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Brown GK, Ten Have T, Henriques GR, Xie SX, Hollander JE, Beck AT. Cognitive Therapy for the Prevention of Suicide Attempts: A Randomized Controlled Trial. JAMA. 2005;294(5):563–570. doi:10.1001/jama.294.5.563
Author Affiliations: Departments of Psychiatry
(Drs Brown and Beck) and Emergency Medicine (Dr Hollander) and Center for
Clinical Epidemiology and Biostatistics (Drs Ten Have and Xie), University
of Pennsylvania, Philadelphia; and Department of Graduate Psychology, James
Madison University, Harrisonburg, Va (Dr Henriques).
Context Suicide attempts constitute a major risk factor for completed suicide,
yet few interventions specifically designed to prevent suicide attempts have
Objective To determine the effectiveness of a 10-session cognitive therapy intervention
designed to prevent repeat suicide attempts in adults who recently attempted
Design, Setting, and Participants Randomized controlled trial of adults (N = 120) who attempted
suicide and were evaluated at a hospital emergency department within 48 hours
of the attempt. Potential participants (N = 350) were consecutively
recruited from October 1999 to September 2002; 66 refused to participate and
164 were ineligible. Participants were followed up for 18 months.
Intervention Cognitive therapy or enhanced usual care with tracking and referral
Main Outcome Measures Incidence of repeat suicide attempts and number of days until a repeat
suicide attempt. Suicide ideation (dichotomized), hopelessness, and depression
severity at 1, 3, 6, 12, and 18 months.
Results From baseline to the 18-month assessment, 13 participants (24.1%) in
the cognitive therapy group and 23 participants (41.6%) in the usual care
group made at least 1 subsequent suicide attempt (asymptotic z score, 1.97; P = .049). Using the Kaplan-Meier
method, the estimated 18-month reattempt-free probability in the cognitive
therapy group was 0.76 (95% confidence interval [CI], 0.62-0.85) and in the
usual care group was 0.58 (95% CI, 0.44-0.70). Participants in the cognitive
therapy group had a significantly lower reattempt rate (Wald χ21 = 3.9; P = .049)
and were 50% less likely to reattempt suicide than participants in the usual
care group (hazard ratio, 0.51; 95% CI, 0.26-0.997). The severity of self-reported
depression was significantly lower for the cognitive therapy group than for
the usual care group at 6 months (P= .02), 12
months (P = .009), and 18 months (P = .046). The cognitive therapy group reported
significantly less hopelessness than the usual care group at 6 months (P = .045). There were no significant differences
between groups based on rates of suicide ideation at any assessment point.
Conclusion Cognitive therapy was effective in preventing suicide attempts for adults
who recently attempted suicide.
In 2002, suicide was the fourth leading cause of death for adults between
the ages of 18 and 65 years with approximately 25 000 suicides for this
age group in the United States.1 As recommended
by the National Strategy for Suicide Prevention,
one public health approach for the prevention of suicide involves identifying
and providing treatment for those individuals who are at high risk for suicide.2
Attempted suicide is one of the strongest risk factors for completed
suicide in adults. A meta-analysis of follow-up mortality studies estimated
that individuals who attempted suicide were 38 to 40 times more likely to
commit suicide than those who had not attempted suicide.3 Prospective
research also has supported the validity of attempted suicide as a risk factor
for eventual suicide.4-7
Empirical evidence for treatments that effectively prevent repetition
of suicide attempts is limited.8 Randomized
controlled trials of individuals who have attempted suicide have used intensive
follow-up treatment or intensive case management,9-11 interpersonal
psychotherapy,12 or cognitive behavior therapy.13 Several studies supporting the efficacy of cognitive
behavior therapy or problem-solving therapy for reducing suicide behavior13,14 have highlighted the need for randomized
controlled trials with sufficient power to detect treatment differences.15
This study was designed with adequate power to determine whether a brief
psychosocial intervention could reduce the rate of repetition for suicide
attempts over an 18-month interval, a longer period than previously reported
in most randomized controlled trials. Cognitive therapy was selected as the
psychosocial intervention for this study because it builds on clinical investigations
regarding the psychopathological characteristics of suicide behaviors16 and it has been shown to be successful in a wide
variety of psychiatric disorders.17 We examined
3 hypotheses. First, the hazard ratio for another suicide attempt would be
lower in the cognitive therapy group compared with the usual care group. Second,
during follow-up, the proportion of participants who attempt suicide would
be lower in the cognitive therapy group compared with the usual care group.
Third, participants in the cognitive therapy group would have significantly
lower scores on measures of depression, hopelessness, and suicide ideation
during follow-up compared with the participants in the usual care group.
The study sample consisted of 120 individuals who attempted suicide
and who received a medical or psychiatric evaluation within 48 hours of the
attempt. Individuals were initially identified in the emergency department
following a suicide attempt or intentional self-injury (eg, overdose, laceration,
gunshot wound) at the Hospital of the University of Pennsylvania, Philadelphia.18 After the patients were medically cleared or stabilized
in the emergency department, they were transferred to the psychiatric emergency
department. Eligible individuals were identified by research assistants in
the emergency department during the initial evaluation and through screening
intake logs at the psychiatric emergency department.
Individuals admitted to an inpatient unit of the hospital were contacted
by research assistants after obtaining permission from the attending physician.
Potential participants who were not admitted to an inpatient unit and discharged
were contacted by telephone. A brief interview was conducted to determine
if an attempt had occurred with verbal consent obtained for the interview.
A suicide attempt was defined as “a potentially
self-injurious behavior with a nonfatal outcome for which there is evidence,
either explicit or implicit, that the individual intended to kill himself
or herself.”19(p247) The Suicide
Intent Scale was used to ascertain suicide intent.20 For
those acts in which it was not clear whether a self-harmful act was an actual
suicide attempt, study investigators were consulted to achieve consensus regarding
an individual’s study eligibility.
A complete description of the study was provided to potential participants
and signed written informed consent was obtained by study personnel. The institutional
review board at the University of Pennsylvania and an independent data and
safety monitoring board approved and monitored the research protocol.
Inclusion criteria consisted of a suicide attempt within 48 hours prior
to being evaluated at the emergency department; age of 16 years or older;
ability to speak English; ability to complete a baseline assessment; ability
to provide at least 2 verifiable contacts to improve tracking for subsequent
assessments; and ability to understand and provide informed consent. Individuals
were excluded if they had a medical disorder that would prevent participation
in an outpatient clinical trial. Individuals were not asked or required to
discontinue any form of mental health or substance abuse treatment prior to
entering the study.
An in-person baseline interview and self-report inventories were administered
within 3 days but no longer than 3 weeks after the suicide attempt by trained
clinicians who held master’s or doctoral degrees. Psychiatric diagnoses
were determined by clinicians trained in administering the Structured Clinical
Interview for Axis I of the Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition21 and
by a study psychologist who reviewed symptoms. Subsequent in-person assessments
were conducted independently of study therapists at 1, 3, 6, 12, and 18 months
following the baseline interview.
Participants (N = 120) were randomly assigned to cognitive
therapy or usual care. A computerized randomization sequence programmed to
prohibit more than 7 consecutive assignments in either treatment group was
used. Although blinded assessments were conducted at baseline, blinded follow-up
evaluations were not possible for 2 reasons. First, the evaluation of a suicide
attempt involved an investigation of the circumstances preceding the self-harmful
act and the postattempt use of mental health services, which presented clues
to the group assignment. Second, information regarding treatment assignment
was often essential for adequate clinical management of acutely suicidal individuals.22,23
Participants in the cognitive therapy intervention were scheduled to
receive 10 outpatient cognitive therapy sessions specifically developed for
preventing suicide attempts.24-26 The
cognitive therapy sessions were provided on a weekly or biweekly basis or
as needed. The central feature of this psychotherapy was the identification
of proximal thoughts, images, and core beliefs that were activated prior to
the suicide attempt. Cognitive and behavioral strategies were applied to address
the identified thoughts and beliefs and participants were helped to develop
adaptive ways of coping with stressors. Specific vulnerability factors that
were addressed included hopelessness, poor problem solving, impaired impulse
control, treatment noncompliance, and social isolation. A relapse prevention
task was conducted near the end of therapy. The objective of this task was
to prime, in session, the specific thoughts, images, and feelings associated
with prior suicide attempts and to determine if participants were able to
respond to their problems in an adaptive way. Successful completion of this
task was justification for completion of the treatment. If the participant
failed to respond adaptively, additional sessions were provided. All cognitive
therapy sessions were audiotaped and each therapist was rated for competency
using the Cognitive Therapy Rating Scale.27 Feedback
was provided to therapists biweekly or as needed if therapists did not adhere
to the treatment manual.
Participants in both study groups received usual care from clinicians
in the community as well as tracking and referral services from the study
case managers.28 In both conditions, study
case managers obtained detailed contact information regarding participants’
family, friends, clergy, probation officers, and mental health workers. These
individuals were contacted by case managers with permission from the participants
if they could not be contacted. Case managers contacted participants throughout
the follow-up period on a weekly to monthly basis by mail and by telephone
using a community voice mail account. Additionally, case managers offered
referrals to community mental health treatment, addiction treatment, and social
services (as needed during the follow-up period) and obtained feedback from
participants regarding their contact with these services. Although participants
in both conditions were encouraged to seek additional mental health and substance
abuse treatment in the community, the study did not cover the costs of these
The primary outcome measure was the occurrence of a suicide attempt
during the follow-up period. The interviewer assessed suicide attempts by
participant report. The clinician-administered 24-item Hamilton Rating Scale
for Depression (HRSD)29 and the self-reported
21-item Beck Depression Inventory II30 were
used to assess the severity of depression. Hopelessness was measured by the
Beck Hopelessness Scale, which consisted of 20 true or false statements designed
to assess the extent of positive and negative beliefs about the future.31 The 19-item Scale for Suicide Ideation evaluated
the intensity of the participant’s specific attitudes, behaviors, and
plans to commit suicide.32 Because the distribution
of scores for the Scale for Suicide Ideation is highly skewed, it was dichotomized
at 0 (vs >0) to indicate any current suicide ideation.33
At any point in the study, participants who were suspected to be at
risk for suicide were asked the following questions by a doctoral-level clinician:
(1) Do you have a desire to kill yourself that you think you might act on?
(2) Do you have a plan for killing yourself and intend to carry the plan out?
Participants were also identified as high risk if they reported a moderate
to severe level of suicide intent as indicated on other self-report measures
or during a clinical interview. A participant randomized to either study group
was referred or transferred to the emergency department if the clinician determined
that he/she was at imminent risk for suicide and could not be safely treated
on an outpatient basis. Participants who were hospitalized during the follow-up
period were allowed to continue with treatment and assessments after they
were discharged. All suicide attempts and deaths were reported to the institutional
review board and data and safety monitoring board.
To test the primary hypothesis that the mean time to the next suicide
attempt during the follow-up period is different between treatment groups,
a priori power calculations were based on the results of a previous randomized
controlled trial with a similar protocol.13 The
current sample size (N = 120) provided at least 80% power to detect
a hazard ratio of 0.44 in terms of time to next suicide attempt between treatment
groups using an assumed repeat attempt rate of 25.8% during the follow-up
period and a 2-sided α level of .05.34
Data entry and verification, data transfer, confidentiality and security,
and data analyses were conducted under the direction of the principal investigators
and statisticians. All effectiveness analyses were conducted using the intent-to-treat
(ITT) principle, which included all randomized participants in the treatment
groups to which they were assigned regardless of their protocol adherence,
actual treatment received, and/or subsequent withdrawal from treatment or
assessment. Descriptive statistics for assessment scores at baseline were
compared between treatment groups to determine if any variables needed to
be included as covariates in the primary analyses of treatment effects.
Survival analyses were conducted using the Cox proportional hazard regression
model35 to test for the effectiveness of the
intervention on the time to the first repeat suicide attempt while controlling
for censoring effects due to the differential length of follow-up or the completion
of follow-up without a repeat suicide attempt. Length of follow-up for each
participant was represented by either the number of days between the date
of baseline evaluation and the date of the repeat suicide attempt or the end
of the follow-up period, whichever came first. Single and multiple covariate
Cox proportional hazards regression models were used. Associated Wald χ2 tests were conducted using a significance level of .05 (2-sided) to
test the null hypothesis that the 2 reattempt-free probabilities were the
same for the cognitive therapy and usual care groups at any time point. To
confirm the single covariate Cox model results, the results of the log-rank
test also were reported. Estimates of participants making at least 1 subsequent
suicide attempt before 18 months and reattempt-free probabilities at any time
point were derived by the Kaplan-Meier method.36 The
between-group difference in the proportion of participants making at least
1 repeat suicide attempt by 18 months was evaluated using the asymptotic properties
of the Kaplan-Meier estimators of survival probabilities. This method was
chosen to account for dropouts based on the ITT principle.
To examine whether cognitive therapy reduced suicide ideation, hopelessness,
and depression more than usual care, comparisons between the 2 study groups
were conducted on continuous measures. Analyses of repeated-measures data
were performed to determine and characterize the patterns of change over time
between treatment groups. Although procedures were developed for maintaining
follow-up during the assessment period, missing data and loss to follow-up
are inevitable. By using latent random-effects variables for each participant,
hierarchical linear (or logit) modeling permits estimation of changes in repeated
measures without necessitating last observation carried forward or exclusion
of participants with missing data. We used SAS software version 8 (SAS Institute
Inc, Cary, NC) for all statistical analyses.
Tests and estimates of ITT differences for both continuous and binary
outcomes were based on longitudinal models with random effects. The longitudinal
random-effects models included main effect and interaction terms that represented
ITT contrasts between groups at each follow-up visit. Using data from all
participants regardless of dropout or treatment adherence status, this modeling
allowed testing of ITT differences at each follow-up visit separately and
together with increased power while accounting for group differences with
respect to participants who dropped out. We first tested for significant ITT
differences in linear trend for each outcome. However, the linear trend model
did not fit any of the outcomes well so we relied on separate ITT tests of
the 5 follow-up visits using separate visit-treatment interactions at each
visit and also jointly across all 5 visits using an omnibus visit-treatment
interaction test with 5 degrees of freedom. The omnibus statistic tests for
significant ITT contrasts at any particular follow-up visit using a time group
interaction with 5 degrees of freedom.37-39 To
assess ITT differences with respect to dropouts, we used a discrete time survival
model.40 Two-sided P values
are presented unadjusted for multiple comparisons so that adjustment of choice,
such as using the Bonferroni adjustment, may be performed by the reader.
Over a 2-year period (October 2000 to September 2002), 350 individuals
were invited to participate (Figure 1).
Of the 230 who were excluded, 164 (71%) did not meet inclusion criteria and
66 (27%) declined to participate in the study. For most excluded individuals,
we determined that the self-harmful act was not a suicide attempt. Of those
who declined to participate, 36 (55%) refused to provide a reason, 21 (32%)
did not wish to receive treatment, 4 (6%) declined for emotional reasons,
and 5 (8%) declined due to situational factors (eg, no child care, no transportation).
Of 186 eligible participants, 120 (65%) were enrolled in the study.
The only demographic variable that was found to be related to participation
was ethnicity (χ21 = 4.9; P = .03). Specifically, blacks were 1.2 times (odds ratio,
1.2; 95% confidence interval [CI], 1.0-1.5) more likely than whites and other
minorities to participate in the clinical trial.
Participant age ranged from 18 to 66 years and 61% were female. As assessed
by participant self-report for the purpose of describing the racial characteristics
of the sample, 60% were black, 35% were white, and 5% were Hispanic, Native
American, or unspecified. The racial composition of the sample is similar
to the racial composition of the general population in the Philadelphia area
where the Hospital of the University of Pennsylvania is located. At baseline,
77% had a major depressive disorder and 68% had a substance use disorder.
Specific substance use disorders included alcohol (30%), cocaine (23%), and
heroin (17%) dependence. Most participants (85%) had more than 1 psychiatric
diagnosis. The majority of participants (58%) attempted suicide by overdosing
using prescription, over-the-counter, or illicit substances. Other methods
were penetrating injury (17%); jumping (7%); and hanging, shooting, or drowning
(4%). Participants in the cognitive therapy and usual care groups did not
differ significantly on demographic variables (Table 1). The groups did not differ on the incidence of major depressive
disorder, substance use disorder, or prevalence of suicide ideation at baseline.
The cumulative dropout rate at the 1-month assessment was 10% (n = 6)
for the cognitive therapy group and 7% (n = 4) for the usual care
group; 3-month assessment, 13% (n = 8) and 10% (n = 6);
6-month assessment, 17% (n = 10) and 13% (n = 8); and
12-month assessment, 18% (n = 11) and 18% (n = 11), respectively.
The cumulative dropout rate at the 18-month follow-up assessment was 25% (n = 15)
for the cognitive therapy group and 34% (n = 20) for the usual care
group (Figure 1). Using a discrete time
survival model,40 drop-out rates did not differ
across all 5 follow-up assessments (P = .36).
The proportion of participants with missed assessment visits was similar between
groups; differences did not exceed 8.3% at any visit (P>.30).
From the baseline to the 18-month assessment, 13 participants (estimated
proportion: 24.1%) in the cognitive therapy group and 23 participants (estimated
proportion: 41.6%) in the usual care group made at least 1 subsequent suicide
attempt (asymptotic z score = 1.97; P = .049). Using the Kaplan-Meier method, the
estimated 6-month reattempt-free probability in the cognitive therapy group
was 0.86 (95% CI, 0.74-0.93) and in the usual care group was 0.68 (95% CI,
0.54-0.79). In addition, the estimated 18-month reattempt-free probability
in the cognitive therapy group was 0.76 (95% CI, 0.62-0.85) and in the usual
care group was 0.58 (95% CI, 0.44-0.70). Kaplan-Meier survival curves illustrate
the differences in repeat suicide attempts between groups over time (Figure 2). Results indicated that participants
in the cognitive therapy group (Wald χ21 = 3.9; P = .049; log-rank χ21 = 4.0; P = .045) had a significantly lower reattempt
rate than those in the usual care group (log-rank χ21 = 4.0; P = .045). The
hazard ratio from this analysis was 0.51 (95% CI, 0.26-0.997), which suggests
that participants in the cognitive therapy group were 50% less likely to attempt
suicide during the follow-up period than participants in the usual care group.
Additional multiple Cox regression models revealed that the impact of cognitive
therapy remained significant even when controlling for the effects of other
outcome measures (ie, Beck Depression Inventory, Beck Hopelessness Scale,
HRSD, Scale for Suicide Ideation) at baseline (hazard ratio, 0.47 [95% CI,
0.24-0.93]; P = .03). Although the effect
of cognitive therapy showed only a trend toward significance when controlling
for age, sex, and minority status (hazard ratio, 0.52 [95% CI, 0.26-1.02]; P = .06), there was only a 2% difference between
the adjusted and unadjusted hazard ratios. All repeat suicide attempts were
determined to be adverse events that were not related to the study. The total
number of cognitive therapy sessions received was not related to repeat suicide
attempt status (OR, 1.08 [95% CI, 0.97-1.92]; χ21 = 2.11; P = .14).
The impact of cognitive therapy on measures of depression, hopelessness,
and suicide ideation was also examined from 1 to 18 months following the baseline
assessment (Table 2). The severity of
depression (measured by the Beck Depression Inventory) was significantly lower
for the cognitive therapy group than for the usual care group at 6-month (P = .02), 12-month (P = .009),
and 18-month (P = .046) assessment points,
yielding a significant overall omnibus test (χ25 = 29.9; P<.001). Although the overall omnibus test for the HRSD
was significant (χ25 = 22.2; P<.001), no significant differences between groups on HRSD were
observed at any assessment point. However, there was significantly less hopelessness
in the cognitive therapy group than in the usual care group at 6 months (P = .045) and the overall omnibus test for the
Beck Hopelessness Scale was significant (χ25 = 19.1; P<.001). There were no differences between groups on
the rates of suicide ideation overall (Scale for Suicide Ideation total score
>0; χ25 = 1.2; P = .95)
or at any assessment visit.
Participants in the cognitive therapy group participated in a mean (SD)
of 8.92 (5.97) cognitive therapy sessions (range, 0-24). Thirty participants
(50%) received 10 or more cognitive therapy sessions. Additional cognitive
therapy sessions were provided until participants completed the relapse prevention
task successfully. Twenty-eight participants (46.7%) received 1 to 9 sessions
and 2 participants (3.3%) did not receive any cognitive therapy. Of those
participants who received 0 to 9 sessions, 21 participants could not be located
and 9 participants refused treatment. Additional (nonstudy) treatments received
by both groups are described in Table 3.
There were no significant differences between the usual care and cognitive
therapy groups with respect to the proportion of participants receiving psychotropic
medication overall (53.6% vs 51.7%; χ21 = 0.3; P = .65) or addiction treatment overall (12.9%
vs 15.8%; χ21 = 1.1; P = .36) or at any assessment point. However, there was a
trend for a larger proportion of the usual care group to participate in nonstudy
psychotherapy treatment overall (27.1% vs 20.6%; χ21 = 3.6; P = .07) and at
the 1-month assessment, specifically (P = .07).
In addition, a significantly larger proportion of the usual care group compared
with the cognitive therapy group did not receive any type of psychotherapy
(cognitive therapy or other psychotherapy), medication, or addiction treatment
overall (31.6% vs 16.8%; χ21 = 10.0; P<.001) or at 1-month (P<.001),
3-month (P<.001), or 6-month (P<.001) assessments. There was no significant difference between
groups in the proportion of participants who were determined to be an imminent
risk and referred or transferred to the emergency department by study investigators
during the follow-up period (13.3% of cognitive therapy group vs 8.3% of usual
care group; χ21= 0.8; P = .38).
The results of this randomized controlled trial indicated that a relatively
brief cognitive therapy intervention was effective in preventing suicide attempts
for adults who recently attempted suicide. Specifically, participants in the
cognitive therapy group were approximately 50% less likely to attempt suicide
during the follow-up period than participants in the usual care group.
The severity of depression as measured by the Beck Depression Inventory
was significantly lower for the cognitive therapy group than for the usual
care group at the 6-month, 12-month, and 18-month assessments. Although there
were no significant differences in the severity of depression as measured
by the HRSD at any assessment point, the superiority of cognitive therapy
was significant overall. The discrepancy between measures of depression severity
across assessment points may be due to differences in the type of assessment
methods (self-report vs clinician-administered).41
The cognitive therapy group also had significantly less hopelessness
than the usual care group at 6 months. Previous research has indicated that
participants whose hopelessness did not significantly change with psychiatric
treatment may be more likely to commit suicide.42 Moreover,
results from a previous clinical trial indicated that stable levels of hopelessness
in individuals with remitted depression are more predictive of a suicide attempt
than a high level of hopelessness at any 1 time point.43
These results are consistent with a previous randomized controlled trial
of suicide attempters that compared cognitive behavior therapy and usual care.13 That study found that cognitive therapy had an impact
on the proportion of participants repeating a suicide attempt at the 6-month
follow-up period. Similar to our results, the previous study reported that
cognitive therapy participants improved significantly more on self-reported
measures of depression and hopelessness but not suicide ideation. Although
both groups demonstrated decreased suicide ideation in the present study,
the differential impact of cognitive therapy on depression and hopelessness
suggests that improvement on these variables may be more highly associated
with a reduced risk of repeat suicide attempts. Given the results of the present
and previous studies, further research that examines the effectiveness of
the techniques specific to cognitive therapy is warranted.
The generalizability of these findings may be limited to suicide attempters
who reside in an urban setting and who are evaluated at an emergency department.
In addition, given that a larger proportion of the sample who consented to
the study was black, additional research is required to investigate this possible
As indicated by a sensitivity analysis, another study limitation concerns
the possibility that small changes in the number of suicide attempts during
the follow-up period may affect the significance of the results. However,
the results of our study are strengthened by the consistency of the results
across several outcomes (ie, suicide attempts, depression, and hopelessness).
An important goal of the National Strategy for Suicide Prevention is
to improve community linkages with primary care and mental health/substance
abuse health systems for translating evidence-based treatments into community-based
settings.2 The short-term feature of cognitive
therapy would make it particularly applicable for the treatment of suicide
attempters at community mental health centers, which typically provide relatively
short-term therapy. Additional studies are warranted to examine the feasibility,
effectiveness, and cost-effectiveness of this intervention in community-based
mental health and substance use treatment settings.
Corresponding Author: Gregory K. Brown,
PhD, Department of Psychiatry, University of Pennsylvania, 3535 Market St,
Room 2030, Philadelphia, PA 19104 (firstname.lastname@example.org).
Author Contributions: Dr Brown had full access
to all of the data in the study and takes responsibility for the integrity
of the data and the accuracy of the data analysis.
Study concept and design: Brown, Ten Have,
Henriques, Hollander, Beck.
Acquisition of data: Brown, Ten Have, Henriques,
Analysis and interpretation of data: Brown,
Ten Have, Xie, Beck.
Drafting of the manuscript: Brown, Ten Have,
Critical revision of the manuscript for important
intellectual content: Brown, Ten Have, Henriques, Xie, Hollander, Beck.
Statistical analysis: Brown, Ten Have, Xie.
Obtained funding: Brown, Ten Have, Beck.
Administrative, technical, or material support:
Brown, Ten Have, Henriques, Hollander, Beck.
Study supervision: Brown, Ten Have, Henriques,
Financial Disclosures: None reported.
Funding/Support: This research was supported
by grants R01 MH60915 and P20 MH71905 from the National Institute of Mental
Health and grant R37 CCR316866 from the Centers for Disease Control and Prevention.
Role of the Sponsor: The funding agencies had
no role in the design and conduct of the study; collection, management, analysis,
and interpretation of the data; and preparation, review, or approval of the
Acknowledgment: We thank the following individuals
who served as study therapists and who received compensation by the funding
sponsors: Michele Berk, PhD, Randy Fingerhut, PhD, Evan Forman, PhD, Gregg
R. Henriques, PhD, Julie Jacobs, PhD, Kenneth Laidlaw, PhD, Christine Ratto,
PhD, Paula Young, PhD, Debbie Warman, PhD, and Joseph Wright, PhD. We also
thank the following individuals who served as study case managers and who
received compensation by the funding sponsors: Sarah Charlesworth, BS, John
Guerry, BA, Jessie Handelsman, BA, Pamela Henderson, RN, Bambi Juryea, BS,
Rachel King, BA, Nathaniel Herr, BS, Joseph Moldover, PsyD, Carly Romeo, BA,
Daniella Sosdjan, MSW, Lisa Starr, BA, and Sarah Tarquini, MS. We offer special
thanks to Frank Sites, RN, for facilitation of participant recruitment and
Mark Carey, PhD, for statistical consultation.