The Collaborative Assessment and Management of Suicidality (CAMS) Stephen S. O Connor, PhD Assistant Professor Associate Director, University of Louisville Depression Center Department of Psychiatry and Behavioral Sciences University of Louisville Disclosure American Foundation for Suicide Prevention Senior Consultant for CAMS-Care Overview Drivers of suicidal ideation Treatments that work Assessment and Treatment with CAMS 1
There are many stressors, including psychiatric diagnosis, experienced by suicidal individuals Relationship problems Depression Indirect drivers of suicidality Homelessness Financial problems The most effective treatments focus on the factors that directly underlie suicidal coping Inability to solve problems Direct drivers of suicidality Intense emotion dysregulation Lack of reasons for living Reasons for dying (e.g., thinking they are a burden) Cognitive Therapy for suicide prevention (10-16 sessions) plus case management is quite effective in reducing suicide attempts. Brown, G. K. et al. JAMA 2005;294:563-570 2
Dialectical Behavior Therapy (DBT) is effective at reducing self harm. Collaborative Assessment and Management of Suicidality (CAMS) Began as semi-structured approach to managing suicide risk in outpatient settings Formalized assessment compiled aspects of the suicidology literature in a useful, innovative way Emphatically non-prescriptive in terms of intervention approach Focus was on management of suicide through clear, concise documentation of the assessment and treatment planning process Core document is called the Suicide Status Form CAMS has evolved into a therapeutic framework as efforts to test and disseminate have increased Series of quasi-experimental and correlations studies showing CAMS may be useful in treating suicidal patients (Jobes et al., 2005; Arkov et al., 2008; Jobes et al., 2009; Nielsen et al., 2011) One small RCT that demonstrated significant reductions in suicidal ideation at 12- months post-treatment compared to treatment as usual in a community mental health setting (Comtois, Jobes, O Connor et al., 2011) RCT comparing DBT to CAMS in Adults with Borderline Personality Traits and Disorder (Andreasson et al., 2016) Sufficiently powered efficacy RCT with suicidal soldiers at Ft. Stewart, GA (N=148) SMART design including CAMS vs. TAU during step 1, CAMS, DBT, and TAU at step 2 for suicidal college students Pilot study of a group version of CAMS informed by recent collaboration with Robley Rex VAMC (Johnson, O Connor et al., 2014) Inpatient protocol created for extended stay inpatient psychiatric setting (Ellis et al., 2014) 3
Total Dollars 9/16/2016 Empirical research from USAF 10 th Medical Group (n=55) has shown that CAMS patients reach complete resolution of suicidality about 4-6 weeks more quickly than treatment as usual patients (Jobes et al., 2005; Wong, 2003) 10 th Medical Group Research: Six Month Period After the Start of Mental Health Care Mean Health Care Costs 1200 1000 800 600 400 200 0 Mental Health ER* Primary Care* Specialty CAMS (n=24) TAU (n=30) * p <.05 CAMS Compared to CUA Comtois et al., 2011 4
DBT vs. CAMS in Adults with BPD Personality Traits and Disorder DBT (n = 57) CAMS (n = 51) Chi-square, odds ratio, and P values Self-harm (week 28) 21 (36.8%) 12 (23.5%) Chi-square: 0.22; OR: 1.90 (95% CI: 0.8 4.4); P=.14 Suicide attempt 12 (19.3%) 5 (9.8%) Chi-square: 0.12; OR: 2.45 (95% CI: 0.8 7.5); P=.12 NSSI 16 (28.1%) 10 (19.6%) Chi-square: 0.37; OR: 1.60 (95% CI: 0.7 3.9); P=.31 HDRS-17 11.6 (SE 3.2) 11.00 (SE 2.1) P =.87 BDI-II 10.8 (SE 1.8) 10.7 (SE 1.8) P =.98 ZAN for BPD 7.6 (SE 2.4) 7.4 (SE 1.3) P =.97 Beck Suicide Ideation 5.6 (SE 1.3) 4.1 (SE 1.2) P =.39 BHS 19.6 (SE 1.1) 17.5 (SE 1.1) P =.19 RSE 21.8 (SE 0.4) 22.6 (SE 0.4) P =.18 Andreasson et al., 2016 Theoretical Foundation of the Suicide Status Form (SSF) Shneidman s Cubic Model Theory Psychological Pain Press Perturbation Beck s Cognitive Theory Hopelessness an overarching expectation that things will not get better no matter what you do. The Cognitive Triad a pervasive sense of hopelessness pertaining to self, others, and the future. Baumeister s Escape Theory Intense self-hate a general and intense feeling of disliking oneself; having no self-esteem; having no self-respect. Escaping intolerable experience of self escape theory suggests that suicide can become a compelling option for escaping an intolerable conscious experience of oneself. SSF Core Assessment 5
Standard clinical interactions, including suicide interventions, are clinician as expert interviewing patient?????? THERAPIST PATIENT DEPRESSION LACK OF SLEEP POOR APPETITE ANHEDONIA...? SUICIDALITY? Suicide is a symptom Traditional treatment = inpatient hospitalization, treating the psychiatric disorder, relying solely on crisis response plans This approach does not create collaboration Instead, the patient may feel Interrogated Shamed They are being run through a checklist The clinician does not get it Being honest about suicidal thoughts is not worth the risk COLLABORATIVELY ASSESSING RISK: Targeting Suicide as the Focus of Treatment Mood SUICIDALITY PAIN STRESS AGITATION HOPELESSNESS SELF-HATE THERAPIST & PATIENT REASONS FOR LIVING VS. REASONS FOR DYING CAMS Treatment = Weekly outpatient care that is suicide-specific, emphasizing the development of other means of coping and problem-solving thereby systematically eliminating the need for suicidal coping 6
This means Directly demonstrate that you empathize with the patient s suicidal wish You have everything to gain and nothing to lose from giving it your all to save your life You can always kill yourself later At the same time, clarify when you would have to take action that they might not choose know you limits If they won t work collaboratively on a treatment plan If they say they cannot control their suicidal urges and are actively planning to kill themselves 7
CAMS Model of Suicidal Ideation Suicide as an Option Describe Bridges and Barriersto Going to Next Level Direct Drivers Describe Bridges and Barriersto Going to Next Level Indirect Drivers 8
Thank you stephen.oconnor@louisville.edu 9