Sachs and colleagues (2001) note that psychotherapy is not a cure for suicidal ideation, but may strengthen protective factors and decrease inclination. Gray and Otto (2001) reviewed psychosocial approaches to suicide prevention and their applicability to bipolar patients. An approach tailored toward psychosocial risk factors, for example, hopelessness, poor problem-solving, negative cognitions and dysfunctional coping strategies, may be particularly helpful. Gainful employment and increasing social supports are also appropriate goals. Gray and Otto (2001) reviewed 17 randomized, controlled studies of efforts to decrease suicidal and self-injurious behavior. The studies could be categorized as brief hospitalization, efforts to enhance treatment utilization, problem-solving interventions and intensive treatments. Brief hospitalization was associated with negative to small effect size, while facilitated/rapid hospital reentry was more promising for subjects with initial episodes of self-harm. Studies of some outreach services found no benefits, while those that included home visits had modest to no reductions in suicidal behavior. One in this latter category with noteworthy results (threefold difference compared with treatment as usual) involved 4 months of weekly or biweekly home-based interventions combining psychotherapy, crisis intervention and family therapy (Welu, 1977). This represents a significant commitment of resources. Problem-solving interventions, for example, around interpersonal conflicts or cognitive behavioral therapy, had moderate effect size, and were largely brief, structured and problem-focused. Intensive treatments (1 year) like dialectical behavior therapy (DBT) reflected a large effect size (Gray and Otto, 2001).
Clinicians should consider three effective strategies: low-ering barriers to care during times of distress, brief training in problem-solving strategies, and comprehensive strategies that combine problem-solving with intensive rehearsal of cognitive, social, emotional-labeling and tolerance, and coping skills. Pa-tients and families should be educated on procedures for access-ing after-hours and emergency care. Cognitive restructuring can address hopelessness, pessimism, cognitive distortions and en-hance reasons for living. The development of distress-tolerance skills may be particularly beneficial for patients who feel unable to resist urges to harm themselves or have chronically maladap-tive responses to stress (Gray and Otto, 2001).