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Treating PTSD in the Context of Concurrent Suicide Risk: Current Evidence and Navigating Complicating Factors

  • PTSD (SK Creech and LM Sippel, Section Editors)
  • Published:
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Abstract

Purpose of Review

There are a number of evidence-based therapies for posttraumatic stress disorder (PTSD; e.g., cognitive processing therapy; prolonged exposure therapy). Many patients with PTSD present to treatment at elevated risk for suicide. In such circumstances, navigating evidence-based treatment for PTSD can be challenging, requiring nuanced approaches to ensure optimal therapeutic outcome while ensuring patient safety.

Recent Finding

This manuscript describes the evidence for treating PTSD in the context of elevated risk for suicide. Methods of navigating clinical complexity (e.g., multimorbidity, psychosocial stressors) while maintaining fidelity to evidence-based protocols are discussed.

Summary

We conclude by noting gaps in understanding, as well as necessary future research directions to ensure optimal care for this clinical population.

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References and Recommended Reading

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  1. Krysinska K, Lester D. Post-traumatic stress disorder and suicide risk: a systematic review. Arch Suicide Res. 2010;14(1):1–23.

    Article  PubMed  Google Scholar 

  2. Panagioti M, Gooding PA, Tarrier N. A meta-analysis of the association between posttraumatic stress disorder and suicidality: the role of comorbid depression. Compr Psychiatry. 2012;53(7):915–30.

    Article  PubMed  Google Scholar 

  3. Kilpatrick DG, Resnick HS, Milanak ME, Miller MW, Keyes KM, Friedman MJ. National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. J Trauma Stress. 2013;26:537–47.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Pai A, Surís AM, North CS. Posttraumatic stress disorder in the DSM-5: controversy, change, and conceptual considerations. Behav Sci. 2017;7(1):7.

    Article  PubMed Central  Google Scholar 

  5. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Publishing.

  6. Steinert, C., Hofmann, M., Leichsenring, F., & Kruse, J. (2015). The course of PTSD in naturalistic long-term studies: high variability of outcomes. A systematic review. Nordic Journal of Psychiatry, 69(7), 483–496.

  7. Lee DJ, Schnitzlein CW, Wolf JP, Vythilingam M, Rasmusson AM, Hoge CW. Psychotherapy versus pharmacotherapy for posttraumatic stress disorder: systemic review and meta-analysis to determine first-line treatments. Depress Anxiety. 2016;33(9):792–806.

    Article  CAS  PubMed  Google Scholar 

  8. Lewis C, Roberts NP, Andrew M, Starling E, Bisson JI. Psychological therapies for post-traumatic stress disorder in adults: systematic review and meta-analysis. Eur J Psychotraumatol. 2020;11(1):1729633.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Watts BV, Schnurr PP, Mayo L, Young-Xu Y, Weeks WB, Friedman MJ. Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. J Clin Psychiatry. 2013;74(6):e541–50.

    Article  PubMed  Google Scholar 

  10. American Psychological Association. (2017). Clinical Practice Guideline for the Treatment of PTSD. Retrieved from https://www.apa.org/ptsd-guideline/ptsd.pdf.

  11. Department of Veterans Affairs & Department of Defense. (2017). VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. Retrieved from https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal012418.pdf

  12. Hefner K, Rosenheck R. Multimorbidity among veterans diagnosed with PTSD in the Veterans Health Administration nationally. Psychiatr Q. 2019;90:275–91.

    Article  PubMed  Google Scholar 

  13. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52(12):1048–60.

    Article  CAS  PubMed  Google Scholar 

  14. Taylor EN, Timko C, Nash A, Owens MD, Harris AHS, Finlay AK. Posttraumatic stress disorder and justice involvement among military veterans: a systematic review and meta-analysis. J Trauma Stress. 2020;33(5):804–12.

    Article  PubMed  PubMed Central  Google Scholar 

  15. •• Holliday, R., Borges, L. M., Stearns-Yoder, K. A., Hoffberg, A. S., Brenner, L. A., & Monteith, L. L. (2020). Posttraumatic stress disorder, suicidal ideation, and suicidal self-directed violence among U.S. military personnel and veterans: a systematic review of the literature from 2010 to 2018. Frontiers in Psychology, 11, 1998. The authors conducted a robust systematic review of the past 10 years of research examining the relationship between PTSD and suicidal ideation, attempt, and suicide. Consistent bivariate associations with PTSD and suicidal thoughts and behaviors were observed. However, multivariate associations between these constructs were mixed. The pathway between PTSD and suicidal thoughts and behaviors is complex and may result from indirect associations between PTSD and comorbidity or other associated clinical features (e.g., social support, psychosocial stressors, depression).

  16. Joiner T. Why People Die by Suicide. Harvard University Press; 2007.

    Book  Google Scholar 

  17. Klonsky ED, May AM. The three-step theory (3ST): a new theory of suicide rooted in the “ideation-to-action” framework. Int J Cogn Ther. 2015;8(2):114–29.

    Article  Google Scholar 

  18. Klonsky ED, May AM, Saffer BY. Suicide, suicide attempts, and suicidal ideation. Annu Rev Clin Psychol. 2016;12:307–30.

    Article  PubMed  Google Scholar 

  19. May AM, Klonsky ED. What distinguishes suicide attempters from suicide ideators? A meta-analysis of potential factors. Clin Psychol Sci Pract. 2016;23(1):5–20.

    Google Scholar 

  20. Nock MK, Borges G, Bromet EJ, Cha CB, Kessler RC, Lee S. Suicide and suicidal behavior. Epidemiol Rev. 2008;30:133–54.

    Article  PubMed  Google Scholar 

  21. Cook JM, Simiola V, Hamblen JL, Bernardy N, Schnurr PP. The influence of patient readiness on implementation of evidence-based PTSD treatments in Veterans Affairs residential programs. Psychol Trauma. 2017;9:51–8.

    Article  PubMed  Google Scholar 

  22. Holliday R, Holder N, Olson-Madden JH, Monteith LL. Treating posttraumatic stress disorder in the presence of acute suicide risk in veterans and active duty service members: a call for research. Journal of Nervous and Mental Disease. 2019;207(7):611–4.

    Article  Google Scholar 

  23. Holder, N., Holliday, R., Khan, A. J., Shiner, B., Neylan, T. C., Madden, E., Li, Y., Patterson, O. V., DuVall, S. L., & Maguen, S. (2021). Influence of suicidal ideation on mental health care following risk assessment among Iraq and Afghanistan war veterans with posttraumatic stress disorder. General Hospital Psychiatry. Published online ahead of print.

  24. Holder N, Shiner B, Li Y, Madden E, Neylan TC, Seal KH, Lujan C, Patterson OV, DuVall SL, Maguen S. Timing of evidence-based psychotherapy for posttraumatic stress disorder initiation among Iraq and Afghanistan war veterans in the Veterans Health Administration. Psychol Trauma Theory Res Pract Policy. 2020;12(3):260–71.

    Article  Google Scholar 

  25. Etingen, B., Hill, J. N., Miller, L. J., Schwartz, A., LaVela, S. L., & Jordan, N. An exploratory pilot study to describe shared decision-making for PTSD treatment planning: the provider perspective. Military Medicine, 184(S1), 467–475.

  26. Zisman-Ilani Y, Barnett E, Harik J, Pavlo A, O’Connell M. Expanding the concept of shared decision making for mental health: systematic search and scoping review of interventions. Ment Health Rev J. 2017;22(3):191–213.

    Article  Google Scholar 

  27. Harned MS, Gallop RJ, Valenstein-Mah HR. What changes when? The course of improvement during a stage-based treatment for suicidal and self-injuring women with borderline personality disorder and PTSD. Psychother Res. 2016;28(5):761–75.

    Article  PubMed  PubMed Central  Google Scholar 

  28. •• Dedert, E. A., LoSavio, S. T., Wells, S. Y., Steel, A. L., Reinhardt, K., Deming, C. A., Ruffin, R. A., Berlin, K. L., Kimbrel, N. A., Wilson, S. M., Boeding, S. E., & Clancy, C. P. (2020). Clinical effectiveness study of a treatment to prepare for trauma-focused evidence-based psychotherapies at a Veterans Affairs specialty posttraumatic stress disorder clinic. Psychological Services. Published online ahead of print. Providers often consider preparatory treatment for patients with PTSD in the presence of a number of complicating factors, including risk for suicide. This study found that those who participated in preparatory treatments experienced decreased therapeutic response in comparison to patients who initially participated in a trauma-focused cognitive-behavioral treatment. Alternative treatments can, and should, be considered when patients present with complicating suicide risk factors (e.g., DBT PE).

  29. Bryan CJ. Treating PTSD within the context of heightened suicide risk. Curr Psychiatry Rep. 2016;18:73.

    Article  PubMed  Google Scholar 

  30. Goodnight JRM, Ragsdale KA, Rauch SAM, Rothbaum BO. Psychotherapy for PTSD: an evidence-based guide to a theranostic approach to treatment. Prog Neuropsychopharmacol Biol Psychiatry. 2019;88:418–26.

    Article  PubMed  Google Scholar 

  31. Wortzel HS, Homaifar B, Matarazzo B, Brenner LA. Therapeutic risk management of the suicidal patient: stratifying risk in terms of severity and temporality. J Psychiatr Pract. 2014;20(1):63–7.

    Article  PubMed  Google Scholar 

  32. Posner K, Brown GK, Stanley B, Brent DA, Yershova KV, … Mann JJ (2011) The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry 168(12): 1266-1277

  33. Homaifar B, Matarazzo B, Wortzel HS. Therapeutic risk management of the suicidal patient: augmenting clinical suicide risk assessment with structured instruments. J Psychiatr Pract. 2013;19(5):406–9.

    Article  PubMed  Google Scholar 

  34. Brown LA, Belli G, Suzuki N, Capaldi S, Foa EB. Reductions in suicidal ideation from prolonged exposure therapy for adolescents. J Clin Child Adolesc Psychol. 2020;49(5):651–9.

    Article  PubMed  Google Scholar 

  35. •• Brown, L. A., McLean, C. P., Zang, Y., Zandberg, L., Mintz, J., … Foa, E. B. (2019). Does prolonged exposure increase suicide risk? Results from an active duty military sample. Behaviour Research and Therapy, 118, 87–93. This study examined PTSD symptom reduction, changes in suicidal ideation, and symptom exacerbations among those participating in a trauma-focused cognitive-behavioral therapy. Prolonged exposure therapy resulted in decreases in both PTSD symptoms and suicidal ideation. Moreover, exacerbations in risk were less likely among those in the trauma-focused cognitive-behavioral therapy relative to the waitlist condition. Prolonged exposure therapy was found to be both a tolerable and effective intervention for addressing PTSD and suicide risk.

  36. Bryan CJ, Clemans TA, Hernandez AM, Mintz J, Peterson AL … Resick PA. Evaluating potential iatrogenic suicide risk in trauma-focused group cognitive behavioral therapy for the treatment of PTSD in active duty military personnel. Depress Anxiety. 2016;33:549 557.

  37. Gradus JL, Suvak MK, Wisco BE, Marx BP, Resick PA. Treatment of posttraumatic stress disorder reduces suicidal ideation. Depress Anxiety. 2013;30(10):1046–53.

    PubMed  Google Scholar 

  38. Holliday R, Holder N, Monteith LL, Surís A. 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. 2018;206(7):575–8.

    Article  Google Scholar 

  39. Johnson, C. M., Holmes, S. C., Suvak, M. K., Song, J., Shields, N., … Monson, C. M. (2020). The effect of PTSD symptom change on suicidal ideation in a combined military and civilian sample engaged in cognitive processing therapy. Behavior Therapy. Published online ahead of print.

  40. Norr AM, Smolenski DJ, Reger GM. Effects of prolonged exposure and virtual reality exposure on suicidal ideation in active duty soldiers: an examination of potential mechanisms. J Psychiatr Res. 2018;103:69–74.

    Article  PubMed  Google Scholar 

  41. •• 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. Published online ahead of print. As providers are often apprehensive to initiate trauma-focused cognitive-behavioral therapy among patients endorsing suicidal thoughts and behaviors, the authors examined course of treatment among patients at risk for suicide who initiated cognitive processing therapy. Elevations in suicidal thoughts and behavior appeared rare and symptom reduction was similar regardless of acuity of suicide risk. This study provides evidence of the tolerability and benefit of a trauma-focused cognitive-behavioral therapy for patients with PTSD and concurrent risk for suicide within a naturalistic setting.

  42. Stayon LE, Martin CE, Pease JL, Chard KM. Changes in suicidal ideation following cognitive processing therapy in a VA residential treatment program. Mil Psychol. 2019;31(4):326–34.

    Article  Google Scholar 

  43. Harned MS, Korslund KE, Linehan MM. A pilot randomized controlled trial of dialectical behavior therapy with and without the dialectical behavior therapy prolonged exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behav Res Ther. 2014;55:7–17.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Paris J. Is hospitalization useful for suicidal patients with borderline personality disorder. J Pers Disord. 2004;18(3):240–7.

    Article  PubMed  Google Scholar 

  45. Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012;19:256–64.

    Article  Google Scholar 

  46. Stanley B, Brown GK, Brenner LA, Galfalvy HC, Currier GW, Knox KL, ... Green KL. Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiat. 2018;75:894-900

  47. Bryan CJ, Mintz J, Clemans TA, Leeson B, Burch TS … Rudd MD. Effect of crisis response planning vs. contracts for safety on suicide risk in U.S. Army Soldiers: a randomized clinical trial. J Affect Disord. 2017;212:64-72

  48. Stanley B, Brown GK, Karlin B, Kemp JE, VonBergen HA. Safety Plan Treatment Manual to Reduce Suicide Risk: Veteran Version. Washington, D.C.: United States Department of Veterans Affairs; 2008.

    Google Scholar 

  49. Matarazzo BB, Homaifar BY, Wortzel HS. Therapeutic risk management of the suicidal patient: safety planning. J Psychiatr Pract. 2014;20:220–4.

    Article  PubMed  Google Scholar 

  50. Holliday R, Rozek DC, Smith NB, McGarity S, Jankovsky M, Monteith LL. Safety planning to prevent suicidal self-directed violence among veterans with posttraumatic stress disorder: clinical considerations. Prof Psychol Res Pract. 2019;50(4):215–27.

    Article  Google Scholar 

  51. Ganzini L, Denneson LM, Press N, Bair MJ, Helmer DA … Dobscha SK. Trust is the basis for effective suicide risk screening and assessment in veterans. J Gen Intern Med. 2013;28(9)1215-1221

  52. Monteith LL, Holliday R, Dorsey Holliman BA, Brenner LA, Simonetti JA. Understanding female veterans’ experiences and perspectives of firearms. J Clin Psychol. 2020;76(9):1736–53.

    Article  PubMed  Google Scholar 

  53. Sadler, A. G., Mengeling, M. A., Cook, B. L., & Torner, J. C. (2021). Factors associated with U.S. military women keeping guns or weapons nearby for personal security following deployment. Journal of Women’s Health, 30(1), 103–112.

  54. Stanley, I. H., Hom, M. A., Marx, B. P., & Reger, M. A. (2020). Post‐traumatic stress disorder and firearm ownership, access, and storage practices: a systematic review. Clinical Psychology: Science and Practice, 27(3), e12358.

  55. Hoyt, T., Holliday, R., Simonetti, J. A., & Monteith, L. L. (in press). Firearm lethal means safety with military personnel and veterans: overcoming barriers using a collaborative approach. Professional Psychology: Research and Practice.

  56. Borges LM, Nazem S, Matarazzo BB, Barnes SM, Wortzel HS. Therapeutic risk management: chain analysis of suicidal ideation and behavior. J Psychiatr Pract. 2019;25(1):46–53.

    Article  PubMed  Google Scholar 

  57. Holder N, Holliday R, Williams R, Mullen K, Surís A. A preliminary examination of the role of psychotherapist fidelity on outcomes of cognitive processing therapy during an RCT for military sexual trauma-related PTSD. Cogn Behav Ther. 2018;47(1):76–89.

    Article  PubMed  Google Scholar 

  58. Farmer CC, Mitchell KS, Parker-Guilbert K, Galovski TE. Fidelity to the cognitive processing therapy protocol: evaluation of critical elements. Behav Ther. 2017;48(2):195–206.

    Article  PubMed  Google Scholar 

  59. Holder N, Holliday R, Pai A, Surís A. Role of borderline personality disorder in the treatment of military sexual trauma-related posttraumatic stress disorder with cognitive processing therapy. Behav Med. 2017;43(3):184–90.

    Article  PubMed  Google Scholar 

  60. Lenz S, Bruijn B, Serman NS, Bailey L. Effectiveness of cognitive processing therapy for treating posttraumatic stress disorder. J Ment Health Couns. 2014;36(4):360–76.

    Article  Google Scholar 

  61. Ragsdale, K. A., Voss Horrell, S. C. (2016). Effectiveness of prolonged exposure and cognitive processing therapy for U.S. veterans with a history of traumatic brain injury. Journal of Traumatic Stress, 29(5), 474–477.

  62. Rauch SAM, Eftekhari A, Ruzek JI. Review of exposure therapy: a gold standard for PTSD treatment. J Rehabil Res Dev. 2012;49(5):679–88.

    Article  PubMed  Google Scholar 

  63. Yuodelis-Flores C, Reis RK. Addiction and suicide: a review. Am J Addict. 2015;24(2):98–104.

    Article  PubMed  Google Scholar 

  64. Back SE, Killeen T, Badour CL, Flanagan JC, Allan NP … Brady KT. Concurrent treatment of substance use disorders and PTSD using prolonged exposure: a randomized clinical trial in military veterans. Addict Behav. 2019;90:369-377

  65. Van Orden KA, Witte TK, Cukrowicz KC, Braithwaite S, Selby EA, Joiner TE. The interpersonal theory of suicide. Psychol Rev. 2010;117(2):575–600.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Galovski TE, Nixon RDV, Kaysen D. Flexible applications of cognitive processing therapy: evidence-based treatment methods. London: Academic Press; 2020.

    Google Scholar 

  67. Linehan MM. Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford Press; 1993.

    Google Scholar 

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Authors and Affiliations

  1. Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, USA

    Ryan Holliday & Lindsey L. Monteith

  2. University of Colorado Anschutz Medical Campus, Aurora, CO, USA

    Ryan Holliday & Lindsey L. Monteith

  3. San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA

    Nicholas Holder

  4. Sierra Pacific Mental Illness Research, Education and Clinical Center, San Francisco, CA, USA

    Nicholas Holder

  5. University of California San Francisco, School of Medicine, San Francisco, CA, USA

    Nicholas Holder

  6. Headstrong Project Inc., New York, NY, USA

    Amy M. Williams

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  1. Ryan Holliday
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  2. Nicholas Holder
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  3. Amy M. Williams
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  4. Lindsey L. Monteith
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Correspondence to Ryan Holliday.

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Holliday, R., Holder, N., Williams, A.M. et al. Treating PTSD in the Context of Concurrent Suicide Risk: Current Evidence and Navigating Complicating Factors. Curr Treat Options Psych 8, 213–228 (2021). https://doi.org/10.1007/s40501-021-00251-1

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