A Novel Cognitive Reappraisal Intervention for Suicide Prevention
Phase: NA
Conditions: Suicide Prevention
Sponsor: Weill Medical College of Cornell University



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BACKGROUND 
Suicide rates in middle-aged and older adults are alarmingly high, and suicide risk 
increases for those who have been hospitalized for suicidal ideation or suicide attempt. 
Reducing suicide rates in at-risk populations is a major NIMH priority. To address this 
need, we developed Cognitive Reappraisal Intervention for Suicide Prevention (CRISP) 
to help middle-aged and older adults (50 years old and older) reduce their suicide risk 
after a suicide- related hospitalization.  
CRISP draws on recent advances in affective neuroscience and aims to improve 
cognitive reappraisal ability (i.e. the ability to modify the appraisal of a situation to alter 
its emotional significance) and reduce suicide risk. Our conceptual framework is based 
on the premises that: a) suicidal ideation and behavior are associated with unsuccessful 
attempts to regulate intense negative emotions, including depression, anxiety, 
hopelessness, irritability, anger, and guilt; b) cognitive reappraisal is an effective 
emotion regulation strategy with identified and investigated neurobiological correlates; 
c) decreased cognitive reappraisal is associated with increased suicide risk; and d)
cognitive reappraisal strategies can be effectively used to reduce suicide risk in our
population. We place emphasis on suicidal ideation, in addition to suicidal behavior,
because suicidal ideation after a suicide-related hospitalization is a known significant
risk factor for suicide. CRISP also employs environmental adaptations/aids to assist
patients in utilizing CRISP techniques between sessions (WellPATH personalized tablet
app, written step-by-step plan, phone calls). We focus on the first 3 months post-
discharge from a suicide-related hospitalization, a period of high suicide risk.
Behavioral interventions for middle-aged and older adults with depression and suicidal 
ideation are scarce. This project aims to meet the needs of middle-aged and older 
adults who have been discharged after a hospitalization for suicidal ideation or suicide 
attempt with any depression or anxiety disorder. We exclude bipolar patients in mixed, 
hypomanic, or manic state, and patients with psychosis or dementia. Regulation of 
emotions associated with mixed, hypomanic and manic state may need different 
techniques than those covered in CRISP. 
Consistent with the NIMH Strategy 3.1, CRISP is a novel intervention on a mechanism 
of action, cognitive reappraisal, to reduce suicide risk. In response to NIMH Strategy 
4.3, The WellPATH app is an innovative tablet application with personalized cognitive 
reappraisal techniques to improve cognitive reappraisal and potentially reduce suicide 
risk. Finally, CRISP’s use of cognitive reappraisal, application to cross-diagnostic 
categories and use of two different levels of analysis are consistent with NIMH’s RDOC 
initiative. 
Middle-aged and older adults, who have been hospitalized for suicidal ideation or 
suicide attempt, are an at-risk and understudied population. If effective, CRISP may 

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decrease suicide risk, reduce depression, and improve quality of life for this vulnerable 
group.  
STUDY AIMS 
The goals of the study are: 
MONTHS 1-3: 
1. Finalize the CRISP Manual and establish feasibility of therapist training. We will
train 4 LMSW/LCSWs: 2 will be trained in the CRISP therapy, 2 will be trained in
Supportive Psychotherapy. We will determine the success rate of training and
number of hours needed to achieve CRISP certification.
MONTHS 4-24: 
2. Assess CRISP’s reach, feasibility and acceptability: We will assess across
conditions:
a. Reach: Number of patients screened, and those who meet inclusion
criteria;
b. Feasibility: Number of patients who receive CRISP or ST for mental health
care and research procedures (timely referrals, assessments);
c. Acceptability: Patient’s treatment satisfaction at 6, 12, and 24 weeks.
Benchmarks of the study progress: Feasibility: At least 75% of CRISP 
participants will complete CRISP. Acceptability: We will obtain treatment 
satisfaction scores at the end of CRISP treatment.  
3. Preliminary Effectiveness: Over the course of 12 weeks, CRISP participants,
compared to participants receiving Supportive Psychotherapy will show an
improvement in cognitive reappraisal and have greater (effect size) and clinically
significant reductions in suicidal risk.

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RESEARCH ASSESSMENTS 
 
 
 
 
 
 
 
Inclusion Criteria: 
1. Age equal to or more than 50 years and up to age 90.
2. Any DSM-5 depression or anxiety diagnosis, including major depressive disorder,
bipolar depression, depressive disorder Not Elsewhere Classified, anxiety
disorder Not Elsewhere Classified, adjustment disorder with anxiety and
depressed mood.
3. Hospitalized for suicidal ideation (either active or passive) or suicide attempt; at
hospital admission, Columbia Suicide Severity Rating Scale should greater or
equal to 3.
4. Mini Mental State Exam more than or equal to 24.
5. English speaking.
6. Capacity to consent.
Exclusion Criteria: 
1. Not having Major Depressive Disorder (by SCID, DSM-IV.)
2. Primary Psychotic Disorder.
3. Currently Hypomanic, Manic or Mixed Episode.
4. Diagnosis of Dementia.
5. Active SI to the point they present as a danger to themselves or others.
a. *Alert Dr. Kiosses & complete Suicide Risk Assessment.
6. Acute or Severe Medical Illness (i.e., delirium; decompensated cardiac, liver or
kidney failure; major surgery; stroke or myocardial infarction during the three
months prior to entry).
7. Aphasia, sensory problems and/or inability to speak English.
*Note: Patients on psychotropic medications, opioids or benzodiazepines will be
included if they do not meet DSM-5 criteria for opioid, anxiolytics or other substance
abuse disorders (Human Subjects).

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INTERVENTION 
CRISP: 
CRISP utilizes a structured, yet personalized, approach. The goals of CRISP are to use 
cognitive reappraisal techniques to reduce negative emotions associated with self-harm 
and to increase involvement in meaningful and pleasurable activities. The CRISP 
therapist uses the following techniques: identification and evaluation of negative 
emotions and their relationship with patient’s difficulties, suicidal ideation and suicidal 
behavior (e.g. explore utility of negative emotions and change perspective about trigger) 
and use of a range of emotion regulation techniques (e.g. situation selection, situation 
modification, attentional deployment, cognitive reappraisal and response modulation). 
Environmental aids, including a personalized tablet application are used to augment the 
CRISP intervention. Finally, at the end of treatment CRISP therapists provide to patients 
a personalized summary of treatment that highlights the problems that were addressed, 
and the successful techniques that had been used to solve them.  
Comparison Condition: Supportive Therapy:  
ST is a control intervention not aimed to improve emotion regulation, including cognitive 
reappraisal. The ST therapist strives to create a positive alliance with the patient by 
emphasizing non-specific therapeutic interactions and techniques that convey to the 
patient, interest, concern and understanding. For the purposes of this study, an effort 
will be made to avoid all emotion regulation techniques that relate to Cognitive 
Reappraisal Intervention for Suicide Prevention (CRISP).  
FOLLOW-UP ASSESSMENTS 
Follow-up assessments are conducted by the WCM research assistant at 6, 12, and 24 
weeks after the baseline and include measures of depression and anxiety symptoms, 
medical burden, and suicidal ideation. Subjects will receive $50 (cash, check, or gift 
card) as compensation for completing each assessment. They may also be eligible for 
up to an additional $10 for one of the EEG computer tasks.   

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PROCEDURES FOR TREATMENT AFTER STUDY COMPLETION 
Participants whose follow-up assessments indicate a need for continued mental health 
services will be provided with mental health referrals.  
DATA MANAGEMENT 
Data will be collected by the study RA at baseline and at follow-up assessments. The 
RA will also be responsible for writing and presenting patient summaries to the PI. The 
therapist will complete updates on the progress of their therapy sessions. Brian Liles 
manages the CRISP database and weekly reporting.  
Research records will be kept confidential to the extent permitted by law. Subjects will 
be assigned ID numbers by the CRISP study team, and all identifying information will be 
removed from records that are submitted to Weill Cornell Medicine for data analysis. 
Paper research records will be kept in locked file cabinets. When necessary for 
purposes of auditing, the Cornell IRB, NIMH, and all Federal oversight agencies will be 
provided access to these files. Computers will be password-protected, and all staff 
participating in the study will be trained in protecting human subjects in research. Data 
will be published in aggregate form without unique identifiers. No analyses will be 
published in which it is possible to identify individuals based on data.