AT THE ANNUAL AAS CONFERENCE
ATLANTA (FRONTLINE MEDICAL NEWS) – The suicide-specific intervention known as CAMS , or Collaborative Assessment and Management of Suicidality, provides protection against suicidal events during psychiatric hospitalization and in the first weeks post discharge, according to a study from the Menninger Clinic.
In this study, 52 patients who received CAMS in addition to the Menninger Clinic’s usual very intensive treatment regimen showed significantly greater improvement on measures of depression, suicidal ideation, hopelessness, and psychological flexibility at discharge, compared with 52 propensity-matched controls who receive the same regimen minus the CAMS. And, in the first 6 months after discharge, the CAMS group made half as many suicide attempts as did the controls, Thomas E. Ellis, Psy.D. , reported at the annual conference of the American Association of Suicidology.
“We’re thinking that CAMS has some kind of buffering or protective effect in the weeks following discharge, which is the highest-risk period,” said Dr. Ellis, who is director of psychology at the Menninger Clinic and professor of psychiatry at the Baylor College of Medicine, both in Houston.
A total of 4%-7% of all suicides occurring in the United States each year happen in inpatient psychiatric settings. That’s a surprising statistic given that psychiatric hospitalization aims to provide a safe harbor for individuals bent on self-harm. Investigators have identified two sharp peaks of elevated risk of suicide in connection with psychiatric hospitalization: one in the first week after admission, the other in the first week after discharge. CAMS appears to flatten out these peaks, according to the psychologist.
CAMS is an intervention developed by David A. Jobes, Ph.D. , professor of psychology at Catholic University in Washington. The intervention often is described as a theoretical framework in which suicide is seen as the primary focus rather than as a symptom. CAMS is nondenominational in terms of its psychotherapeutic orientation: It is being used today by therapists whose approach runs the gamut from psychodynamic to cognitive-behavioral therapy. The emphasis is on helping the patient problem-solve to find alternatives to suicide as a coping response and providing psychotherapy to address underlying vulnerabilities. A key element of CAMS is early assessment via the CAMS Suicide Status Form , which is used for problem identification and treatment planning, Dr. Ellis explained.
In recent years, he and Dr. Jobes have worked to adapt the CAMS approach to the unique setting of the Menninger Clinic. The clinic is a 100-bed private psychiatric hospital that often is seen as “a last chance” for patients who previously have been hospitalized elsewhere for multiple treatment-resistant conditions, often including substance abuse and personality disorders as well as refractory major depression. The average length of stay is 6-7 weeks – “that’s almost unheard of,” he noted – in contrast to the 3- to 7-day hospitalizations that are typical elsewhere.
The 104 study participants had a mean of 1.7 prior suicide attempts. The 52 controls were selected from a pool of 310 suicidal patients on the basis of propensity score matching by age, sex, treatment unit, severity of suicidal ideation, and number of previous suicide attempts. All subjects got the usual Menninger treatment package, which includes medications, group therapy, psychosocial groups, milieu therapy, nursing care, family counseling, vocational counseling, and individual psychotherapy. The only difference was that the individual psychotherapy included CAMS in 52 patients, while the other 52 received their individual psychotherapy from practitioners who were not involved in CAMS.
Both groups showed significant improvement during hospitalization, but the CAMS group showed significantly greater gains on measures of depression, suicidal ideation, and suicidal cognition.
However, when patients were reassessed at 3 and 6 months post discharge, the picture became more complex. The controls showed late improvement in these measures such that by 3 months’ follow-up, there were no longer significant differences between the two groups on measures of suicide ideation intention on the Columbia Suicide Severity Rating Scale , functional impairment on the World Health Organization Disability Assessment Scale , and thoughts of self-harm on the Patient Health Questionnaire-9 ( PHQ-9 ). It’s not that the CAMS group was backsliding, they were in fact remaining stable on these measures post hospitalization while the controls were getting better. For example, depression scores on the PHQ-9 in the CAMS group were 8.8 at discharge, 9.2 at 3 months, and 9.5 at 6 months, in contrast to 13.7, 10.4, and 10.5 in controls.
Three suicide attempts occurred in the CAMS group post discharge at a mean of 53 and median of 57 days, compared with six attempts in controls at a mean of 38 and median 19 days. But while suicide attempts were fewer in number and occurred later in the CAMS group, these favorable outcome trends did not achieve statistical significance, as the study was not powered to look at that relatively infrequent endpoint, Dr. Ellis said.
To his dismay, rehospitalization rates were higher in the CAMS group: 0 versus 3.8% in controls during the first 2 weeks post discharge, but 9.8%, compared with 5.8% at 3 months and 15.4% vs. 7.6% in controls at 6 months.
Those differences are not statistically significant, but “the raw numbers are of concern,” Dr. Ellis said. He added that the rehospitalization data were compiled only quite recently, and he and his coinvestigators are still trying to figure out the explanation. That will be key in achieving their goal, which is to sustain the gains achieved via CAMS during hospitalization and the first few weeks afterward out to 6 months and beyond.
The study was funded by the Menninger Foundation and other nonprofit organizations. Dr. Ellis reported having no financial conflicts.