Evidence-Based Reviews

Beyond lithium: Using psychotherapy to reduce suicide risk in bipolar disorder

Current Psychiatry. 2011 October;10(10):39-45

References

1. McIntyre RS, Konarski JZ. Bipolar disorder: a national health concern. CNS Spectr. 2004;9(11 suppl 12):6-15.

2. Tsai SY, Lee CH, Kuo CJ, et al. A retrospective analysis of risk and protective factors for natural death in bipolar disorder. J Clin Psychiatry. 2005;66(12):1586-1591.

3. Osby U, Brandt L, Correia N, et al. Excess mortality in bipolar and unipolar disorder in Sweden. Arch Gen Psychiatry. 2001;58(9):844-850.

4. Baldessarini RJ, Pompili M, Tondo L. Suicide in bipolar disorder: risks and management. CNS Spectr. 2006;11(6):465-471.

5. Gelenberg AJ. Can lithium help to prevent suicide? Acta Psychiatr Scand. 2001;104(3):161-162.

6. Schou M. Suicidal behavior and prophylactic lithium treatment of major mood disorders: a review of reviews. Suicide Life Threat Behav. 2001;30(3):289-293.

7. Burgess S, Geddes J, Hawton K, et al. Lithium for maintenance treatment of mood disorders. Cochrane Database Syst Rev. 2001;(3):CD003013.-

8. Baldessarini RJ, Tondo L, Davis P, et al. Decreased risk of suicides and attempts during long-term lithium treatment: a meta-analytic review. Bipolar Disord. 2006;8(5 Pt 2):625-639.

9. Tondo L, Baldessarini RJ. Long-term lithium treatment in the prevention of suicidal behavior in bipolar disorder patients. Epidemiol Psichiatr Soc. 2009;18(3):179-183.

10. Miklowitz DJ. Adjunctive psychotherapy for bipolar disorder: state of the evidence. Am J Psychiatry. 2008;165(11):1408-1419.

11. Hirschfeld RMA, Harris TH, Davis HK. Making efficacious choices: the integration of pharmacotherapy and nonpharmacologic approaches to the treatment of patients with bipolar disorder. Current Psychiatry. 2009;8(10 suppl):S6-S11.

12. Rucci P, Frank E, Kostelnik B, et al. Suicide attempts in patients with bipolar I disorder during acute and maintenance phases of intensive treatment with pharmacotherapy and adjunctive psychotherapy. Am J Psychiatry. 2002;159(7):1160-1164.

13. Fountoulakis KN, Gonda X, Siamouli M, et al. Psychotherapeutic intervention and suicide risk reduction in bipolar disorder: a review of the evidence. J Affect Disord. 2009;113(1-2):21-29.

14. Pompili M, Rihmer Z, Innamorati M, et al. Assessment and treatment of suicide risk in bipolar disorders. Expert Rev Neurother. 2009;9(1):109-136.

15. Assagioli R. Psychosynthesis: a collection of basic writings. New York NY: The Viking Press Inc.; 1965.

16. Assagioli R. The act of will. New York NY: The Viking Press Inc.; 1973.

17. Williams JM, Alatiq Y, Crane C, et al. Mindfulness-based cognitive therapy (MBCT) in bipolar disorder: preliminary evaluation of immediate effects on between-episode functioning. J Affect Disord. 2008;107(1-3):275-279.

18. Shea SC. The delicate art of eliciting suicidal ideation. Psychiatric Annals. 2004;34:385-400.

19. Torem MS. “Back from the future”: a powerful age-progression technique. Am J Clin Hypn. 1992;35(2):81-88.

20. Torem MS. Treating depression: a remedy from the future. In: Yapko MD ed. Hypnosis and treating depression: applications in clinical practice. New York, NY: Routledge; 2006:97–119.

The psychosynthesis model of helping patients disidentify and therefore disown suicidal thoughts is compatible with interventions that use mindfulness-based cognitive therapy training to teach patients to experience their thoughts as just passing through their consciousness without taking ownership of them.¹⁷

Table 2

Examples of ego-syntonic vs ego-dystonic suicidal thoughts

Ego-syntonic	Ego-dystonic
‘I want to be dead. I found a simple and sure way to do it’	‘I am having suicidal thoughts again and I don’t like it’
‘I know my family will be better off without me’	‘I’m afraid the illness is coming back. I can’t stop these images’
‘Life is too hard, too much pain. I just want to end it all’	‘I see my body in a coffin. It scares the hell out of me’
‘I’ve come to the end, life for me is over and done’	‘I don’t want to die. Please help me get well again’
‘I know my life is over. I just have to find the right way to do it’	‘It is as if a part of me wants to die but the rest of me wants to live’
‘Nobody cares about me. It is as if I am already dead’	‘I know my family needs me. I want to be there for them’
‘I have nothing to live for’	‘I have so much to live for, why am I having such crazy thoughts?’

The intervention

Assessment of suicidality is a fundamental skill for every mental health clinician.¹⁸ The psychotherapeutic intervention I use integrates the cognitive therapy principles of reframing, relabeling, and restructuring patients’ thoughts with disidentification from dysfunctional thoughts, feelings, and desires, based on psychosynthesis principles.

Clinical Point

This intervention calls for patients to restructure suicidal thoughts as a manifestation of bipolar disorder

First, I conduct a comprehensive mental status examination that includes an in-depth exploration of the patient’s suicidal thoughts to determine if they are ego-syntonic or ego-dystonic. I begin by asking patients to clarify and elaborate on their statements referring to suicide, asking questions such as “Is there a part of you that objects to these thoughts?” and “Is there a part of you that wants to live?” If a patient indicates that he or she does experience inner conflict regarding such thoughts, these thoughts are classified as ego-dystonic. If a patient does not have any counter thoughts regarding the suicidal thoughts and fully identifies with them, the thoughts are classified as ego-syntonic.

I follow this with a treatment plan that helps patients change their view of their suicidal thoughts. I ask the patient to change these suicidal thoughts to ego-dystonic by focusing on the following statement: “I, (patient’s name), am a human being and like all human beings, I have thoughts; however, I am not my thoughts, I am much more than that.” I ask my patient to read this out loud and to mindfully meditate on this statement several times a day to reinforce the new understanding that these suicidal thoughts are a manifestation of the chemical imbalance of the mood disorder, and do not represent the patient as a person.

Clinical Point

Patients whose suicidal thoughts are ego-dystonic typically want to eliminate such thoughts

This intervention is paired with a future-focused internalized imagery experience I have described in previous articles.^19,20 In this part of the treatment, the patient and I discuss a specific expected life milestone that is positive and for which he or she would want to be present (eg, children graduating from high school or college, a wedding, birth of a child/grandchild, etc.). Using guided imagery, the patient experiences this event with all 5 senses during the session. I instruct the patient to internalize the experience and bring it back from the future to the present. This creates a “hook into the future” that is coupled with this desired milestone event in the patient’s life.

The following 3 case studies provide examples of the application of this treatment intervention.

CASE 1: Disidentifying family history

Mrs. G, a 42-year-old mother of 2, suffers from bipolar II disorder with recurrent episodes of depression associated with ego-syntonic suicidal thoughts. She states that at times she feels she is a burden to her husband and children and believes they may be better off without her. She says she believes “ending it all” must be her destiny. After further investigation, I learn Mrs. G has a family history of BD and 3 relatives have committed suicide. This family history may partially explain her belief that suicide must be “in her genes.”

I discuss with Mrs. G the strategy of changing her thoughts. I tell her to write in her journal—which she brings to her sessions—the following statements: “I am a human being. I am an adult woman and mother of 2 children. I know I have thoughts but I am not my thoughts, I am much more than that. I know I have genes but I am not my genes, I am much more than that. I know I have feelings, but I am not my feelings, I am much more than that. I know I have cousins, uncles, aunts, and other relatives but I am not my relatives. I am uniquely myself, different from the others.”