Table of Contents
Introduction
The paper objective is to assess depression and suicidality in adults by putting light on the interventions, such as Collaborative Assessment and Management of Suicidality (CAMS), Brief Psychodynamic and Psychotherapy. Both depression and suicidality are not pure clinical challenges because social background and social causes are some of those aspects which have a particular relevance and significance relating to both challenges. Keeping in view their social and economic aspects, this study attempts to put light on the depression and suicidality by applying the above mentioned interventions so as to evaluate and understand the effectiveness and efficacy of such interventions for mitigating the effects of suicidality. In the following parts of this paper, first literature review part has been included in which twelve relevant articles and their findings have been mentioned. In the subsequent part, a critical analysis of all previous studies has been mentioned. Before the conclusion part, future directions and recommendations part has been included in the paper.
Literature Review
Randomized Controlled Trials (RCTs) have become effective tools for assessing and evaluating suicidal tendencies. Comtois, Jobes, O’Connor, Atkins, Janis, Chessen, Landes, Holen, & Yuodelis-Flores (2011) carried out empirically-supported intervention for suicidality with the application of Collaborative Assessment and Management of Suicidality (CAMS) especially within alongside Next-Day Appointment for outpatient. Subsequently, a selection of 32 suicidal patients was made as they were asked to perform CAMS and Enhanced Care as Usual (E-CAU); more importantly, the assessment procedure was carried out throughout all stages of intervention process (before, during, and after cure) along with continuous check-up in the subsequent periods of 2, 4, 6, and 12 months period (Comtois et al., 2011). The subsequent intervention findings were as followed: Both types of participants experienced appropriate recovery from their respective treatments as they began to feel reduced number of suicidal ideation and diminished level of stress; the satisfaction of CAMS patients was considerably better than the patients representing the E-CAU treatment method; more importantly, at the end of 12 months period, decrease in suicidal ideation was largely visible in the group representing CAMS when compared with the reduction rate of suicidal ideation in the other group (Comtois et al., 2011).
Problem-solving therapy has also been used for treating with patients facing the problem suicidal ideation or suicidal attempts (Hatcher, Sharon, Parag, & Collins, 2011). Hatcher et al., (2011) have carried out an empirical work to evaluate the effectiveness of Problem-Solving Therapy (PST) and usual care. For this objective, a Zelen randomized controlled trial in New Zealand’s hospital and health boards for one year was carried out for 1094 patients (Hatcher et al., 2011). The subsequent findings reveal that there was no substantial difference at 12 months; at the same time, it is not reasonable to recommend PST for all patients with suicidal tendencies (Hatcher et al., 2011).
The Impacts of CAMS have proven their usefulness for reducing the suicidal cases (Nielsen, Alberdi, & Rosenbaum, 2011). In their evidence-based experiment, real-life clinical arrangement for investigating the effects of CAMS in Denmark was employed in which 42 patients were observed from 1 August 2008 to 30 September, 2009 at the Centre of Excellence in Suicide Prevention (Nielsen, Alberdi, & Rosenbaum, 2011). For this real-life experiment, both qualitative and quantitative related data were employed especially before and after the application of CAMS cure (Nielsen, Alberdi, & Rosenbaum, 2011). Additionally, the subsequent results were as followed: around eighty one percent of the patients successfully complied and finished their related cure and sixty eight percent finished their the final check-up; around seventy four percent of respondents from the group observed the trial sessions as the primary intervention for helping them reduce their suicidal ideation and tendencies; a considerable reduction was seen in 5 suicidal pointers accounted for the forty-two patients involved; however, one suicide case was reported and one suicide attempt was also noted during this period (Nielsen, Alberdi, & Rosenbaum, 2011).
Psychiatric patients and CAMS studies are go hand in hand. Hospitalized inpatients admitted for psychiatric evaluation and diagnosis have higher chances for developing suicide ideation and suicide cognition (Ellis, Green, Allen, Jobes, & Nadorff, 2012). To assess the effectiveness of CAMS for psychiatric patients, this observational study was carried out for fifty one days in which twenty patients (comprising of sixteen female and four male patients) participated in this case-focused strategy for patients adapting CAMS (Ellis et al., 2012). The subsequent results highlighted that a substantial amount of decrease was observed in patients especially facing the problems of suicide ideation, depression, suicide cognition, and hopelessness (Ellis et al., 2012). At the same time, it was stipulated that the findings were not only statistically significant but also clinically effective as well (Ellis et al., 2012).
Post-Admission Cognitive Therapy (PACT) has been identified as an important intervention for treating patients with suicide cognition and suicide ideation (Ghahramanlou-Holloway, Cox, & Greene, 2012). in order to evaluate the efficacy of this clinically significant intervention, the PACT has been overviewed empirically so as to ascertain its application and intervention effectiveness for controlling the problem of suicide tendencies especially for inpatients (Ghahramanlou-Holloway, Cox, & Greene, 2012). Here, it is worth arguing that the authors have not mentioned methodology or number of subjects for evaluating the intervention effectiveness instead they have primarily focused on the descriptive effectiveness of the PACT by highlighting and discussing its various intervention steps carried out to assess the framework of PACT. For example, in their published work, they have highlighted that the PACT is carried out through the application of three steps: (1) establishing a therapeutic connection along with devising a cognitive framework on the available suicide cases; (2) inculcating hope, developing and practicing recovery mechanism along with highlighting the shortcomings in the process of problem-solving techniques; and (3) averting decline alongside making a constructive safety strategy and insisting the importance of post-treatment services (Ghahramanlou-Holloway, Cox, & Greene, 2012). Additionally, other studies have focused on the other aspects of suicide ideation. For example, alcohol consumption and depression are two important factors that further increase the tendency towards suicide or suicide ideation and suicide cognition (Handley, Kay-Lambkin, Baker, Lewin, Kelly, Inder, Attia, & Kavanagh, 2013). In order to assess their association with suicide ideation and hopelessness, they carried out an empirical study in which three hundred three subjects were chosen at baseline and twelve months; the subsequent findings reveal that depressive symptoms were highly correlated with hopelessness and suicide ideation but no substantial or strong linkage was established between alcohol intake and suicide ideation and hopelessness during this period (Handley et al., 2013).
Various studies have also applied psychodynamic psychotherapies to identify and measure the different aspects of suicide, its symptoms, and other associations. For example, Angeletti, Pompili, Innamorati, Santucci, Savoja, Goldblatt, & Girardi (2013) carried out an observational work for ascertaining the effectiveness of Short-Term Psychodynamic Psychotherapy (STPP) relating to hopelessness, male depression, and suicide risk. For this objective, they chosen a very small sample of thirty-five patient respondents (including five male participants and thirty females) facing the problem of moderate-to-severe male depression; in order to measure the symptoms of male depression, Goltland Scale ≥ 13 is applied; they, subsequently, used both Gotland Scale for Male Depression (GSMD) and Beck Hopelessness Scale (BHS) (Angeletti et al., 2013). The final findings of this paper were as followed: the effects of Short-Term Psychodynamic Psychotherapy (STPP) were visible especially in patients suffering from male depression and but there were little difference of effectiveness was visible in patients facing the problem of hopelessness (Angeletti et al., 2013).
On the same topic but with different interventions and different clinical situations, a study was carried out in Denmark. Corona, Jobes, Nielsen, Pedersen, Jennings, Lento, & Brazaitis (2013) carried out a research work on treatment and interventions for different suicidal situations especially in outpatients in Denmark. For this paper, they applied two types of methodologies for obtaining objectives of the paper: First, clinical data-based classification of patients was made into two different groups (study group one and study group two) (Corona et al., 2013). The prime objective was to assess risk and provide treatment; fifty-two outpatients were chosen for carrying out the experiment (Corona et al., 2013). Additionally, “Self-report ratings of 6 Suicide Status Form (SSF) Core Constructs (Psychological Pain, Stress, Agitation, Hopelessness, Self-Hate, and Overall Risk of Suicide) recorded both at intake and at completion of treatment were then compared to determine differences in Core Construct ratings among groups at different time points” (Corona et al., 2013, p.1).
The subsequent findings were highlighted: In the first study group, which was classified as “suicidal motivation” group, the findings revealed a considerable amount of differences especially for ratings at intake of self-hate, psychological pain and overall risk of suicide (Corona, 2013). However, in the second category, the differences were largely displayed by sub-groups, such as wish to die, ambivalent, wish to live, were considerably substantial especially ratings at intake of suicide overall risk (Corona, 2013). Based on this, the authors conclude that classifying suicide patients by inspiration and by the environment of their inner fight could be highly useful for assessing the different types of risks and determining interventions essential for mitigating the effects of suicide ideation and suicide cognition (Corona et al., 2013).
The effects of psychotherapy for reducing suicide ideation and suicide cognition especially for adults patients are unclear (Cuijpers, de-Beurs, van-Spijker, Berking, Andersson, & Kerkhof, 2013). In this meta-data analysis study, the authors combined 13 comprehensive studies in which six hundred and sixteen patients were evaluated for assessing the impacts of psychotherapy for depression, and around 11 studies focused on the relationship between psychotherapy intervention on the problem of hopelessness (Cuijpers et al., 2013). The subsequent findings reveal that the effects of psychotherapy on suicide ideation and its associated risk were statistically insignificant; at the same time, publication prejudice was also highlighted as the effect magnitude was decreased to g=0.60 which was g=0.47 prior to the publication of the paper findings (Cuijpers et al., 2013).
Depression and suicide inclinations are highly correlated (Weitz, Hollon, Kherkhof, & Cuijpers, 2014). In order to assess and establish the relationship between depression and suicide tendency, the researchers investigated the impact of different interventions, such as CBT, IPT, placebo, and pharmacotherapy (Weitz et al., 2014). For this, multivariate linear regression model was used and the subsequent findings revealed that both IPT and medication were highly successful for reducing the impacts of depression leading to suicide tendencies (Weitz et al., 2014).
Still, the psychotherapeutic interventions have long way to prove their effectiveness for decreasing the number of deaths caused by suicide (Brown & Jager-Hyman, 2014). They carried out research on the empirical studies of other researchers on the subject; they collected their all data, research methodology, findings, outcomes, and recommendations; additionally, they focused on the state of the art methods, such as the efficacy of RCTs for reducing the tendencies for suicidal ideation and suicide cognition (Brown & Jager-Hyman, 2014). For example, one of the findings of this piece of work was that all evidence-based experiments and observations faced by the problem of methodology and they recommended that the current and future researchers must focus on the effective and appropriate selection of methodology for identifying the most effective ways to develop different interventions treating the patients with the problem of suicide ideation and suicide cognition (Brown & Jager-Hyman, 2014). Based on this, it looks reasonable to state that the perspective of both authors does not look different but realistic as various studies have not found one effective intervention method curing the patients struggling with the problem of suicide.
CAMS and TAU treatments have also been examined for their effectiveness relating to controlling suicide (Ryberg, Fosse, Zahl, Brorson, Moller, Landro, & Jobes, 2016). Ryberg et al., (2016) also investigated the efficiency and effectiveness of both CAMS and TAU through the application of RCTs in Norway. additionally, 100 patients were chosen and they scored thirteen on Beck’s Scale for Suicide Ideation; diagnosis was not essentially regarded as randomized sample was chosen and the respondents were interviewed at four intervals: baseline, two weeks, six months, and twelve months (Ryberg et al., 2016). As a result, this empirical work concluded that the findings from this sophisticated trail are not uncommon and they did not bring anything new but reflected a similar pattern observed in a routine clinical outcome; and the full application and implementation of CAMS in the mental hospitals would not generate different outcomes (Ryberg et al., 2016).
Critique
The work of Comtois et al., (2011) has various limitations. First, they have selected a very small sample size for carrying out CAMS procedure for assessing suicide ideation and suicide cognition. Considering the magnitude of the suicide cases, the use of thirty-two patients for satisfying the paper objectives does not look adequate. As a result, it is difficult to generalize the results and findings on a greater scale. However, it is worth highlighting that the application of both CAMS and E-CAU have provided more important insights relating to suicide ideation and the stress levels. Additionally, the major strength of the paper are those findings which have been found at the end of twelve months. Moreover, the application of RCT proves its usefulness for highlighting the important findings. Currently, this state of the art method is common in the clinical social research and it has proven by especially highlighting the relevant findings in the study.
The work of Hatcher et al., (2011) did not find any significant different at the end of tweleve months. They (Hatcher et al., 2011) employed zelen randomized controlled trial for ascertaining the strength of problem-solving therapy for treating paitents with suicide ideation and cognition. Despite the fact that they chose a large sample size (i.e. 1094), the findings did not bring any effective usefulness of the therapy applied for the suicide patients. Here, it is vital to insist that they have not mentioned number of male or female subjects involved in the study. In the absence of this important classification, it is difficult to rely on the effectiveness of such findings because gender and its relevance with the suicide ideation and suicide cognition are highly correlated aspects. Similarly, the work of Handley et al., (2013) has certain strengths and weaknesses. For example, the findings of the study are highly comprehensive as they point out the relationship between alcohol consumption has no correlation but depression and suicide ideation and suicide cognition are highly interlinked. However, social background, economic situation, family matters, and other social indicators are also important but they have not been mentioned instead they have purely relied on the clinical methods for assessing the relationship between depression and suicide ideation and suicide cognition.
The work of Corona et al., (2013) has both positive and weak aspects. First, they have employed clinical data in which fifty two outpatients were observed. This is the most effective way to observe such patients especially in clinical setting. However, small sample size and absence of further background information about the patients are some of major weaknesses found in the case study.
Some studies have highlighted findings relating to psychotherapy and suicide ideation and suicide cognition. For example, the work of Cuijpers et al., (2013) has put light on the studies of previous researchers on the topic so as to establish the effectiveness of psychotherapy treating patients with suicide tendencies. However, this piece of work has concluded that the effects of psychotherapy on suicide ideation were statistically insignificant.
The work of Ellis et al., 2012) has certain strengths. For example, they have clearly mentioned gender of the subjects in the study. However, no background information about the participant makes this study less acceptable.
Future Directions for Social Work
Social background information should always be focused while conducting research relating to suicide cases. It has been observed that the majority of the studies do not focus on the social profile or social background, social circumstances and other social aspects. In the absence of such information, it would be highly difficult to properly diagnose or assess the condition and context of suicide patients. In this regard, it is vital to mention that the role of social worker, especially in such type of cases, is considerably wide; it is not just about collecting their information, counseling, or any other related aspects, but it also includes clinical assessment of such patients.
While covering the literature review aspects, it was observed that almost all studies fail to put light on the social, economic, family, even religious aspects of such cases. More specifically, a suicide case develops when above factors either work collectively or individually to disturb the mental functioning of the subjects. Under this situation, if the clinicians only focus on their current state of mind, it would only highlight that they are just focusing on the effects rather than causes which are highly central for assessing and evaluating the suicide patients.
More importantly, economic background information was also missing in the literature review. Majority of the studies avoid to highlight non-medical aspects of suicide cases and that is totally contrary to the risk assessment of suicide as it is society, and particularly economic circumstances, which develop and provide context for suicide ideation and suicide cognition as well. in this regard, it is vital to insist that the role of social worker should also focus on economic aspects as well; additionally, the current studies fail to focus on the disturbance in the family life. In today’s environment, already the importance of family life has reduced and material thinking has overshadowed the relevance of such social institutions. Therefore, it is highly recommended that social profile should also include information relating to the economic aspect and family life so as to assess the gravity of the problem.
At the same time, almost all studies focused on the clinical trials, such as RCTs, Zelen randomized controlled trials and others. this approach is partial as it, again, emphasizes that suicide is only a medical condition and medical challenge and that is not a complete truth but the complete truth is that the suicide is socio-economic challenge as it is normally developed when society or members of society fail to complete their part of work in the required manner.
More importantly, depression and suicide are two different mental stages. In the social work experience, it has been observed that suicide does not take place directly but social and other types of circumstances develop and provide context to such action. Among various factors, and social causes, depression is one of the main reasons behind suicide attempts. In order to control the tendency for suicide, it is vital to mention that work on depression, its symptoms and their social cure should be sought so as to avoid it affecting the whole mindset of any depressed individual.
Conclusion
The work of previous researchers have partially contributed for ascertain depression and suicidality causes in adults through CAMS, Brief Psychodynamic and Psychotherapy approaches. For example, some studies found that the CAMs has been very effective intervention for reducing the impacts of not only depression but also suicidality while others found that related approaches were ineffective. However, the collected studies have various limitations. Many studies use a small sample size besides ignoring the importance of social profile of such patients. More specifically, they only consider the medical context of both depression and suicidality. Therefore, it is highly recommended that developing and considering the social profile of such patients is highly essential as it provides contextual knowledge and information necessary for evaluating reasons behind depression and suicidality. At the same time, for current and future social workers, it is highly suggested that the non-clinical setting are important and they should be considered for collecting and developing understanding of such patients.
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