Suicide-focused therapy improves pain and social functioning, not just ideation

Design

Secondary analysis of a two-arm parallel randomised controlled trial with generalised estimating equations

Population

85 adults with active suicidal ideation or recent suicide attempt

Primary outcome

PROMIS-43 physical functioning, pain interference and social participation to 12 months

Effect

Significant improvement in all three domains (all P at or below 0.028), largest in the first three months, with no significant difference between treatments

Trials of suicide-focused psychotherapy almost always report suicidal ideation and behaviour and stop there. This secondary analysis of a two-arm randomised trial in 85 adults with active suicidal ideation or a recent attempt looked at what else changed, using the PROMIS-43 at baseline and at 3, 6, 9 and 12 months across brief cognitive behavioural therapy and present-centred therapy.

Baseline impairment was the first finding: at least mild impairment in physical functioning in 50.0 per cent, pain interference in 65.9 per cent and social functioning in 81.0 per cent. All three domains improved significantly over follow-up (all P at or below 0.028), with most of the gain in the first three months, and the trajectories did not differ between the two treatments. By the end of follow-up more patients on brief cognitive behavioural therapy had returned to within normal limits for pain interference (58.9 against 42.5 per cent) and social functioning (58.4 against 45.4 per cent). Meaningful improvement substantially outnumbered meaningful worsening in both arms.

Two things follow. Function is worth measuring in this population, because four in five arrive socially impaired and that is what a patient means when asked whether they are better. And the finding that both treatments worked equally on function, as they did on the primary outcomes, argues that what is being delivered - structured contact, a plan, a clinician who returns - carries more of the effect than the specific modality. In services where trained cognitive behavioural therapists are scarce, that is a usable conclusion rather than a disappointing one.

• Ask about pain interference and social participation at intake in anyone at elevated suicide risk; both are usually impaired.
• Expect most functional gain in the first three months, and review at that point rather than at a year.
• Do not delay treatment waiting for a specific modality; both arms improved function equally.
• Use a short standardised functional measure so change is visible to the patient as well as to you.
• Note the sample: 85 adults, so treat the between-arm percentages as descriptive rather than as a difference.

The statistics, in plain English

With 85 patients split across two arms, this analysis can show change over time convincingly but cannot reliably separate the treatments; the differences in return-to-normal rates of about 15 percentage points are not accompanied by a significance test and should be read as suggestive. Defining meaningful change as a 5-point PROMIS T-score shift is a standard and reasonably conservative threshold. A secondary analysis of outcomes the trial was not powered for is hypothesis-generating by definition.

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