J Affect Disord. 2012 Jul 23;
Authors: Cuijpers P, de Beurs DP, van Spijker BA, Berking M, Andersson G, Kerkhof AJ
Abstract
BACKGROUND:
Although treatment guidelines suggest that suicidal patients with depression should be treated for depression with psychotherapy, it is not clear whether these psychological treatments actually reduce suicidal ideation or suicide risk.
METHODS:
We conducted a systematic review and meta-analysis of studies on psychotherapy for depression in which outcomes on suicidality were reported. We also focused on outcomes on hopelessness because this is strongly associated with suicidal behavior in depression.
RESULTS:
Thirteen studies (with 616 patients) were included, three of which examined the effects of psychotherapy for depression on suicidal ideation and suicide risk, and eleven on hopelessness. No studies were found with suicide attempts or completed suicides as the outcome variables. The effects on suicidal ideation and suicide risk were small (g=0.12; 95% CI: -0.20-0.44) and not statistically significant. A power calculation showed that these studies only had sufficient power to find an effect size of g=0.47. The effects on hopelessness were large (g=1.10; 95% CI: 0.72-1.48) and significant, although heterogeneity was very high. Furthermore, significant publication bias was found. After adjustment of publication bias the effect size was reduced to g=0.60.
DISCUSSION:
At this point, there is insufficient evidence for the assumption that suicidality in depressed patients can be reduced with psychotherapy for depression. Although psychotherapy of depression may have small positive effects on suicidality, available data suggest that psychotherapy for depression cannot be considered to be a sufficient treatment. The effects on hopelessness are probably higher.
PMID: 22832172
The problem of studying psychotherapies as a group is that each form of therapy is different in effectiveness. And each therapist is different in effectiveness. A single study will give the average result of a single form of therapy averaged among a group of therapists. A meta-analysis gives you the average of the average result from several studies. Thus, if there is an effective therapy for suicidality, then it may be cancelled by the ineffectiveness of other forms of therapy. As this study showed, the heterogeneity of the results is very high.
Additionally, this study had a significant weakness: there were no measures of suicide attempts in the 13 studies reviewed. Thus, the individual studies would not be able to determine the risk of suicide and therapy’s effect on such risk from a more concrete, objective point.
In regard to therapy, the best form of therapy I have seen for reducing suicide risk is a full Dialectical Behavioral Therapy program with outpatient partial-hospitalization or very intensive therapy (e.g. daily half-day or full day program). In its heyday – i.e. when it could be funded – this reduced the number of hospitalizations and suicide in a county I work in down to zero for weeks at a time. And once stable, we were able to transition patients to more conventional individual Dialectical Behavioral Therapy for maintenance treatment. Patients stopped attempting suicide because they developed more effective, ingrained, and unconscious skills in distress tolerance, mindfulness, problem-solving, relationships, etc. that could only be developed with an intensive therapy program.
Two keys to any form of therapy is accomplishing a significant improvement in the patient’s belief system and significant improvement in the patient’s ingrained and unconscious skills for adapting to their stresses. Only through repeated sessions can therapeutic intervention accomplish the neuroplastic changes in the brain neural circuits necessary for these improvements in function.
As the saying goes: Practice, practice, practice is the only way to get to Carnegie Hall. Therapy is like learning to hit a baseball coming at you at 100 miles per hour with a baseball bat. The conscious mind is physically unable to do this since processing is so slow. Only unconscious mind is fully capable of processing the information quickly enough to hit the baseball. The training in therapy has to be transferred to the unconscious mind.