., Weinstein, H.R., & Rozek, D.C. (2021). Treating veterans at risk for suicide: An examination of the safety, tolerability, and outcomes of cognitive processing therapy. Journal of Traumatic Stress.

Tarrier, N., & Gregg, L. (2004). Suicide risk in civilian PTSD patients–predictors of suicidal ideation, planning and attempts. Social psychiatry and psychiatric epidemiology, 39(8), 655–661. https://doi.org/10.1007/s00127-004-0799-4

Parts of this blog also appeared on https://psychpd.com.au/category/ptsd/

Larsen and colleagues (2020) examined this question in a community sample of participants receiving CPT. Previous investigations had been primarily in randomized clinical trials. The concern with these trials has been that the participants and therapists are in some way different to the “average” community-based clinic. For example, therapists may be receiving more specialised training and participants may receive more frequents sessions.

Larsen et al (2020) community sample were receiving weekly treatment and attending in community settings such as private practice or government funded agencies. Therapists had attended a standardized 2-day CPT workshop and were participating in consultation.

Larsen’s group (2020) found that in their sample most participants experienced at least one symptom exacerbation during treatment (67.3%), and 26.9% experienced more than one exacerbation. They highlighted a few important points.

1. Symptom increases did NOT predict:

• Treatment noncompletion
• Posttreatment PTSD symptom levels
• Loss of probable PTSD diagnosis.
• The trajectory of PTSD symptoms over the course of treatment.

2. Those with symptom exacerbations showed no less change in PTSD symptoms over the course of treatment (than those without symptom exacerbation).

3. Demographic variables examined were NOT associated with exacerbations

• Age
• Gender
• Years of education
• Employment status
• Military enrolment
• Veteran status

4. Diagnostic variables examined were NOT associated with exacerbations:

• Depression
• Anxiety
• Substance use
• Personality disorder

5. Strategies used to train clinicians did NOT predict exacerbations.

Summary

Larsen and colleagues provided an important Clinical Impact Statement that can be a useful guide.

“It is relatively common to experience temporary symptom increases during participation in cognitive processing therapy and other trauma-focused therapies. Our results indicate that these symptom increases may be common but are not problematic for overall treatment prognosis. Clinicians can be encouraged that clients can benefit from trauma-focused treatment even if they experience symptom exacerbations during therapy.”

This article also appeared on the blog by Dr Jon Finch, The clinician’s PTSD blog which includes articles about PTSD in general.

Reference

Larsen, S. E., Mackintosh, M.-A., La Bash, H., Evans, W. R., Suvak, M. K., Shields, N., Lane, J. E. M., Sijercic, I., Monson, C. M., & Wiltsey Stirman, S. (2020, January 23). Temporary PTSD Symptom Increases Among Individuals Receiving CPT in a Hybrid Effectiveness-Implementation Trial: Potential Predictors and Association With Overall Symptom Change Trajectory. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. http://dx.doi.org/10.1037/tra0000545

With the potential for people in rural and remote areas of Australia to now access services via video conferencing the question is, can Cognitive Processing Therapy delivered by video work?

There are now four noninferiority trials (yes trials to find out if video conference delivery was inferior or not) showing that Cognitive Processing Therapy (CPT) delivered via telehealth is just as effective as if delivered in person.

Morland et al (2014) tested Group CPT via telehealth with a sample of male Veterans, predominantly of the Vietnam era. They reported that clinical and process outcomes for CPT video conference were noninferior to CPT in-person treatment. Significant reductions in PTSD symptoms were identified at posttreatment and maintained at 3-month and 6-month follow-up. High levels of therapeutic alliance, treatment compliance, and satisfaction and moderate levels of treatment expectancies were reported, with no differences between video conference therapy and in person therapy groups.

Morland et al (2015) tested individual CPT+A with women, 20% of whom were veterans. They found improvements in PTSD symptoms in the CPT video conferencing condition were noninferior to outcomes in the in-person CPT therapy condition. Clinical outcomes obtained when both conditions were pooled together demonstrated that PTSD symptoms declined substantially posttreatment and gains were maintained at 3-month and 6-month follow-up. Veterans demonstrated smaller symptom reductions posttreatment than civilian women.

Maieritsch et al. 2015 tested individual CPT with Operation Iraqi Freedom and Operation Enduring Freedom veterans who were predominantly male. There were some limitations in this study, including a dropout rate of 43.3%. Despite this Maieritsch et al. 2015 reported that a trend was observed which suggested that CPT via video conference may be equivalent to the treatment delivered in person, as suggested by previous studies. Regardless of treatment, veterans who received the intervention in both conditions reported significant decreases on post-treatment measures.

Liu et al. (2019) examined veterans who had an average age of 48, almost 50% of the CPT video conferencing group had participated in World War two. They reported that both completer and intention to treat analyses showed that improvement in CAPS scores in the video conference condition was non-inferior to that in the in-person CPT therapy condition at six-month follow-up. Unlike the previous trials the video conferencing condition was inferior to in person therapy condition for improvement in CAPS at post-treatment. Non-inferiority was supported by completer analyses for PCL–S and PHQ–9 in both post-treatment change and six-month follow-up change, and the intention to treat analysis supported the significant non-inferiority for PCL at posttreatment change.

Summary
CPT can be effectively delivered by video conferencing facilities. More research is needed to understand differences in response over time.

References
Liu, L., Thorp, S. R., Moreno, L., Wells, S. Y., Glassman, L. H., Busch, A. C., . . . Agha, Z. (2019). Videoconferencing psychotherapy for veterans with PTSD: Results from a
randomized controlled non-inferiority trial. Journal of Telemedicine and Telecare. Advance online publication. PTSDpubs ID: 52097

Maieritsch, K. P., Smith, T. L., Hessinger, J. D., Ahearn, E. P., Eickhoff, J. C., & Zhao, Q. (2016). Randomized controlled equivalence trial comparing videoconference and in person delivery of cognitive processing therapy for PTSD. Journal of Telemedicine and Telecare, 22(4), 238-243. doi:http://dx.doi.org/10.1177/1357633X15596109

Morland, L. A., Mackintosh, M., Greene, C. J., Rosen, C. S., Chard, K. M., Resick, P., & Frueh, B. C. (2014). Cognitive processing therapy for posttraumatic stress disorder delivered to rural veterans via telemental health: A randomized noninferiority clinical trial. The Journal of Clinical Psychiatry, 75(5), 470-476. doi:http://dx.doi.org/10.4088/JCP.13m08842

Morland, L. A., Mackintosh, M., Rosen, C. S., Willis, E., Resick, P., Chard, K., & Frueh, B. C. (2015). Telemedicine versus in-person delivery of cognitive processing therapy for women with posttraumatic stress disorder: a randomized noninferiority trial. Depression and Anxiety, 32(11), 811-820. doi:http://dx.doi.org/10.1002/da.22397