Research may one day allow suicidal behavior to be directly treated--independently of other comorbidities.
But very little data are available on effective treatments for suicidal behavior.
Marsha M. Linehan, Ph.D., known for her work in developing dialectic behavior therapy (DBT) for treating patients with borderline personality disorder (BPD), thinks the modality not only can be effective for suicidal patients with BPD but for those with other conditions as well.
"DBT is primarily viewed as a treatment for borderline personality disorder, although it's beginning to be used for eating disorders and other disorders. As people become more aware of the data on suicide, it'll be more widely used," she predicted in an interview with this newspaper.
DBT blends accepting patients with teaching them to change maladaptive behaviors, according to her book, "Cognitive-Behavioral Treatment of Borderline Personality Disorder" (the Guilford Press, 1993). Practitioners who use DBT must work to build a collaborative, positive interpersonal relationship with patients. Validating the patient's emotional desperation while pointing out the kernel of truth in their communications is essential, said Dr. Linehan, director of the Behavior Research & Therapy Clinics at the University of Washington, Seattle.
In addition, therapists are expected to coach and encourage patients and bring humor and flexibility to their treatment. Patients are given homework assignments as part of treatment and are taught coping skills for specific problems. Steps as simple as sending encouraging postcards to patients long after the end of their therapy sessions have proven useful in lowering a patient's suicide risk.
"There's loads of research on suicide. There's not a lot of research on the treatment of suicide," she said. "There are several reasons for that. One is, there's been a pervasive belief that suicide is a symptom of a disorder, and therefore, if you treated the disorder, then you would reduce suicides. There was a belief that you don't treat suicide, since it's a symptom. You treat the disorder," said Dr. Linehan, also a professor in the department of psychology at the university.
But although there is little evidence to support the theory that treating a disorder that's correlated with suicide--such as depression--changes the suicide rate, it remains a pervasive belief.
Dr. Linehan sees the situation differently. Why not focus on patients' suicidal tendencies directly, she says, and maybe that approach would lead fewer patients to commit suicide. "People think depression causes people to be suicidal, but it's just as reasonable to think being suicidal causes you to be depressed," she said.
Data supporting the effectiveness of hospitalizing suicidal patients are also scant. Yet suicide is the leading cause of death in psychiatric hospitals (Lancet 360:319-326, 2002). "There's never been a study that shows that putting a suicidal person in a hospital increases their life by even 5 minutes, much less keeps them from killing themselves," Dr. Linehan commented.
Given the lack of data, why hospitalize these patients? Dr. Linehan points to liability concerns. "In suicide, you get sued not for your treatment, [but for] the outcome of the treatment," she said.
With the proper training in DBT, psychiatrists and other mental health professionals can have a real impact on the treatment of suicidal patients, said Dr. Linehan, who also has written a skills training manual on the therapy and has worked closely with psychiatrists in the course of DBT. Training psychiatrists is crucial because the patients who need DBT are typically difficult to treat.
The American Psychiatric Association does not have an official position on DBT, a spokesperson said. But Dr. Linehan thinks the therapy has been well received among psychiatrists.
"My experience with the psychiatric community is, they've opened their arms to DBT. …