Suicide is a leading cause of death. In the U.S., more than 38,000 individuals died by suicide in 2010 (National Center for Injury Prevention and Control 2012). Worldwide, almost one million people die by suicide each year (World Health Organization 2012). Suicide attempts in the U.S. occur at rates up to 25 times higher than suicides (Goldsmith et al. 2002). Given the incidence and prevalence of suicide and suicide attempt, identifying interventions to prevent suicidal behavior in individuals identified as at risk is imperative. However, designing and testing such interventions is challenging for several reasons: (1) There are ethical concerns to consider when offering novel treatment to some but not all individuals at acute risk for suicidal behavior, e.g., when randomizing high suicide-risk patients to enhanced treatment or treatment as usual (TAU). (2) Pinpointing efficacious treatments is difficult given the nature of the primary outcomes in suicide intervention research. That is, when suicidal ideation and suicide attempts are the primary outcomes of interest, natural regression to the mean and the low incidence of suicide-related events, limit power to detect pre- to postôtreatment gains. (3) Suicidal patients are a heterogeneous group (Carballo et al. 2008), posing a challenge to identifying what works and what works for whom among the different types of suicide attempters and completers.

Despite such difficulties, several psychotherapeutic treatments to prevent suicide and suicide-related behavior are available and empirically supported. In this chapter, we provide a comprehensive review of multi-session psychotherapeutic treatments to prevent suicidal behavior among high suicide-risk groups, and we summarize the most promising very brief (i.e., one session) interventions for suicidal patients that are begun or even completed at the time and place where suicidal individuals present for help (e.g., emergency departments). Our review is focused on describing treatments for suicidal adults and adolescents and the evidence base. We also suggest directions for future research, highlighting the need for research that could lead to the refinement of available psychotherapeutic treatments for suicidal behavior and the development of additional brief interventions.

Despite the promise of longer-term psychotherapeutic treatment approaches to suicidal behavior, the majority of suicidal individuals do not seek or maintain in outpatient or voluntary mental health treatment (see Lizardi and Stanley (2010) for a review; Hamdi et al. (2008)). Thus, some very brief crisis interventions have been designed to address and prevent the recurrence of suicidal behavior among patients presenting with suicidal ideation or behavior. Such interventions require at most one face-to-face individual session and can be delivered by professionals or trained paraprofessionals. These brief interventions help clinicians meet some needs of suicidal patients and attend to their legal and professional duties (American Psychiatric 2003) while respecting limits to patient willingness and ability to engage in and sometimes pay for longer-term treatment.

Brief interventions to prevent suicidal behavior can be broadly categorized into contact- and CT-based interventions. Most have been implemented and tested among patients presenting with suicidal behavior to acute care settings.

Motto and Bostrom (Motto 2001) developed a stand-alone, low-level contact intervention for individuals at high risk for suicide. Specifically, patients who refused treatment following an inpatient hospitalization for suicidal behavior or depression were sent up to 24 personalized and unique letters from inpatient staff for a period of 5 years. The letters were brief and simply offered well wishes and the opportunity for the patient to respond, if he or she felt so inclined. In a RCT, Motto and Bostrom (2001) found that the patient group who received this brief, cost-effective contact intervention had significantly lower rates of suicide for 2 years post-discharge compared to a control group who received no further follow-up contact.

Subsequent studies have not found as robust results for a contact intervention. Carter et al. (2005) tested a contact intervention where patients who presented to an emergency department for self-poisoning, regardless of suicidal intent, were sent monthly and then bi-monthly postcards for 1 year. They found that this intervention significantly reduced the incidence of self-harm behaviors. However, the proportion of individuals reengaging in self-harm behavior did not differ between those in the intervention and control groups. Beautrais et al. (2010), meanwhile, found that differences in rates of acute care visits for self-harm behaviors did not differ between those who received a contact intervention and those who did not once the number of visits for self-harm behaviors in the year prior to the index event was considered. They concluded that the contact intervention may only be efficacious for a subset of individuals who engage in suicidal behavior.

Despite these mixed findings, contact interventions continue to be implemented and tested internationally. Chen et al. (2010) developed an intervention where individuals who were seen in an emergency department or inpatient unit for self-harm behaviors received weekly supportive text messages. This intervention was found to be acceptable and was perceived to be helpful by participants. Fleischmann et al. (2008) conducted a multinational RCT of a combined intervention that consisted of a 1-hour psychoeducational session prior to discharge from the ED and brief follow-up contacts. The psychoeducational session focused on identifying risk factors and coping skills to manage suicidal urges. The authors found that suicide attempters who received the combined intervention were significantly less likely to commit suicide during an 18-month follow-up period.