Brief Cognitive Behaviour Therapy to Prevent Suicide Reattempts: A Feasibility Study in Swedish Psychiatric Inpatient Care

Suicide attempts and self-harm represent major public health concerns, with approximately 11,000 individuals in Sweden requiring emergency or inpatient care each year following suicidal behaviour. The period immediately following discharge from psychiatric inpatient care is associated with an extremely elevated risk of suicide, with studies indicating up to a 200-fold increase compared to the general population. Despite this high-risk period, there is currently a lack of structured, evidence-based psychological interventions specifically designed for inpatient psychiatric settings, where care primarily focuses on pharmacological treatment and acute stabilisation.

Brief Cognitive Behaviour Therapy (BCBT) is a structured, four-session psychological intervention based on cognitive behavioural principles and specifically adapted to target suicidal behaviour. BCBT is grounded in the Fluid Vulnerability Theory of suicide, which conceptualises suicide risk as a dynamic process influenced by both enduring vulnerabilities and acute stressors. The intervention aims to reduce suicide risk by targeting modifiable cognitive, emotional, and behavioural processes, enhancing coping skills, and preventing the activation or escalation of suicidal crises.

This study is a single-arm feasibility study designed to evaluate the acceptability and feasibility of BCBT among adult psychiatric inpatients in Sweden. A total of 20 participants aged 18 years or older will be recruited from inpatient psychiatric units at Psykiatri Sydväst and Psykosvård Stockholm.

Participants will receive four individual BCBT sessions delivered by trained clinical psychologists during the participants' inpatient stay. Each session lasts approximately 60-90 minutes and focuses on specific therapeutic components. The first session includes psychoeducation, a narrative of the suicide attempt, and development of an individualised case conceptualisation and safety plan. The second session focuses on cognitive flexibility and identifying reasons for living, including the creation of a "hope box". The third session addresses restriction of access to lethal means and development of coping strategies, including coping cards. The fourth session focuses on consolidation of skills and relapse prevention, including guided imagery exercises to prepare for future crises. If discharge occurs before completion, sessions may be continued after discharge. All participants will continue to receive treatment as usual in accordance with standard inpatient care.

In addition, semi-structured qualitative interviews will be conducted with patients, focusing on the acceptability, perceived effects, and satisfaction with the treatment. The investigators will also conduct semi-structured qualitative interviews with treating psychologists, clinical staff, and managers (approximately 8-12 participants). These interviews aim to explore feasibility, and barriers and facilitators to implementation of BCBT in routine inpatient psychiatric care.

• Decline rate [Time frame: From first potentially eligible participant approached until recruitment of 20 patients is completed (anticipated duration: 6 months)]
• Recruitment pace [Time frame: From first potentially eligible participant approached until recruitment of 20 patients is completed (anticipated duration: 6 months)]
• Likelihood of treatment component use [Time frame: During the 4-session treatment period (planned for 4 consecutive days), assessed at each session]
• Use and perceived helpfulness of treatment components [Time frame: 1- and 3-month follow-up after the final treatment session]
• Adverse events and negative effects of treatment [Time frame: During the 4-session treatment period (planned for 4 consecutive days), assessed at each session; posttreatment assessment (performed within 2 working days after the final treatment session); and 1- and 3-month follow-up after the final treatment session]
• Semi-structured interviews with personnel [Time frame: Interviews will be conducted within 1 month after recruitment of the final patient (n=20) is completed (anticipated recruitment duration: approximately 6 months)]
• Semi-structured interviews with patients [Time frame: Interviews will be conducted on the same day, directly following the 1-month follow-up assessment (i.e., one month after the final treatment session).]
• Suicidal ideation [Time frame: Assessed at screening (baseline), posttreatment (within 2 working days after the final treatment session), and at 1-month and 3-month follow-up after the final treatment session. Primary endpoint: 3-month follow-up after the final treatment session.]
• Suicide attempts [Time frame: Assessed at screening (baseline), posttreatment (within 2 working days after the final treatment session), and at 1-month and 3-month follow-up after the final treatment session. Primary endpoint: 3-month follow-up after the final treatment session.]