The current study explored the clinical utility of the Brief Suicide Cognitions Scale (B-SCS) in multiple samples, including a normative sample and three clinical samples with varying degrees of suicide risk. Derived cutting scores were identical across an inpatient randomized clinical trial (RCT) sample, an emergency department (ED) sample, and an inpatient consecutive admission sample, with B-SCS scores at intake correctly predicting 96 % and 94 % of suicide attempts over six-month follow-up periods in the RCT and ED samples, respectively. Additionally, the B-SCS intake scores in the RCT sample predicted differences in high and low suicide ideation groups over the six-month follow-up period, with those below the B-SCS intake cutoff score reporting suicidal ideation scores within normal limits throughout the entirety of post-discharge follow-up. Current results support the recommendation that evaluation of the clinical utility of instruments identifying suicide risk require variable criteria depending on the specific clinical context and related clinical decision-making. With respect to post-discharge monitoring and related treatment tailoring for inpatient and ED clinical environments, instruments with strong sensitivity and high negative predictive value (NPV) estimates are of particular importance given the need to accurately recognize both the resolution of an acute episode of suicide risk and identify those vulnerable for future episodes. In the current study, the B-SCS had sensitivity estimates of .96 and .94 and NPV estimates of .97 and .93. in these clinical settings. Implications for day-to-day practice, the need for future research, and study limitations are discussed.

The Death-Implicit Association Test (D-IAT) was developed to assess implicit cognitions that may indicate a bias towards suicide or death. Although the D-IAT is widely used, little is known about its prospective validity. The current study assessed the prospective validity and treatment sensitivity of the D-IAT in a large sample of inpatients at high risk of suicide. We hypothesized that baseline D-IAT scores would (a) improve from pre- to post- inpatient admission, reflecting a stronger association between self and life; and (b) predict suicidal thoughts and behaviors across a 6-month follow-up period post-discharge. Participants were 200 individuals admitted to the psychiatric inpatient unit for suicide risk. They were randomly assigned to receive inpatient treatment as usual (TAU) or brief cognitive-behavioral therapy for suicide prevention (BCBT) and completed the D-IAT before and after treatment and monthly for six months after discharge. Contrary to our hypotheses, D-IAT scores did not significantly change from pre- to post-admission and did not predict suicidal thoughts or behaviors across the follow-up period, with the exception of aborted attempts. The findings largely do not support the prospective validity of the D-IAT nor its sensitivity to detect treatment effects, although replication in samples with greater frequency of suicidal behaviors across the follow-up period will be needed.

Gender minority stress may contribute to elevated suicide risk for transgender individuals. Yet, it is unclear to what extent minority stress themes are addressed in existing suicide prevention treatments. To address this gap, it is important to explore if and how clinicians incorporate themes of minority stress in suicide prevention treatment. Qualitative and quantitative content analysis was conducted for Brief Cognitive-Behavioral Therapy-Inpatient (BCBT-I) treatment sessions of six transgender participants. Themes related to minority stress and the treatment process were coded. Despite variability in explicit querying by clinicians, minority stress components were uniformly discussed in relation to participant's BCBT-I case formulation and/or skills development. Content related to social connection and disconnection were the most frequently identified themes. Content related to gender dysphoria, identity disclosure, negative external events, and anticipation of negative events were discussed less frequently. These findings highlight that discussions of transgender minority stress can be incorporated into existing, evidence-based models of suicide prevention treatment. Training clinicians to specifically raise pertinent issues for transgender people may be beneficial for identifying specific vulnerabilities and sources of resilience for transgender clients. Future exploration of the efficacy of BCBT-I for transgender participants is needed.

Objective: Diefenbach and colleagues (2024) found that inpatient Brief Cognitive-Behavioral Therapy for Suicide Prevention (BCBT-I) reduced the rate of six-month post-discharge psychiatric readmissions compared to treatment as usual (TAU). This treatment effect; however, was limited to inpatients, whom were not diagnosed with substance use disorder (SUD). The aim of this secondary analysis was to determine BCBT-I treatment effects and SUD moderation on post-discharge emergency department (ED) utilization. Methods: Inpatients with a history of suicide attempt were assigned to BCBT-I + TAU (n = 94) or TAU alone (n = 106). Presence and number of ED visits were determined via self-report and electronic medical record review for six months after discharge. Generalized linear models for count and binary data were conducted. Results: Adding BCBT-I to TAU reduced the odds and rate of post-discharge ED visits by three quarters [Odds Ratio estimate = 0.25, 95 % CI:(0.12, 0.46); Rate Ratio estimate = 0.24, 95 % CI:(0.11, 0.53)], but only among participants without SUD. Over one-third (36 %) of ED visits were related to suicide. Findings for suicide-related ED visits mirrored those of all-cause ED visits. Conclusions: Adding BCBT-I to TAU reduced post-discharge ED utilization in participants without SUD. Additional research is needed to improve the efficacy of BCBT-I for patients with SUD.

This state-of-the-science review describes the relatively new diagnosis of hoarding disorder (HD), characterized by difficulty discarding possessions and resulting clutter in living spaces. We review current theoretical models of HD, including a cognitive-behavioral model, a biopsychosocial model, an attachment model, and an addictions model. We then describe interventions for HD, focusing largely on cognitive-behavioral therapy for hoarding disorder (CBT-HD), the only treatment with conclusive evidence of efficacy. We review the components of CBT-HD and their rationale, noting that clinical results have been modest. The cross-cultural efficacy of CBT-HD is unclear, as are the effects of cultural modifications to the treatment. Future clinical and research directions are discussed.

Adults with clinically significant borderline personality disorder traits (BPTs) are at high risk of experiencing suicidal thoughts and behaviors (STBs). STBs among those with BPTs have been associated with suicidal beliefs (e.g., that one is unlovable or that distress is intolerable). However, the extent to which suicidal beliefs uniquely mediate the relationship between emotional distress and STBs among individuals with BPTs is not known. Individuals admitted to an inpatient unit (N = 198) with recent STBs completed assessments of BPTs, depression, suicidal beliefs, suicidal ideation, and suicide attempt history. Moderated mediation models were used to explore whether suicidal beliefs mediated the relationship between depression and STBs conditional on BPTs. Suicidal patients with versus without BPTs reported stronger suicidal beliefs and more severe STBs (i.e., suicidal ideation, lifetime attempts). Exploratory moderated mediation analysis demonstrated that suicidal beliefs mediated the relationship between depression and suicidal ideation as well as suicide attempts. The mediation effect of suicidal beliefs on the depression-ideation and depression-attempt relationship was not significantly moderated by BPTs. This study was cross-sectional and therefore the estimated mediation models must be considered exploratory. Longitudinal research will be needed to assess the potential causal mediation of suicidal beliefs on the relationship between depression and STBs. The results of this study suggest that suicidal beliefs may play a significant role in the relationship between depression and STBs for inpatients with a history of suicidality regardless of BPTs. This suggests suicidal beliefs may be an important treatment target for adults with a history of STBs.

OBJECTIVES:Quality of life (QOL) is a multidimensional construct including emotional well-being, life satisfaction, and physical health. Individuals with posttraumatic stress disorder (PTSD) consistently report low QOL, highlighting the importance of assessing the effectiveness of first-line PTSD treatments (e.g., exposure-based therapies) on QOL. This meta-analysis examined the efficacy of exposure therapy for PTSD on QOL compared to control conditions (e.g., waitlist, medication, treatment-as-usual) at posttreatment and follow-up (ranging from 1 month to 2 years). METHODS:Building on a previous meta-analysis of exposure-based therapy for PTSD, we searched PsycINFO and Medline in December 2021, July 2022, and March 2023 to include randomized controlled trials of exposure-based treatments for adult PTSD assessing QOL. We screened 295 abstracts for initial eligibility; 20 articles met inclusion criteria and were included (N = 2729 participants). Risk of bias was evaluated using the Cochrane Risk of Bias tool 2.0. RESULTS:At posttreatment, exposure-based therapies showed a medium effect on QOL relative to control conditions (k = 25, g = 0.67). This effect was not observed at follow-up for the small subset of studies with follow-up data (k = 8, g = 0.16). At posttreatment, effect size varied significantly as a function of the control condition (p < .0001). There were no differences in QOL effects across exposure therapies at posttreatment or follow-up (p = .09). CONCLUSION:Exposure therapy was associated with greater improvement in QOL compared to control conditions at posttreatment. Exposure was not superior to control conditions at follow-up, and the longer-term impact of exposure on QOL is unclear. The implications of these findings are discussed, along with the need for more PTSD treatment studies to examine QOL outcomes at posttreatment and follow-up.

The Parenting Anxious Kids Rating Scale-Parent Report (PAKRS-PR) measures five types of anxiogenic parenting. The present study aimed to extend the previous psychometric evaluation of the PAKRS-PR to a treatment-seeking sample and examine sensitivity to change over 15 sessions of cognitive behavioral therapy. The sample included 383 parent–child dyads presenting to treatment at a specialty outpatient clinic. Cronbach’s α was acceptable for the PAKRS-PR Total scale and several subscales, although the Accommodation/Beliefs and Warmth/Support subscales were in the unacceptable/questionable range. Convergent validity was found to be mixed with the closest relationship between anxiety severity and the Accommodation/Beliefs, Warmth/Support, and Conflict PAKRS-PR subscales. Additionally, the PAKRS-PR Total score and subscales changed significantly throughout treatment, but were not associated with treatment response or child- or clinician-rated treatment outcome measures. Overall, the current findings demonstrate some support for the psychometric properties of the PAKRS-PR; however, further refinement of the PAKRS-PR at the item-level is recommended to further strengthen the measure.

Effective and efficient measures of functional impairment in youth are needed, as few validated measures exist. The youth-adapted Sheehan Disability Scale (Y-SDS) measures (1) child-reported impairment (Y-SDS-C), (2) parent reported child impairment (Y-SDS-PC), and (3) parent report of their own impairment due to the child’s symptoms (Y-SDS-PP). The present study aimed to evaluate the psychometric properties of the Y-SDS, explore potential age-related differences, and examine sensitivity to change over 15 sessions of cognitive behavioral therapy. The sample included 583 parent-child dyads presenting to treatment at a specialty outpatient clinic. Youth and parents reported mild to moderate impairment across domains. Cronbach’s α was acceptable for all three scales with some variation in child report by age. Inter-rater agreement was fair between parent and child report of child’s functional impairment. Greater Y-SDS-C and Y-SDS-PC were significantly correlated with higher clinician-rated illness, anxiety, and depression severity at baseline. Significant reductions in functional impairment were found across treatment and improvements were correlated with improved severity on clinician and child reported measures. Overall, the Y-SDS is a reliable and valid measure of youth and parent functional impairment with utility as an outcome measure in treatment.

Importance Suicide risk is elevated after discharge from inpatient level of care. Empirically supported inpatient suicide prevention treatments are needed. Objective To determine whether adding an inpatient version of brief cognitive behavioral therapy for suicide prevention to treatment as usual reduces postdischarge suicide attempts, suicidal ideation, and psychiatric readmissions and to determine whether substance use disorder moderates treatment effects. Design, Setting, and Participants This randomized clinical trial compared treatment as usual (n = 106) to treatment as usual plus brief cognitive behavioral therapy for inpatients (n = 94) at a private psychiatric hospital in Connecticut. Follow-up assessments were completed monthly for 6 months postdischarge. Participants were enrolled from January 2020 through February 2023. Inpatients admitted following a suicidal crisis (past-week suicide attempt or ideation with plan on admission and attempt within previous 2 years) were included. Medical records of consecutive admissions (n = 4137) were screened, 213 were study eligible and randomized, and 200 were analyzed. A total of 114 participants (57.0%) completed 6-month follow-up assessments. Data from medical records were also obtained through 6-month follow-up. Intervention Up to 4 individual sessions of brief cognitive behavioral therapy for suicide prevention designed for inpatients. Main Outcomes and Measures Suicide attempts and readmissions were assessed via blind interviews and medical record review. Suicidal ideation was assessed via self-report. Results The mean (SD) age among 200 analyzed participants was 32.8 (12.6) years; 117 participants were female and 83 were male. Brief cognitive behavioral therapy–inpatient reduced the occurrence of suicide attempt over 6 months postdischarge by 60% (odds ratio, 0.40; 95% CI, 0.20-0.80; number needed to treat, 7) in the entire patient group, and the rate of psychiatric readmissions by 71% (rate ratio, 0.29; 95% CI, 0.09-0.90) in those without a substance use disorder. The effect of treatment condition on suicidal ideation was less clear, although post hoc analyses indicated less severe suicidal ideation following brief cognitive behavioral therapy–inpatient vs treatment as usual at 1 and 2 months postdischarge. Conclusions and Relevance Brief cognitive behavioral therapy–inpatient reduced 6-month postdischarge suicide reattempts and rate of readmissions when added to treatment as usual. Substance use disorder moderated the treatment’s effect on readmission rates. Treatment effects on suicidal ideation were less clear. Implementation research is needed to facilitate dissemination. Additional research is also needed to optimize outcomes for individuals with substance use disorders. Trial Registration ClinicalTrials.gov Identifier: NCT04168645

Purpose Research suggests that performance on the Death-Implicit Association Test (D-IAT) converges with explicit indicators of suicide risk (e.g., suicidal ideation, suicidal behaviors). However, the utility of the D-IAT in acute care settings has been questioned given limited studies and inconsistent findings. Additionally, it remains unclear whether the D-IAT incrementally improves the assessment of suicide risk beyond explicit measures. Method The present study evaluated the validity of the D-IAT in a large sample of psychiatric inpatients who attempted suicide within the past two years ( N = 203; M age = 32.93 [ SD = 12.61]; 50.7% female; 63.5% White; 22.7% Hispanic/Latino). The D-IAT was scored three ways: (1) conventional D scoring where positive scores indicate stronger implicit associations with death, (2) dichotomized D scores where participants were categorized based on positive or negative D score, and (3) DD scoring, which is a novel procedure that differentiates self-identification with death (Me- DD ) from a lack of identification with life (Not Me- DD ). Results D and Not Me- DD were weakly associated with suicide cognitions, hopelessness, suicidal ideation, and wishes to live/die and there were corresponding mean differences based on dichotomized D scores. D and Not Me- DD were also weakly correlated with number of lifetime suicide attempts. Me- DD evidenced fewer significant associations than Not Me- DD suggesting that a lack of association with life may be the central component of D scores. Conclusions Findings suggest that the D-IAT may not be a useful standalone measure of suicide risk in high-risk populations.

Objective: Psychiatric multimorbidity is a well-documented risk factor for suicide. However, diagnostic heterogeneity and patterns of comorbidity likely exists within the population of those who attempt suicide. Person-centered statistical approaches, such as latent class analysis (LCA), extract distinguishable groups differentiated by prevalence and comorbidity of psychiatric disorders. Method: The present study used LCA to identify typologies of psychiatric heterogeneity in a sample of 213 inpatients (M age = 33.04 [SD = 12.67]; 57.3% female; 62.4% White; 23.9% Hispanic/Latino) with a history of suicide attempt who were recruited for a suicide prevention clinical trial. Class differences in suicide history characteristics; demographic characteristics; and cognitive-affective and behavioral risk factors, obtained from an initial evaluation involving the administration of a semi-structured diagnostic interview, suicide risk assessment, and battery of self-report measures, were explored. Results: LCA identified three classes in the best-fitting solution: Depressive-High Comorbidity (n = 68), Depressive-Low Comorbidity (n = 86), and Bipolar (n = 59). The Depressive-Low Comorbidity class reported less severe suicidal ideation (p < .001), anxiety (p < .001), stress (p < .001), unlovability beliefs (p = .006), and impulsivity (p < .001). The Depressive-Low Comorbidity class also reported fewer actual attempts than the Bipolar class (p = .001) and fewer interrupted attempts than the Depressive-High Comorbidity class (p = .004). Conclusions: The Depressive-High Comorbidity and Bipolar classes consistently endorsed higher levels of suicide risk factors. These findings may help to illuminate typologies of suicide attempters with unique clinical needs, which is an essential step toward personalized medicine.

Because outcomes from cognitive-behavioral therapy (CBT) are modest for hoarding disorder (HD), the objectives of this study were a) to characterize if CBT-related improvements were predicted by anterior cingulate cortex (ACC) or other cingulo-opercular network changes shown to be dysfunctional in our prior HD neuroimaging research, and b) to learn if CBT outcomes could be predicted by pre-CBT brain activity.

This article describes the work of a task force, commissioned by the American Psychological Association’s Society of Clinical Psychology (SCP), to define “psychological treatment.” We discuss SCP’s rationale for needing such a definition, including the potential for non-psychological interventions to be considered under the current model of empirically supported treatments. The task force, in collaboration with the membership of SCP, proposes the following definition: Psychological treatment is an intervention consisting of specific actions between a person or persons and a mental health professional or designee, with the intent of engaging cognitive, emotional, behavioral, or interpersonal processes, in the service of modifying health or functional outcomes, and whose core assumptions about its procedures and mechanisms of change are founded in psychological science and consistent with scientific understanding. We outline our thinking around this definition and discuss alternatives that were rejected. The definition proposed here is largely consistent with the clinical practice guidelines of the American Psychological Association, though we note that at least one of those guidelines goes well beyond interventions that could reasonably be called psychological treatments. Potential uses and misuses of this definition are outlined, and we suggest additional areas for exploration and clarification.

Individuals with hoarding disorder (HD) have difficulty parting with personal possessions, which leads to the accumulation of excessive clutter. According to a proposed biphasic neurobiological model, HD is characterized by blunted central and peripheral nervous system activity at rest and during neutral (non-discarding) decisions, and exaggerated activity during decision-making about discarding personal possessions. Here, we compared the error-related negativity (ERN) and psychophysiological responses (skin conductance, heart rate and heart rate variability, and end tidal CO2) during neutral and discarding-related decisions in 26 individuals with HD, 37 control participants with anxiety disorders, and 28 healthy control participants without psychiatric diagnoses. We also compared alpha asymmetry between the HD and control groups during a baseline resting phase. Participants completed a series of Go/No Go decision-making tasks, one involving choosing certain shapes (neutral task) and the other involving choosing images of newspapers to imaginally “discard” (discarding task). While all participants showed expected increased frontal negativity to commission of an error, contrary to hypotheses, there were no group differences in the ERN or any psychophysiological measures. Alpha asymmetry at rest also did not differ between groups. The findings suggest that the ERN and psychophysiological responses may not differ in individuals with HD during simulated discarding decisions relative to control participants, although the null results may be explained by methodological challenges in using Go/No Go tasks as discarding tasks. Future replication and extension of these results will be needed using ecologically valid discarding tasks.

Broad deficits in emotion regulation skills have been observed in children with anxiety-related disorders. These deficits typically improve during cognitive-behavioral therapy (CBT), but few studies have examined changes in expressive suppression and cognitive reappraisal in youth with anxiety disorders and/or obsessive–compulsive disorder (OCD) during CBT, especially in real-world settings. In a naturalistic treatment-seeking sample, 123 youth completed measures of anxiety, depression, and emotion regulation strategy use before and after 15 sessions of CBT. For anxious youth, anxiety and expressive suppression decreased over treatment, while cognitive reappraisal increased. Reductions in expressive suppression and increases in cognitive reappraisal were significantly associated with improvements in anxiety and remained significantly associated with post-treatment anxiety after accounting for baseline anxiety and depression. Changes in expressive suppression and cognitive reappraisal over the course of treatment were not found for youth with primary OCD. Thus, CBT improves emotion regulation abilities in anxious youth, and these improvements are associated with anxiety reduction; improvements in emotion regulation do not appear to drive changes in OCD symptoms. Further research is needed to determine whether changes in emotion regulation strategies mediate changes in anxiety among youth receiving CBT.

The efficacy of cognitive-behavioral therapy (CBT) for reducing anxiety disorder symptoms is well documented. However, limited research has investigated how symptom amelioration is temporally associated with changes in psychosocial functioning, such as interpersonal and social role functioning, during CBT. Participants were 288 (M age = 37.00 [SD = 14.41]; 59.0% female; 69.0% White; 6.6% Hispanic/Latino) outpatients diagnosed with an anxiety disorder who received CBT at a specialized hospital-based clinic. Participants completed the Outcome Questionnaire-45, a measure of symptom distress, social role performance, and interpersonal problems, at initial assessment and prior to each treatment session. Symptom distress and indicators of psychosocial functioning were robustly related during 25 sessions of CBT. Cross-lagged analyses revealed that reductions in symptom distress predicted subsequent improvements in psychosocial functioning during treatment, and vice versa. Associations from symptom distress to subsequent psychosocial functioning evidenced larger effect sizes than the reverse. Lower levels of severity at intake and presence of comorbid depression attenuated the association between symptom reduction and subsequent social role performance improvement. In sum, anxiety symptoms and psychosocial functioning bidirectionally improve during CBT for anxiety disorders. Maximally effective treatments may be those that simultaneously ameliorate symptoms and focus on improving functioning in key domains.

Research suggests that estradiol may moderate fear extinction. It is unclear whether these results generalize to exposure therapy. The aim of the current study was to determine whether estradiol moderates outcomes in exposure therapy among women with anxiety disorders. Participants were 35 women with a primary diagnosis of an anxiety disorder who participated in the study as part of routine care at an anxiety specialty clinic. Endogenous estradiol was assessed via saliva. They provided subjective distress ratings before (pre) and after (post) an exposure session, as well as after a brief delay (recall). Contrary to predictions, there were no significant differences in exposure outcomes between the high and low estradiol groups. However, among participants with primary obsessive-compulsive disorder (OCD), results were partially consistent with the hypotheses. Women with lower estradiol initially demonstrated more improvement in subjective distress from pre- to post-exposure, but after the delay, significantly greater distress (attenuated extinction recall). Results suggest that women with lower estradiol may respond less favorably to exposure therapy for OCD relative to women with higher estradiol. These findings await replication in larger samples with longer recall delays. Should replication occur, these results may inform the use of estradiol to augment exposure therapy.

BACKGROUND:Experiential avoidance (EA) may serve as a risk factor for a wide range of anxiety-related psychopathology. Anxiety is thought to trigger the use of EA, while also serving as a consequence of EA efforts. Previous ecological momentary assessment (EMA) studies found that EA was associated with greater anxiety in nonclinical undergraduates and patients with social anxiety disorder. METHODS:The present study examined the in-the-moment, bidirectional relationship between EA, perceived stress, and two facets of anxiety (autonomic arousal and worry/misery) in a sample of treatment-seeking patients broadly diagnosed with an anxiety-related disorder (N = 46). Participants completed a baseline assessment followed by an EMA assessment period (assessments three times daily for seven days). We hypothesized that there would be a bidirectional relationship between EA and anxiety/stress. RESULTS:Results largely supported a unidirectional relationship such that greater EA at one time point predicted higher stress at a later time point controlling for previous stress levels and linear time. Trend-level associations between EA and anxiety symptoms are discussed. CONCLUSIONS:The current study provides important insight into the relationship between EA and anxiety symptoms in a clinical sample of participants with anxiety-related disorders.

Introduction: Expert consensus operationalized treatment response and remission in obsessive -compulsive disorder (OCD) as a Yale -Brown Obsessive -Compulsive Scale (Y-BOCS) reduction >= 35% and score <= 12 with <= 2 on Clinical Global Impressions Improvement (CGI-I) and Severity (CGI-S) scales, respectively. However, there has been scant empirical evidence supporting these definitions. Methods: We conducted a systematic review and an individual participant data meta -analysis of randomizedcontrolled trials (RCTs) in adults with OCD to determine optimal Y-BOCS thresholds for response and remission. We estimated pooled sensitivity/specificity for each percent reduction threshold (response) or posttreatment score (remission) to determine response and remission defined by a CGI-I and CGI-S <= 2, respectively. Results: Individual participant data from 25 of 94 eligible RCTs (1235 participants) were included. The optimal threshold for response was >= 30% Y-BOCS reduction and for remission was <= 15 posttreatment Y-BOCS. However, differences in sensitivity and specificity between the optimal and nearby thresholds for response and remission were small with some uncertainty demonstrated by the confidence ellipses. Conclusion: While the empirically derived Y-BOCS thresholds in our meta -analysis differ from expert consensus, given the predominance of data from more recent trials of OCD, which involved more refractory participants and novel treatment modalities as opposed to first -line therapies, we recommend the continued use of the consensus definitions.