Currently, it is uncertain which treatments work best to reduce the frequency and
intensity of suicidal thoughts in adolescents and young adults. Usual care typically
involves a combination of counseling and psychiatric medications targeting the underlying
psychiatric conditions. However, usual care is sometimes ineffective at reducing thoughts
of suicide. In previous studies, Dynamic Deconstructive Psychotherapy (DDP) and Brief
Intervention and Contact (BIC) have been shown to be more effective than usual care at
reducing suicidality. The investigators anticipate that participants in the DDP treatment
group will achieve greater reductions in suicidal thoughts after 6 months of treatment
than participants in the BIC treatment group, as assessed by a combined measure of
suicide ideation (CSI).
DDP is a manual-based psychodynamic therapy developed at Upstate by the principal
investigator for severely ill individuals with borderline personality disorder, but has
since been applied to other disorders. DDP combines elements of translational
neuroscience, object relations theory, and deconstruction philosophy and involves weekly
one-hour individual sessions for up to 12 months. DDP differs fundamentally from most
other therapies in that it is a recovery-based model, instead of a chronic illness-based
model of care. Instead of providing advice, problem-solving, or skills to cope with the
symptoms and dysfunction of chronic illnesses, DDP attempts to address the underlying
vulnerabilities of these illnesses in order to provide transformative healing leading to
recovery. During weekly sessions, clients recount recent emotion-laden experiences,
explore their emotions and reactions, reflect upon their experiences in increasingly
integrative, complex, and realistic ways, learn how to develop close, authentic
relationships, and work towards self-acceptance and self-compassion.
Two randomized controlled trials of DDP have been conducted and published, one in
Syracuse and the other in Iran by independent groups of investigators. These trials
showed strong and significant treatment effects across a broad range of outcomes,
including borderline personality disorder symptoms, social and occupational functioning,
depression, substance use, dissociation, and suicidal behaviors. A naturalistic cohort
study comparing DDP to dialectical behavior therapy indicated statistically significant
superiority of DDP for depression, borderline personality disorder, functioning, and
self-injury. After an independent investigation of the evidence-base of DDP research, the
federal agency SAMHSA included DDP in its National Registry of Evidence-Based Programs
and Practices and later in its national Suicide Prevention Resource Center as a treatment
with evidence of effectiveness for depression, alcohol abuse, borderline personality
disorder, and suicidal behaviors.
BIC is a well-established protocol-based intervention developed by the World Health
Organization for providing brief supportive contacts and coordination of care. There have
been numerous studies documenting reductions in suicide ideation and/or attempts when
safety planning is combined with brief supportive contacts by phone, postcards, or brief
follow-up visits after suicide-related events. Brief supportive contacts in combination
with safety planning and facilitation of transitions in care from inpatient to outpatient
settings have become a best practice in suicide prevention, and are essential components
of the Zero Suicide Model of care. In randomized controlled trials, BIC has shown
efficacy in preventing suicide and reducing suicide attempts, as well as in reducing
suicide ideation when combined with safety planning.
This study will enroll 106 participants, with 53 participants in each group. Participants
will be randomly assigned to receive either DDP plus safety planning and psychiatric
management or BIC plus safety planning and psychiatric management. Participants in the
DDP treatment group will meet with an assigned therapist for 50 to 60 minutes on a weekly
basis for 12 months. Participants in the BIC treatment group will meet with an assigned
therapist for a 60-minute initial session and then eight 30-minute follow-up visits
scheduled at 1, 2, 4 weeks and 2, 3, 4, 6, and 12 months after study entry. Outcome
measures are administered by a research coordinator at baseline and 3, 6, 9, and 12
months after study entry.
Randomization will involve a minimization method of group assignment to ensure
comparability of the two treatment groups on the following three variables: 1) treatment
arm; 2) adolescent vs. adult and 3) initial C-SSRS suicide ideation score of 2 or 3 vs.
score of 4 or 5. This approach of matched group metrics involves assigning scores to each
group based upon the distribution of the selected variables within each group and on each
group's total number of participants. Participants are assigned to a given group so as to
minimize the differences in total scores between the two groups. In the instances where
differences in scores between the groups are equivalent, the participant is assigned
randomly by a random number generator.
The investigators will compare the two groups of study participants (DDP and BIC) in
intent-to-treat analyses. The primary outcome will be the change in Combined Suicide
Ideation (CSI) over the first 6-month time interval. The change in CSI scores over the
first 6 months will be analyzed by two-factor mixed model analysis of variance (ANOVA),
with time as the repeated measure within-subject factor and group (DDP and BIC) as a
between-subject factor. Missing data points will be estimated through multiple
imputation.