Replies to comments by Paniagua (see record 2027-90077-005) on the original article by Jobes and Barnett (see record 2024-78987-001). The quality of research on psychological interventions for suicide risk and for the use of medications alone and in conjunction with psychological interventions is discussed. Risks associated with medication treatment and benefits of psychological interventions are considered. The need to address the underlying causes of suicidality is emphasized with thoughtful attention to relying on the strongest possible research evidence available today to optimally treat suicidal risk to decrease suffering and help save lives. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

Psychic pain (PsyPn) refers to intense emotional suffering that is experienced as both unbearable and irreversible. PsyPn has been shown in cross-sectional studies to be associated with greater depression, distress, and suicide risk. Although PsyPn is frequently discussed as a primary driver of suicide, few studies have evaluated its short-term predictive value for detecting changes in risk, and few have examined how PsyPn influences risk in interaction with other established factors, such as hopelessness. To address these gaps, the current study utilized ecological momentary assessment (EMA) to identify links between PsyPn, well-established psychosocial risk factors for suicide (hopelessness, loneliness, and burdensomeness), and the short-term emergence of suicidal ideation (SI) and planning. Thirty-nine adults across three clinical sites enrolled in the study after being identified during prescreen as being at elevated suicide risk. Subjects completed a baseline measure of vulnerability to PsyPn (Psychic Pain Scale), followed by an EMA protocol evaluating negative mental states, PsyPn, and SI and planning six times daily over a 14-day period. Multilevel modeling was used to estimate both within-and between-person associations between PsyPn, negative mental states, and SI and planning. Across suicide-related outcomes and timescales, PsyPn was associated with increased suicide risk, and greater PsyPn at both baseline and near-term levels amplified the influence of other daily living risk factors on suicide-related outcomes. The implications of these findings for suicide risk assessment and intervention are discussed, particularly in terms of informing specific targets and timescales of interventions.

This study used magnetoencephalography (MEG) and the life/death dot-probe task to investigate neural correlates of suicide risk, specifically whether suicide risk moderates selective attention to death-related cues. Three groups were examined: individuals with a lifetime history of suicide attempt or ideation (suicide risk; n = 17); those with depression but no suicide risk (clinical controls; n = 17); and healthy volunteers (n = 19). Individuals with suicide risk exhibited decreased activity in the superior parietal lobule (SPL), entorhinal cortex (EC), and middle temporal gyrus (MTG) in the death and incongruent conditions across multiple bandwidths (ps < 0.05), indicating suicide risk-associated dysregulation of brain regions related to signal processing. Dynamic causal modeling was used to estimate effective connectivity. In the death condition, reduced feedforward connectivity was observed from the early visual cortex to the EC, then to the SPL, and finally to the MTG in the suicide risk group (posteriorps > 0.90), suggesting potential deficits in updating sensory inputs and regulating selective attention. Conversely, in the life condition, reduced connectivity was observed from the MTG to the SPL in the suicide risk group (posteriorps > 0.90), suggesting subtle impairments in downregulating attention orientation during life-related cognitive processes. Abnormalities in selective attention to death-related cues may serve as potential biomarkers for suicide risk.

OBJECTIVE:Suicide remains a growing concern in the United States, with a 35% increase since 2000. Leading experts emphasize the urgent need for effective, suicide-specific treatments. This retrospective study followed a quality improvement design, using a convenience sample and providing transparency of the treatment being provided. Pre- and post- test scores on the Suicide Status Form (SSF-4) were utilized to evaluate suicidal resolution outcomes of The Hope Institute (THI), a novel approach to outpatient treatment for suicidal ideation. THI was built upon evidence-based models, developing a structured approach to suicide treatment that can be implemented and replicated in an outpatient setting. METHOD:The study sample consisted of 58 participants with a mean age of 20 years. Notably, 31% of participants had no prior mental health diagnosis, reinforcing the need for interventions that address suicide risk beyond traditional psychiatric models. RESULTS:Results demonstrated significant reductions in SSF-4 Core Assessment during treatment, with a large effect size (t(57) = 8.1, p < .001, d = 1.02). Participants achieved resolution in an average of 5.6 weeks, with 98% successfully completing treatment and 5% experiencing readmission to THI or another facility within 90 days. The timeline reflects the adaptability of THI, with trained clinicians collaborating with patients to determine treatment frequency and focus on a patient-centered, evidence-based, approach to foster patient autonomy and suicidal resolution. CONCLUSION:Individuals in the sample demonstrated statistically significant pre/post improvements in reductions in suicide risk scores, warranting additional research on THI program effectiveness in larger community samples.

This article describes a professional journey in the field of clinical suicidology that led to the creation and the development of an evidence-based, suicide-focused, clinical treatment called the “Collaborative Assessment and Management of Suicidality” (CAMS). Several professional challenges and successes are described along with personal experiences that have shaped this approach to working with suicidal risk. Some reflections and lessons-learned about effective psychotherapy are proffered based on over four decades of work as a clinician, researcher, teacher, and supervisor. It Is argued that evidence-based, patient-centered, psychotherapy that stresses empathy, collaboration, and honesty is an ethical and professional imperative for providing effective care and realizing optimal clinical outcomes.

BackgroundSuicidal ideation is increasing among university students. Despite growing demand for services, university counseling centers (UCCs) face limited resources to meet the complex needs of students who are suicidal. ObjectiveThe Comprehensive Adaptive Multisite Prevention of University Student Suicide (CAMPUS) Trial evaluates 4 treatment sequences within UCCs to develop evidence-based treatment guidelines. MethodsThe CAMPUS Trial consists of a feasibility study followed by a sequential multiple-assignment randomized trial (SMART). The original CAMPUS protocol was modified during the COVID-19 pandemic to accommodate new UCC tele–mental health services, including remote treatment, assessments, and monitoring. A smaller-scale feasibility study was conducted to (1) evaluate implementation of hybrid telehealth and in-person interventions and (2) fine-tune online procedures. Following the feasibility study, university students (aged 18-25 years) seeking UCC services with moderate to severe suicidal ideation will enroll in the CAMPUS Trial. Student participants are randomly assigned to 1 of 4 treatment sequences with 2 stages of intervention. In stage 1, students receive 4 to 6 weeks of either (1) a suicide-focused treatment—Collaborative Assessment and Management of Suicidality—or (2) enhanced treatment as usual. Treatment responders enter the maintenance phase. In stage 2, nonresponders are rerandomized for an additional 1 to 8 weeks of (1) Collaborative Assessment and Management of Suicidality or (2) an intensive skills-based treatment—dialectical behavior therapy for UCC settings. UCC counselors will enroll in the CAMPUS Trial to complete measures about their experience working with students who are suicidal. CAMPUS Trial administration includes representation from all sites to facilitate cross-site coordination and an advisory board of stakeholders from all UCCs to facilitate treatment implementation. ResultsStudent participant recruitment began on October 25, 2022, and ended on May 16, 2024. As of November 2024, data collection for the SMART was ongoing with active study participants. Data collection was completed in November 2024, and as of April 2025, data analysis is underway. Full results will be available in 2025. ConclusionsThe CAMPUS Trial offers a model for future SMARTs for the treatment of suicidal thoughts or behaviors (or both) across various settings. The results will inform treatment guidelines for students presenting with suicidality at UCCs. Trial RegistrationClinicalTrials.gov NCT04707066; http://clinicaltrials.gov/ct2/show/NCT04707066 International Registered Report Identifier (IRRID)DERR1-10.2196/68441

Suicide is a leading cause of death for youth and young adults. There is a need for interventions that are suicide-specific, developmentally relevant, and accessible. The current study examines Suicide Index Score (SIS) typologies through the Collaborative Assessment and Management of Suicidality in an adolescent sample (CAMS-4Teens). METHOD:108 participants (59.4 % female, 78.9 % Caucasian, and mean age of 14.9 years) during an ongoing study who participated in up to 4 sessions of CAMS-4Teens were categorized using the SIS typologies: wish to live (WTL), ambivalent (AMB), and wish to die (WTD). Caregiver burden and family connectedness were also assessed. Main outcomes included pre-post differences in CAMS overall suicide risk scores and SSF Core Assessment scores. Two-way mixed repeated measures ANOVAs and their interactions were conducted. RESULTS:Analyses revealed significant interactions between pre-post differences in CAMS overall suicide risk for the SIS groups, with WTD having the most significant reductions. None of the remaining interactions were significant, yet there were significant main effects over time for all pre-post outcomes regardless of SIS group status. Findings from exploratory analyses involving participants who completed a single session of CAMS are also discussed. CONCLUSION:This was the first study to examine SIS typologies among an adolescent sample and demonstrates the benefits of identifying treatment targets for youth receiving CAMS and their family.

INTRODUCTION:The Collaborative Assessment of Suicidality (CAMS) is an effective clinical framework to treat suicidal thoughts and behaviours. CAMS employs the Suicide Status Form (SSF) to monitor suicide risk factors across sessions. The first six items (termed the SSF Core Assessment) include psychological pain, stress, agitation, hopelessness, self-hate and self-reported overall behavioural risk for suicide. The first five are theoretically derived risk factors. While CAMS employs session-by-session tracking, no research has investigated how the five risk factors vary together and concurrently and prospectively predict self-perceived suicide risk when assessed via ambulatory assessment. METHODS:Undergraduates (n = 52) with past-2-week suicidal ideation completed 5 ambulatory assessment surveys of the SSF Core Assessment variables daily over 10 days. Descriptive and variability statistics were used to describe the core assessment constructs. Multilevel models were used to examine how the first five items predicted overall behavioural risk of suicide. RESULTS:Each of the SSF Core Assessment variables demonstrated variability over the study period, with stress exhibiting the greatest and overall risk the lowest variability. Self-hate and hopelessness concurrently predicted self-reported overall risk for suicide within the same model. Only self-hate and agitation were significantly prospectively predictive of overall behavioural risk, even after controlling for suicidal ideation. CONCLUSIONS:This is the first study to provide insight into the short-term variability and predictive capabilities of the SSF Core Assessment constructs. Each construct varies considerably over short time scales, suggesting that more frequent monitoring of these constructs may be an important consideration within future CAMS treatment research.

Identifying typologies of patients who are suicidal has important clinical implications. The Suicide Status Form (SSF) of the Collaborative Assessment and Management of Suicidality (CAMS) is a well-validated and rich suicide assessment tool that may help derive clinical subtypes. Despite the strong psychometric properties of different sections of the SSF, no prior studies have examined all initial session SSF variables in aggregate. This study used latent profile analysis (LPA) to statistically generate subtypes of patients who are suicidal based on a diverse and aggregate sample from three clinical trials conducted in an inpatient setting, an active-duty Army outpatient clinic, and a university counseling center. Based on fit indices, the four-profile model yielded the best fit with the data. The four profiles were characterized by (1) acute stress, (2) history of multiple attempts, (3) features of borderline personality disorder, and (4) externalized distress. The first two profiles were overall the most responsive to CAMS by termination, despite preliminary descriptive data indicating that these individuals were more likely to attempt suicide during the study period. A limitation is that the sample size is relatively small for LPA, despite the stability and face validity of the profiles. This study identified four distinct suicide typologies as derived from a widely used clinical assessment tool. These typologies also varied according to gender distributions, history of suicide attempts, acute stressors, borderline personality traits, and externalizing behaviors. Clinical implications and future directions for research also are discussed.

The Suicide Status Form (SSF) is a theory-based and empirically supported suicide assessment instrument that has evolved over decades to become a highly effective therapeutic tool. Developed to address the limitations of clinical judgement and problems with existing suicide risk tools, the SSF employs both quantitative ratings and qualitative prompts to assess suicide risk based on extensive theory and research. Beyond quantitative aspects, qualitative assessments provide insights into a patient's lived experience and the factors that drive patient suicidality. The SSF is the central tool within the Collaborative Assessment and Management of Suicidality (CAMS) framework, facilitating reliable and therapeutic assessment and collaborative engagement in treatment. The SSF thus weaves together a comprehensive and psychometrically sound clinical assessment experience that also incorporates the patient's voice, prompting a dynamic and empathetic dialogue between patient and clinician. In turn, this dialogue can enhance a patient-centered assessment experience that can facilitate effective suicide-focused clinical care.

Around the world, suicide ideation, attempts, and deaths pose a major public and mental health challenge for patients (and their loved ones). Accordingly, there is a clear need for effective clinical treatments that reliably reduce suicidal thoughts and behaviors. In this article, we review the Collaborative Assessment and Management of Suicidality (CAMS) and Dialectical Behavior Therapy (DBT), two clinical treatments that rise to the highest levels of empirical rigor. Both CAMS and DBT are now supported by randomized controlled trials (RCTs), with independent replications, and meta-analyses. There are also supportive data related to training clinical providers to use CAMS and DBT with adherence. RCTs that investigate the use of both interventions within clinical trial research designs and the increasing use of these complementary approaches within routine clinical practice are discussed. Future directions for research and clinical use of CAMS and DBT are explored as means to effectively treat suicidal risk.

Free AccessEditorialZero Suicide – What About "Treat"?Julie Goldstein Grumet and David A. JobesJulie Goldstein GrumetJulie Goldstein, Zero Suicide Institute, Education Development Center, Waltham, MA, USA, [email protected]Zero Suicide Institute, Education Development Center, Waltham, MA, USA and David A. JobesDepartment of Psychology, The Catholic University of America, Washington, DC, USAPublished Online:May 03, 2024https://doi.org/10.1027/0227-5910/a000958PDF ToolsAdd to favoritesDownload CitationsTrack Citations Cite ShareShare onFacebookTwitterLinkedInRedditE-Mail SectionsMoreThe ChallengeIn the United States annually there are 42,000 breast cancer deaths and 52,000 colorectal cancer deaths. Importantly, these leading killers have seen notable mortality declines over several decades largely due to robust screening, early detection, and use of proven clinical interventions (Caswell-Jin et al., 2024; Siegel et al., 2023). It is unimaginable that healthcare providers would disregard the use of evidence-based clinical practices for identifying and treating individuals for leading causes of death. To do otherwise would be utterly unacceptable within contemporary healthcare delivery. Yet evidence-based treatment approaches to suicidal thoughts and behaviors are routinely underutilized by providers.Suicide is a global issue, taking more than 700,000 lives annually (https://www.who.int/news-room/fact-sheets/detail/suicide). Provisional data in the US for 2022 indicate that there were 49,449 suicides in the country—the highest suicide death count in recorded history (www.cdc.gov/nchs). Moreover, 2,553,000 American adults and teens reported attempting suicide that year and a whopping 16,600,000 Americans reported serious thoughts of suicide (Substance Abuse and Mental Health Services Administration, 2023). For individuals (and families) facing a suicide crisis, finding effective care can be fraught with challenges including timely access to care, insurance barriers, stigma, and the taboo to openly discuss it. While not all will access health-care providers for support or treatment, for those who do have the courage to ask for help, they should expect nothing less than compassion, clinical skill, and a reliance on proven treatments.Zero SuicideZero Suicide is a quality improvement framework that transforms system-wide suicide care, establishing suicide prevention as a core health-care responsibility in the US and abroad (National Action Alliance for Suicide Prevention, Clinical Care & Intervention Task Force, 2012). Seven core elements comprise the model: "lead," "train," and "improve" are the structural components embedded throughout the system and necessary for change success, fidelity, and continuous quality improvement. "Identify," "engage," "treat," and "transition" are clinical components of the model and define the care patients should receive.Despite evidence supporting each component, use of the full model within systems of care varies. Many Zero Suicide implementation efforts focus on identification followed by brief interventions to reduce acute suicide risk. Central to Zero Suicide care management is a standardized suicide prevention pathway (SPP) that typically includes screening and assessment leading to a collaborative safety plan, reducing access to lethal means, and caring contacts/warm hand-offs. Although "treat" is integral to the model, it is often addressed after adopting other components of the model first, and the SPPs of some organizations fail to explicitly incorporate clinical treatments of suicidal thoughts and behaviors altogether.The Zero Suicide approach has demonstrated notable reductions in suicide and suicide behaviors. For example, a study in Australia of Zero Suicide within a health-care system of over 600,000 people found that individuals who were on the SPP experienced significantly lower risk of repeated suicide attempts within 90 days of the first attempt. Further, there was approximately a 23.3% reduction in suicide deaths (Turner et al., 2021). In the US, Centerstone – a large behavioral health nonprofit and early adopter of Zero Suicide – saw a 64% reduction in suicides 2 years after implementation (Hogan & Goldstein Grumet, 2016). Zero Suicide case studies reveal readmission rates were reduced by 17%–21%; rehospitalization among patients with suicidal ideation decreased by 45%; care transition teams reduced emergency department visits by 70% and hospital bed days by 90%; and mobile crisis teams diverted 94% of patients away from emergency departments (Department of Health and Human Services, 2023). Finally, another study found that greater fidelity to Zero Suicide practices was associated with lower risk for suicide-related behaviors within outpatient care (Layman et al., 2021).The apparent success of Zero Suicide over the past decade has been compelling; however, "treat" tends to be underemphasized within Zero Suicide based clinical care. "Treat" is defined as: "Treat suicidal thoughts and behaviors using evidence-based treatments." Notably, proven clinical treatments for suicide risk are rarely described in published papers of Zero Suicide implementation. Emblematic of this concern is an excellent application of Zero Suicide in New York (Labouliere et al., 2018) with a publicly available SPP for those at risk for suicide. Within this example there is an emphasis on increasing clinical contact, treatment plans focused on reducing risk factors and increasing protective factors, and providing long-term interventions to address mental health symptoms, including providing suicide-specific treatments "if available" (i.e., if clinicians have training in these practices). This example is not unique and highlights an inherent challenge; the lack of suicide-specific treatment emphasis within Zero Suicide is common.We are encouraged that current Zero Suicide strategies appear to be working, and yet, it is discouraging that once a person has been stabilized and is out of acute crisis, the treatment of what makes them suicidal is too often missing to ensure a lasting recovery. While saving lives is vital, reducing ongoing suicide despair for millions should be a priority (Jobes & Joiner, 2019).Clinician TrainingThere is an online evolving toolkit available at www.ZeroSuicide.EDC.org supporting the adoption of the Zero Suicide model that includes tools, research behind the interventions, and resources, including the Zero Suicide Workforce Survey, developed to measure health-care staff's self-perception of their comfort, confidence, and skill in delivering suicide-specific interventions. Over 700 health-care organizations, representing both the US and abroad, have used this survey; and among 20,000+ respondents who are responsible for delivering treatment, fewer than half report receiving training on suicide-specific evidence-based treatment approaches. Moreover, only 32.8% strongly agree that they are confident in their ability to provide treatment to individuals with suicidal thoughts or behaviors and only 35.3% report comfort-providing treatment (Goldstein Grumet et al., 2023). These results are unacceptable if we truly aspire to save lives and decrease suffering.The clinical science of treating suicidality has evolved such that we now have several proven suicide-specific treatments with additional promising treatments in development (Jobes, 2023; Jobes & Barnett, in press). However, graduate programs, professional certification, and continuing education rarely focus on suicide-specific treatments as a competency for graduation or licensure. This may help explain why so many surveyed providers (many in practice for 20+ years) have limited experience in training and comfort using these interventions clinically.Admittedly, challenges to using evidence-based practices (EBPs) do exist. Reasons health-care systems and providers share for not using evidence-based suicide-specific clinical interventions include the costs associated with obtaining training, lack of time needed to deliver interventions, high patient demands, inconsistent patient attendance, lack of management support or supervision of EBPs for suicide care, and high staff turnover. Randomized controlled trials (RCTs) too often under-represent minority populations or patients with comorbid conditions and therefore may not be as generalizable to real-world settings (Cook et al., 2017). Further, mental health providers routinely default to long-established familiar interventions or treatment modalities that have no, mixed, or limited evidence of being effective for suicide care. These include brief inpatient admissions that, for some, can actually be iatrogenic (Czyz et al., 2016; Large et al., 2014; Ward-Ciesielski & Rizvi, 2021), involuntary hospitalizations that may in fact do more harm than good (Borecky et al., 2019; Stefan, 2016), and an over-reliance on medications that have little to no impact on suicidality (with exceptions, e.g., Ballard et al., 2014) and may even increase suicidal risk (Li et al., 2022). Finally, US clinicians are often plagued by the prospect of malpractice tort litigation for "wrongful death" if a suicide outcome occurs. The fear of litigation can drive "better safe than sorry" clinical practices that may not be in the patient's best interest (Jobes, 2017). In truth, the best clinical risk management strategy is to use EBPs proven to effectively treat suicidality and to document that work well (Jobes & Barnett, in press).Clinical Treatments for Suicidal RiskThe empirically supported treatments for suicide behaviors that have emerged over the past 30 years are primarily used on an outpatient basis and focus on the underlying causes of longer-term distress with the goal of reducing suicide attempts and ideation. What follows is a brief review of suicide treatments well supported by RCTs – the gold standard methodology for establishing the highest level of causal impact of an intervention. These treatments have replicated (and independent) RCT support (i.e., similar RCT findings by investigators who did not develop the treatment being studied).Dialectical Behavior TherapyThe most proven treatment with a well-established impact on suicide attempts and self-harm behaviors is dialectical behavior therapy (DBT; Linehan, 1993) with dozens of supportive and independent RCTs. In short, DBT is an intensive team treatment that emphasizes (1) skills group, (2) individual therapy (supporting DBT-based skills), (3) phone-coaching to practice skills, and (4) consultation support of the treatment team (Linehan, 1993). DeCou et al.'s (2019) meta-analysis of 18 DBT RCTs showed that DBT reduces suicidal and self-harm behaviors.Suicide-Focused Cognitive Behavioral TherapyThere are two similar cognitive behavioral therapy (CBT)-oriented treatments with RCTs demonstrating impressive outcomes. The first is cognitive therapy for suicide prevention (CT-SP) developed by Brown et al. (2005). CT-SP was shown to effectively reduce suicide attempts by 50% after 10 sessions when comparing treatment with usual care (Brown et al., 2005).The second CBT-oriented treatment is brief cognitive behavioral therapy for suicide prevention (BCBT-SP; Rudd et al., 2015). BCBT-SP is a phasic treatment that centers on the suicidal mode concept and incorporates a relapse prevention protocol (Bryan & Rudd, 2018). In their RCT with high-risk US Army soldiers, BCBT-SP reduced suicide attempts by 60% when compared with usual treatment control care at the 18-months follow-up. Similar to CT-SP, BCBT-SP did not necessarily reduce suicidal ideation. Importantly, having general CBT training does not mean one can deliver CT-SP or BCBT-SP with fidelity.Collaborative Assessment and Management of SuicidalityDeveloped by Jobes (2000, 2023), the collaborative assessment and management of suicidality (CAMS) is a suicide-focused therapeutic framework. CAMS employs a multipurpose assessment, stabilization, treatment planning, tracking, and clinical outcome tool called the "Suicide Status Form" (SSF) that targets patient-identified "drivers" of their suicidality (i.e., problems that cause them to consider suicide). There are eleven correlational clinical trials, seven published RCTs, and two published meta-analyses providing ample support for CAMS (Jobes, 2023). CAMS reliably reduces suicidal ideation, symptom distress, and hopelessness (while increasing hope) in comparison with control care (Swift et al., 2021). CAMS can significantly reduce suicide attempts (Santel et al., 2023), is cost-effective (McCutchan et al., 2022), and telehealth-CAMS is effective (O'Neill et al., 2023).Emerging Suicide TreatmentsClinical suicidology is now a vibrant focus of research with several other excellent suicide treatments in need of RCT replication and/or independent replication. These include attachment-based family therapy, mentalization-based therapy, the Attempted Suicide Short Intervention Program, problem solving therapy, and the Coping with Long-Term Active Suicide Program.Addressing the Challenge of "Treat"Health-care systems and dedicated providers can undoubtedly decrease suicidal suffering and save lives. If suicide-specific effective treatments are reliably provided within a Zero Suicide framework, we contend that the best possible approach to care will have been rendered, which should meaningfully reduce suicidal suffering and ultimately help save lives. To help realize the promise of this vision, we propose the following broad recommendations:Research Addressing Obstacles to Using EBPsWhile we have presented many potential reasons why health-care systems and providers are reluctant to utilize EBPs, additional research on barriers and solutions is needed to better inform our treatment efforts.Structural Changes to Suicide-Focused CareThere is a need to fundamentally move away from the routine use of the familiar and comfortable. For example, emergency department (ED) care can be meaningfully transformed by offering care that is more healing for people who are suicidal. There is support for EmPATH units that offer an alternative model to ED care emphasizing peer support and more nurturing environments (https://www.vituity.com/healthcare-services/psychiatry/empath-units/). Technology can be used to create a suicide-focused therapeutic ED experience (e.g., https://jasprhealth.com/). Use of evidence-based suicide-focused treatment could significantly improve the psychiatric inpatient experience (e.g., Bohus et al., 2004; Santel et al., 2023).Since 2007, suicide prevention clinics have existed across Denmark for individuals with suicidality where their distress can be managed quickly through counseling, therapy, and practical support. This has been associated with a reduction in long-term fatal (29%) and nonfatal (18%) suicidal acts (Healthcare Denmark, 2023). The Hope Institute in the US is another example of an outpatient clinic model for suicide care that averts ED visits and inpatient admissions (Jobes, 2023). Launching new models for rapid suicide-focused treatment should become a mental health priority.Increased Awareness and TrainingThere is a need for more and better training in suicide-specific EBPs both while in professional training programs and throughout careers. We must convince providers that treating suicide risk with proven clinical care is available and crucial. Identifying and promoting common elements of effective care that cut across different treatment settings and disciplines and are integrated into routine clinical practice could offer a better overall patient experience (Rudd et al., 2022).Malpractice and Root Cause Analysis ReformA restorative just culture is an underlying and necessary principle in Zero Suicide (Turner et al., 2020) whereby system learning and improvement is the focus when errors or adverse events occur, rather than on placing blame. While the US is particularly plagued by a litigious culture related to malpractice liability, there are approaches to tort reform and proactive use of informed consent that could help providers feel less paralyzed by the threat of litigation (Stefan, 2016). Even in less overtly litigious countries, there are still coroner's inquests and "root cause analyses" that can become focused on blaming providers or systems of care. Sometimes, even optimal evidence-based care, be it for suicidality, stroke, cancer, or childbirth, still results in an adverse and tragic outcome, yet is a legally defendable outcome as a provider.Reimbursement for Suicide-Specific EBPsMental health treatment and care has long suffered in terms of parity to medical care. Within medicine, new technologies and surgical procedures are constantly advancing and providers routinely receive training to ensure they are ready to deliver optimal care. Cost for training remains one prohibitive reason for the lack of use of treatment-focused EBPs related to suicide as the margins for reimbursement are lower for mental health and there are additional costs incurred when providers are not delivering direct care. Therefore, we propose that insurers establish CPT codes for suicide-focused interventions known to be effective, thereby defraying the cost of training to the health-care system and provider. While this reference to CPT codes is specific to the US, other countries face similar challenges. Further, we suggest that value-based and/or payment bundles for effective suicide care be made available and propose a pilot program of this approach.Accountability, Accreditation, and LicensingThe Joint Commission (TJC) and Commission on Accreditation of Rehabilitation Facilities (CARF) in the US have updated their suicide care standards. These were strong and aggressive notices that the evidence was available that more could and should be done in health care to address suicide risk. However, longer-term treatment with EBPs that reduce suicide distress, once the acute risk has been reduced, are not yet incorporated into accreditation requirements at this time. We contend that TJC and CARF – and similar organizations in other countries – should require demonstration that treatment-specific EBPs be offered as part of the suicide care management plan in outpatient settings. In the US, there are currently 11 states requiring suicide prevention training for licensed providers in order to maintain their license. We propose that governing bodies consider adopting some minimal hours specific to suicide treatment and care as part of continuing education and licensure.ConclusionWe have noted meaningful gains in systems-level suicide prevention efforts and believe that the international embrace of the Zero Suicide framework has in part contributed to these encouraging gains. And yet, there has been a general hesitancy to fully embrace the "treat" element of Zero Suicide despite evidence of its value. When comparing treatments and adoption of available EBPs for other leading causes of death, the apparent evidence-to-practice gap in suicide care is hard to understand or justify. Accordingly, Jobes and Barnett (in press) have argued that using evidence-based clinical care for suicidal risk has become an ethical and professional imperative within contemporary mental health care. Although notable challenges to such care exist, the good news is that treatment works, offering an opportunity to ameliorate the suffering of millions with serious suicidal thoughts and saving lives too often lost to suicide.Author BiographiesDr. Goldstein Grumet has provided leadership for the Zero Suicide framework since its launch in 2012. She has expertise in behavioral health transformation, state and local community suicide prevention, and the use of evidence-based practices for suicide care. She has a PhD in clinical psychology from The George Washington University.With a BA in psychology from University of Colorado and a MA and PhD in clinical psychology from American University, Dr. Jobes directs the Catholic University Suicide Prevention Laboratory researching clinical suicidology. He is on the Board of the American Foundation of Suicide Prevention and Chairs AFSP's Public Policy Council.ReferencesBallard, E. D., Ionescu, D. F., Vande Voort, J. L., Niciu, N. J., Richards, E. M., Luckenbaugh, D. A., Brutsché, N. E., Ameli, R., Furey, M. L., & Zarate, C. A. (2014). Improvement in suicidal ideation after ketamine infusion: Relationship to reductions in depression and anxiety. Journal of Psychiatric Research, 58, 161–166. 10.1016/j.jpsychires.2014.07.027 First citation in articleCrossref Medline, Google ScholarBohus, M., Haaf, B., Simms, T., Limberger, M. F., Schmahl, C., Unckel, C., Lieb, K., Linehan, M. M. (2004). 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BACKGROUND:Suicide is a leading cause of death in young persons. While ketamine has demonstrated rapid anti-suicidal effects, its safety and efficacy in youth has not been fully investigated. The Collaborative Assessment and Management of Suicidality (CAMS), a suicide-focused treatment shown to decrease suicidal ideation and symptom distress, has never been studied in combination with ketamine. OBJECTIVES:This study investigates whether ketamine infusion, as compared to placebo, rapidly reduces severe suicidality in youth and young adults and enhances effectiveness of CAMS to decrease suicidality after acute treatment and at 3-month follow-up. We explore whether participants who receive ketamine, as compared to placebo, have decreased suicidality, suicide attempts, emergency department visits for suicidality, and psychiatric readmissions over 3-month follow-up. METHODS:This randomized controlled trial is enrolling 140 participants (ages 14-30) hospitalized with severe suicidal ideation or after attempted suicide. While hospitalized, participants are randomized to receive up to 6 treatments of either ketamine or placebo. Concurrently, participants engage in CAMS sessions, starting while inpatient and continuing post-discharge for up to 12 sessions via telehealth or until resolution of suicidality criteria are met. Monthly follow-up assessments are conducted for 3 months. DISCUSSION:Historically, hospital admissions have not decreased suicidal behavior following discharge. We hypothesize that ketamine, as compared to placebo, will lead to rapid improvement in suicidality and enhance engagement in CAMS, requiring significantly fewer sessions to resolve high-risk suicidality after discharge. We hypothesize that the ketamine group will have decreased suicidality, suicide attempts, and readmissions compared to the placebo group over 3-month follow-up.

The Collaborative Assessment and Management of Suicidality (CAMS) is an evidence-based, suicide-focused, clinical framework that effectively treats people who are suicidal across clinical settings. A central tool within CAMS is the Suicide Status Form (SSF) which is a multipurpose assessment, treatment planning, tracking, to clinical outcome tool that guides suicide-focused care from the start of CAMS treatment to completion. Previous SSF assessment research investigated the content of patient-written qualitative responses to SSF assessment prompts which were reliably coded into twelve content categories. Four coding categories captured 70% of written responses revealing the content of patients' suicidal ideation which centered on: relationships, vocation, the self, and unpleasant internal states. While qualitative SSF assessment research has thus revealed key information about suicidal ideation content, patient-identified "drivers" of suicide within CAMS treatment planning have not yet been examined qualitatively. "Drivers" of suicide are the issues that compel one to consider suicide, and ultimately become the focus of CAMS treatment; thus, it is important to examine their qualitative content. The present exploratory study investigated suicide driver content collected in the context of two randomized controlled trials of CAMS. Reliably coded qualitative content of patient-articulated drivers were comparable to previously noted SSF content assessment results, emphasizing the following driver issues: (1) Relationships, (2) Unpleasant Internal States (e.g., suffering and anxiety), (3) Role Responsibility (vocational concerns), and (4) the Self (e.g., self-hatred or esteem issues). These four coding themes captured 70% of 332 total treatment planning drivers obtained from 166 patients who were suicidal and seeking treatment. Implications of these findings are discussed.

Suicide is a major public and mental health problem in the United States and around the world. According to recent survey research, there were 16,600,000 American adults and adolescents in 2022 who reported having serious thoughts of suicide (Substance Abuse and Mental Health Services Administration, 2023), which underscores a profound need for effective clinical care for people who are suicidal. Yet there is evidence that clinical providers may avoid patients who are suicidal (out of fear and perceived concerns about malpractice liability) and that too many rely on interventions (i.e., inpatient hospitalization and medications) that have little to no evidence for decreasing suicidal ideation and behavior (and may even increase risk). Fortunately, there is an emerging and robust evidence-based clinical literature on suicide-related assessment, acute clinical stabilization, and the actual treatment of suicide risk through psychological interventions supported by replicated randomized controlled trials. Considering the pervasiveness of suicidality, the life versus death implications, and the availability of proven approaches, it is argued that providers should embrace evidence-based practices for suicidal risk as their best possible risk management strategy. Such an embrace is entirely consistent with expert recommendations as well as professional and ethical standards. Finally, a call to action is made with a series of specific recommendations to help psychologists (and other disciplines) use evidence-based, suicide-specific, approaches to help decrease suicide-related suffering and deaths. It is argued that doing so has now become both an ethical and professional imperative. Given the challenge of this issue, it is also simply the right thing to do. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

ObjectiveThe purpose of this study was to assess the implementation of suicide-focused treatments delivered via a hybrid telemental health (TMH) and in-person format.MethodThis study was conducted at four university counseling centers (UCCs) across the United States. Treatment-seeking clients were recruited from their local UCCs and participated in adaptive treatment strategies (ATSs) involving Treatment as Usual (TAU), Collaborative Assessment and Management of Suicidality (CAMS), and Dialectical Behavior Therapy (DBT). Implementation outcomes, including appropriateness, acceptability, feasibility, fidelity, safety, and client satisfaction, were assessed. UCC clinicians participated in qualitative interviews focused on implementation of TMH for clients presenting with suicidal ideation (SI).ResultsOverall, treatments delivered via hybrid format were reported to be appropriate, acceptable, feasible, and satisfactory by clinicians and clients. Implementation of TMH was reported to be equivalent to in-person treatment across multiple measurement methods.ConclusionResults from this study demonstrate that TMH is an implementable treatment modality for addressing suicidality, particularly for college students presenting to UCCs with SI. This study has implications for real-world clinical settings planning to offer hybrid treatment modalities to address SI.Trial registration: ClinicalTrials.gov identifier: NCT04728815.ConclusionResults from this study demonstrate that TMH is an implementable treatment modality for addressing suicidality, particularly for college students presenting to UCCs with SI. This study has implications for real-world clinical settings planning to offer hybrid treatment modalities to address SI.Trial registration: ClinicalTrials.gov identifier: NCT04728815.

BACKGROUND:Empirically supported suicide risk assessment and conceptualization is a central aim of the Zero Suicide model. The Suicide Status Form (SSF) is the essential document and scaffolding of the Collaborative Assessment and Management of Suicidality-Brief Intervention (CAMS-BI) and is hypothesized as an example of a psychological assessment as therapeutic intervention (PATI). However, this hypothesis has never been directly tested. METHODS:N = 57 patients deemed at risk for outpatient suicidal behavior and treated as part of an inpatient psychiatric consultation and liaison service were recruited to participate in CAMS-BI at a Level 1 trauma center in the southeastern United States. During the CAMS-BI process, patients were asked to rate their subjective units of distress (SUDS) at five time points throughout the intervention (k = 285). RESULTS:The omnibus random intercept multilevel model revealed a significant difference in pre- to post-session ratings of SUDS across patients. Post hoc pairwise comparisons revealed no significant differences between SSF sections (e.g., Section A, Section B, and Section C) and relative reductions in SUDS; however, there was an observable trend toward a favorable effect of Section A of the SSF. CONCLUSIONS:The SSF may represent an example of PATI pending replication and extension of the current results.

According to SAMHSA (2023), approximately 16,600,000 American adults and teens reported having serious thoughts of suicide in 2022. While suicide prevention has primarily focused on suicide deaths and attempts, we contend that suicidal ideation (SI) deserves more in-depth investigation and should be an essential intervention target on its own. In support of this point, we provide three examples of ways to improve specificity in understanding of SI through the study of controllability of SI, the language used to assess SI, and measuring SI in real time. We also consider qualitative work on the content of SI, its treatment, and definitional considerations. We thus call for an increased general focus on SI within research, clinical care, and policy.

Background: Medically ill adults are at elevated risk for suicide. Chronic pain and hopelessness are associated with suicide; however, few studies have examined the interaction between chronic pain and hopelessness in predicting suicide risk among hospitalized adults. Objective: This study aimed to describe the association between chronic pain, hopelessness, and suicide risk, defined fi ned as recent suicidal ideation or lifetime suicidal behavior. In addition, we examined the interaction between chronic pain and hopelessness. Methods: This was a secondary analysis of a multisite study to validate the Ask Suicide-Screening Questions (ASQ) among adult medical inpatients. Participants reported if they experienced chronic pain that impacted daily life and if they felt hopeless about their medical condition and provided their current pain rating on a 1 to 10 scale, with 10 being the most severe pain. A t-test compared pain severity scores by ASQ outcome. A binary logistic regression model described the association between chronic pain, hopelessness, and suicide risk; parameter estimates are expressed as odds ratios (OR) for interpretation. The interaction between chronic pain and hopelessness was examined in both the transformed (logit) and natural (probability) scales of the generalized linear model. Results: The sample included 720 participants (53.2% male, 62.4% White, mean age: 50.1 [16.3] years, range = 18-93). On the ASQ, 15.7% (113/720) of patients screened positive. Half (360/720) of the sample self- reported chronic pain. Individuals who screened positive had higher pain rating scores than those who screened negative (t =-4.2, df = 147.6, P < 0.001). Among all patients, 27.2% (196/720) felt hopeless about their medical condition. In the logistic regression model, patients with chronic pain (adjusted OR: 2.29, 95% confidence fi dence interval [CI]: 1.21-4.43, P = 0.01) or hopelessness (adjusted OR: 5.69, 95% CI: 2.52-12.64, P < 0.001) had greater odds of screening positive on the ASQ. The interaction effect between pain and hopelessness was not significant fi cant in the transformed (B =-0.15, 95% CI:-1.11 to 0.82, P = 0.76) or natural (B = 0.08, 95% CI:-0.07 to 0.23, P = 0.28) scale. Conclusions: There were significant fi cant independent associations between (1) chronic pain and suicide risk and between (2) hopelessness and suicide risk. Future research should examine the temporality and mechanisms underlying these relationships to inform prevention efforts for medically ill adults. (Journal of the Academy of Consultation-Liaison Psychiatry 2024; 65:126-135)