Cognitive Behavioral Therapy With Narrative Assessment Linked to Lower Suicide Attempt Risk
Key Clinical Summary
- A meta-analysis of 23 randomized clinical trials (n=3262) examined cognitive behavioral therapy (CBT) interventions with and without narrative assessment.
- CBT including a narrative assessment significantly reduced suicide attempts (relative risk [RR], 0.68; 95% CI, 0.53–0.87).
- Findings suggest narrative assessment may strengthen suicide prevention strategies in clinical practice.
A meta-analysis published in JAMA Network Open analyzed whether cognitive behavioral interventions that incorporate a narrative assessment are more effective at reducing suicide attempts than those without. The review, assessing 23 randomized clinical trials and over 3200 participants, found that integrating a narrative component substantially improved prevention outcomes.
Study Findings
Researchers examined data from the Metapsy Suicide Prevention Database (version 25.0.1), which includes published and unpublished randomized clinical trials through April 2025. Eligible studies assessed suicide attempts following CBT interventions. Trials using waiting list controls or reporting only suicidal ideation were excluded.
Among the 23 included studies (n=3262), interventions that included a narrative assessment were associated with significantly lower risk of suicide attempts compared with controls (RR, 0.68; 95% CI, 0.53–0.87; 1764 participants across 14 studies). In contrast, CBT interventions without a narrative component did not demonstrate significant benefit (RR, 1.17; 95% CI, 0.63–2.20; 1498 participants across 9 studies).
A subgroup comparison revealed a statistically significant difference between groups (Q₁ = 7.27; P = .007; I² = 86%). Studies excluding the narrative assessment tended to enroll younger participants and had lower event rates and higher bias risk.
The findings suggest that the inclusion of a narrative assessment, which involve structured methods to explore an individual’s lived experience and suicide-related drivers, may strengthen therapeutic engagement and insight.
Clinical Implications
These results highlight the potential clinical utility of narrative-based assessment within CBT protocols for suicide prevention. Incorporating a structured narrative component could help clinicians identify the psychological and situational factors driving suicidal behavior, thereby enabling more personalized and targeted interventions.
Given the lack of standardized, evidence-based tools to discern why individuals attempt suicide, this approach could fill an important gap in clinical practice.
Expert Commentary
“These results suggest that a narrative assessment may be a simple and effective way to capture the forces that lead to suicide attempts and to direct interventions toward their prevention,” wrote Wilco C. Janssen, MSc, 113 Suicide Prevention, Amsterdam, the Netherlands, and study coauthors.
The authors also highlighted that further randomized, head-to-head trials are needed to confirm causality and determine optimal implementation methods in diverse care settings.
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As mental health professionals continue refining evidence-based interventions for suicide prevention, this meta-analysis suggests that narrative-driven approaches may represent a practical step toward reducing suicide risk and improving patient-centered care.
