The existing interventions for suicide prevention tend to overlook psychosis-specific experiences, but the need for tailored support remains (Bornheimer et al., 2020; Donker et al., 2013). Risk of suicidal ideation is heightened especially in people diagnosed with psychosis within the past year (Baird et al., 2025), while suicide attempts are prevalent in up to 18% of people with psychosis (Taylor et al., 2014).
Together with the lack of specialised NICE guidelines, this poses a significant challenge for healthcare professionals. In fact, some argue that “psychosis impacts the phenomenology of suicide” (Chalker et al., 2024). Positive symptoms, such as command hallucinations, can fuel suicidal ideation and increase suicide risk (Cassidy et al., 2017). Further fear of hospitalisation, failure to recognise own suicidal thoughts, and complex stigma will also shape the way suicidal ideation is experienced in patients with psychosis (Chalker et al., 2024). The question is: will explicitly recognising and targeting these lived experiences be effective in suicide prevention?
Responding to this gap, Gooding et al. (2025) developed and tested a suicide-focused psychological therapy that directly addressed the mechanisms previously disregarded.
Suicide prevention in psychosis may require interventions crafted with clinical specificity and grounded in an intersectional understanding of psychosis.
Methods
The study was a multicentre, assessor-masked, randomised controlled trial conducted across multiple sites in the UK. Participants from four NHS sites were aged 18 and above with a diagnosis of non-affective psychosis* and recent suicidal ideation/behaviour. In total, 292 participants were randomly allocated to the CARMS intervention plus treatment as usual (TAU) or TAU only. Most participants (85%) were White/Caucasian and were aged 35 on average.
The CARMS therapy – Cognitive Behavioural Suicide Prevention for psychosis (CBSPp) – showed effectiveness in a preceding pilot study. In the main trial, CBSPp consisted of up to 24 sessions (50 min/session) over six months.
CBSPp drew on cognitive models of suicide, focusing the treatment around:
- improving emotional regulation and problem-solving, including reducing feelings of defeat, entrapment, and hopelessness;
- identifying and modifying suicidal thoughts;
- enhancing coping strategies;
- building a meaningful alternative to suicide.
Participants were assessed at baseline, 6 months, and 12 months. The primary outcome was suicidal ideation at 6 months, using a standardised self-report scale (the Adult Suicidal Ideation Questionnaire). Secondary outcomes included suicidal behaviours, depression, hopelessness, and quality of life, and mediators like appraisals of defeat, entrapment, and perceived social support.
*Non-affective psychosis does not show prominent mood disturbance and typically refers to disorders like schizophrenia (Cerqueira et al., 2022).
CBSPp (Cognitive Behavioural Suicide Prevention for psychosis) focused on emotional regulation, coping skills, and building hope – offering a meaningful alternative to suicide.
Results
Both groups improved over time, but suicidal ideation at 6 months did not differ significantly between CBSPp and TAU (p=0.07). This means that CBSPp did not show higher effectiveness in managing suicidal ideation and behaviours than a standard treatment that does not explicitly address suicidal ideation.
However, additional findings suggest that CBSPp may have several advantages, with particular benefit for higher-risk populations. Firstly, CBSPp reduced suicidal ideation at a significantly earlier time point than TAU. Secondly, the biggest improvements were seen in participants who were the most suicidal at the start of the trial.
Additionally, social support appraisals mediated the impact of treatment on suicidal ideation, supporting previous theory (e.g., Brewin et al., 1989). Nevertheless, this was the only statistically significant mediator out of the ones that were evaluated. At 6 months, improvement in perceived social support was greater in the treatment group, suggesting that social support appraisals are an important cognitive appraisal to target. However, this effect was not maintained at 12 months.
Overall, CBSPp showed greater improvements on secondary measures, including reduced depression and hopelessness, and better overall wellbeing. The study further supported the evidence on the non-maleficence of explicitly addressing suicidal ideation (e.g., Blades et al., 2018). While there were four deaths during the trial, these were not by suicide, and no harms were seen in relation to the intervention.
While CBSPp did not show advantages in reducing suicidal ideation, its effects were seen sooner and still had positive effects on overall wellbeing, making it promising for high-risk individuals.
Conclusions
CBSPp appears to be similarly effective as existing treatments that do not specifically target suicide-related experiences. However, it may offer more immediate benefits for individuals experiencing severe suicidal ideation and heightened overall risk. The impact of perceived social support on treatment outcomes also warrants further exploration.
Overall, the findings highlight the need for continued development of suicide-focused interventions in psychosis, particularly those incorporating relevant therapeutic strategies and psychoeducational content.
Patients with psychosis who present with suicidal ideation/behaviour may benefit from psychological support that includes an open dialogue about suicide.
Strengths and limitations
This research by Gooding and colleagues bears several strengths. The RCT is the first of its kind to evaluate both the efficacy and mechanistic pathways of a suicide-focused CBT intervention specifically for individuals with non-affective psychosis and recent suicidal experiences. Including this understudied yet high-risk population adds critical evidence for suicide prevention research. Exploring cognitive appraisals as mechanisms of change can reveal how therapy works, helping us understand the specific processes behind its impact and adding depth to the outcome findings.
Further, the CBSPp was not just symptom-based, but aimed at underlying cognitive-emotional appraisals that are thought to drive suicidality. Participants’ positive feedback and low attrition rates further suggest the acceptability of this intervention. Also, the researchers reported comprehensive adverse event tracking, which adds reassurance about discussing suicidality in psychosis therapy.
Yet, several limitations should be kept in mind. Most importantly, CBSPp did not show a significant benefit over TAU. This raises doubts about how much this specialised therapy is needed. Also, seeing that only social support appraisals, and no other appraisals (e.g., hopelessness, emotional difficulties, etc.) had a mediating effect, I wonder what this means for the broader theoretical underpinnings of this therapy. To build on Chalker et al. (2024), I am curious to see whether more emphasis on the subjective experience of psychosis is needed when designing and delivering suicide-focused interventions.
Another limitation is that the trial included an ethnically homogeneous group and considered only non-affective psychosis. This limits the generalisability of these findings to other populations, who might be at even greater risk of suicide. Also, the trial included only non-affective psychosis, while the prevalence of attempted suicide is highest in schizoaffective disorder, which combines symptoms of psychosis and mood disorders (46.8%; Álvarez et al., 2022).
Despite its limitations, this study is commendable for its methodological rigour and academic transparency, including randomisation, masking, pre-specified analysis plans, and independence from the funder. While non-significant findings may partly reflect limited statistical power, they also underscore the importance of considering whether the intervention adequately addresses the needs and lived experiences of the target population. Gooding and colleagues make a valuable contribution by identifying key mechanisms, particularly social support, that can guide the future development of suicide-focused therapies for people with psychosis.
Interventions need further development and trialling to accommodate for psychosis-specific experiences across diverse populations and with sustained therapeutic outcomes.
Implications for practice
Clinicians working with suicide risk in psychosis may consider integrating social support appraisal work into therapy. For instance, routinely assessing patients’ perception of belonging or social connectedness. Involving family, peer or community support may also be appropriate for improving the treatment outcomes for suicidal ideation. Additionally, during clinical formulation, professionals may consider explicitly acknowledging the interplay between psychotic and suicidal experiences. It is crucial to create a safe therapeutic environment that is risk-sensitive yet non-avoidant of discussing suicidal experiences with patients with psychosis.
Based on the evidence from Gooding et al., talking about suicide will not worsen the symptoms or increase the risk of suicide. Meanwhile, avoidance of this topic or lack of a compassionate approach from the clinicians’ side (which can be seen as part of social support) could further stigmatise the person’s experience (Xu et al., 2016).
It is also important to consider the intersectionality of patients’ experiences, including the role of gender identity, sexual orientation, ethnicity and race (Akouri-Shan et al., 2022; Forrest et al., 2023), as well as how these intertwine with the healthcare power dynamics in psychosis (e.g., Laugharne et al., 2011). For instance, Social Graces and LUUUTT model are prominent methods to a more culturally sensitive and personalised formulation that recognises lived experience.
Given that the treatment gains were not sustained by 12 months, it may be vital to plan long-term strategies and/or offer booster sessions and peer support groups. I would be curious to see if such additional support, especially social support, can help sustain the therapeutic gains for patients with psychosis.
It remains crucial to provide non-judgemental, compassionate and person-centred support in suicide-related experiences in patients with psychosis.
Statement of interests
No conflict of interest to declare.
Links
Primary paper
Gooding, P., Pratt, D., Edwards, D., Awenat, Y., Drake, R., Emsley, R., … & Haddock, G. (2025). Underlying mechanisms and efficacy of a suicide-focused psychological intervention for psychosis, the cognitive approaches to combatting suicidality (CARMS): a multicentre, assessor-masked, randomised controlled trial in the UK. The Lancet Psychiatry, 12(3), 177-188. https://doi.org/10.1016/s2215-0366(24)00399-7
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