Highlight
Key points
– The MSPIRE randomized clinical trial (NCT03769259) enrolled 108 US military personnel and veterans with recent suicidal ideation and/or behavior and compared brief cognitive behavioral therapy (BCBT) with present‑centered therapy (PCT).
– Over follow‑up, suicide attempts occurred in 2 participants (estimated 5.6%) assigned to BCBT versus 8 participants (estimated 27.9%) assigned to PCT; BCBT yielded a hazard ratio of 0.25 (90% CI, 0.07–0.90; P = .04).
– Suicidal ideation declined significantly in both arms with no between‑group difference, suggesting BCBT reduced transition from ideation to attempt beyond effects on ideation alone.
Background and disease burden
Suicide is a leading cause of preventable death worldwide and remains a pressing public health priority in the US military and veteran populations. Rates of suicide among active‑duty service members and veterans have exceeded those in many civilian populations, prompting DoD and VA investments in targeted prevention and treatment strategies. Psychotherapeutic interventions that can lower the risk of suicide attempts in high‑risk patients are central to clinical prevention efforts because attempts are strong predictors of future suicide and confer immediate morbidity and mortality risk.
Brief, targeted psychotherapies adapted for suicidal individuals — including variants of cognitive behavioral therapy (CBT) that emphasize skills for emotion regulation, problem solving, and crisis planning — have been developed for use in high‑risk clinical settings where rapid, practical effects are needed. Prior trials suggested that BCBT can reduce suicide attempts among military personnel, but replication in randomized trials with active comparators is necessary to strengthen the evidence base and guide implementation.
Study design
This multisite, two‑arm, parallel randomized clinical trial (MSPIRE) was conducted across three US outpatient psychiatric clinics between 2020 and 2025. The trial enrolled US military personnel and veterans who had reported suicidal ideation in the past week and/or suicidal behavior within the prior month. Participants were either self‑referred or referred by treating clinicians. A computerized randomization algorithm stratified allocation by sex and number of prior suicide attempts.
Interventions
– BCBT: A brief cognitive behavioral therapy designed for suicidal patients, focusing on building emotion regulation skills, behavioral strategies to reduce the likelihood of engaging in suicidal behavior, and personalized relapse prevention planning. Sessions are structured and skills‑oriented with an emphasis on applying techniques in high‑risk moments.
– PCT (active comparator): Present‑centered therapy emphasizing problem identification and supportive problem solving without the specific cognitive‑behavioral skills training central to BCBT.
Primary outcome
The primary outcome was occurrence of suicide attempt during follow‑up, assessed by the Self‑Injurious Thoughts and Behaviors Interview‑Revised (SITBI‑R). Secondary outcomes included suicidal ideation trajectories and rates of subsequent attempts (attempts per participant‑year).
Key findings
Population characteristics
Of 154 individuals assessed, 108 participants were randomized (mean [SD] age 32.8 [12.8] years; 79 male [73.1%]). Baseline levels of suicidal ideation and recent suicidal behavior met enrollment criteria.
Primary outcome: suicide attempts
– BCBT arm: 2 participants experienced suicide attempts during follow‑up (estimated proportion = 5.6%).
– PCT arm: 8 participants experienced suicide attempts (estimated proportion = 27.9%).
Time‑to‑event analysis showed a mean time to first suicide attempt of 755.9 days (90% CI, 715.1–796.8) in the BCBT group versus 638.6 days (90% CI, 557.8–719.3) in the PCT group. The survival analysis favored BCBT (log‑rank χ2(1) = 3.6; P = .03).
Effect sizes
– Hazard ratio for any suicide attempt with BCBT vs PCT: 0.25 (90% CI, 0.07–0.90; P = .04), indicating a 75% relative reduction in hazard.
– Rate of follow‑up suicide attempts: 0.06 attempts per participant‑year in BCBT vs 0.18 in PCT; risk ratio 0.24 (90% CI, 0.08–0.70; P = .02).
Suicidal ideation
Both groups experienced significant reductions in suicidal ideation over time (F8,264 = 7.2, P < .001). There was no statistically significant difference between BCBT and PCT on ideation trajectories (F8,266 = 0.2; P = .49), indicating that BCBT’s advantage was specific to prevention of suicidal behavior rather than greater reduction of self‑reported ideation.
Interpretation of results
The primary and secondary outcomes consistently favored BCBT for prevention of suicide attempts. The discrepancy between similar reductions in ideation and divergent attempt rates points to an important clinical distinction: interventions can differ in their ability to prevent progression from thinking about suicide to acting on those thoughts. BCBT’s skills‑based approach may better equip patients to tolerate crises and implement coping plans at points of highest risk.
Safety and adverse events
The published summary provided counts of suicide attempts as the primary safety‑relevant events. No unexpected safety signals were reported. Clinicians implementing suicide‑focused psychotherapy should continue standard safety practices including risk assessment, crisis planning, and coordination with emergency services as needed.
Expert commentary and contextualization
Strengths
– Randomized design with an active comparator (PCT) strengthens causal inference and addresses nonspecific therapeutic effects.
– Stratified randomization reduced confounding by sex and prior attempt history.
– Use of the SITBI‑R, a structured instrument for suicidality, improves outcome ascertainment.
– The trial replicates earlier findings that brief CBT can reduce suicide attempts among military personnel and veterans.
Limitations
– Sample size was modest (n = 108), and the number of events (attempts) was small, which widens confidence intervals and makes estimates less precise.
– The sample was predominantly male (73%), which may limit generalizability to female service members and veterans.
– Details on the total duration of follow‑up for all participants, adherence to sessions, fidelity monitoring, and use of adjunctive services (pharmacotherapy, case management) are important for implementation but were not detailed in the summary provided here.
– The trial was conducted in outpatient psychiatric clinics; results may not generalize to primary care, inpatient, or community settings without adaptation.
Mechanistic plausibility
BCBT targets cognitive and behavioral processes implicated in suicidal behavior, including crisis response, distress tolerance, and maladaptive problem solving. Skills acquisition may reduce impulsive or planned attempts by modifying responses to acute suicidal crises. The finding that ideation decreased equally in both groups but attempts diverged supports a model in which BCBT specifically reduces enactment of suicidal behavior rather than simply reducing ideation scores.
Comparison with broader evidence
This trial adds to an emerging literature supporting brief, structured CBT approaches for suicide prevention in high‑risk populations. Replication of prior positive findings strengthens the argument for integrating BCBT into military and veteran mental health services, while highlighting the need for larger pragmatic trials and implementation research.
Clinical and policy implications
– Prioritizing skills‑based, suicide‑focused psychotherapy in military and VA mental health settings may reduce suicide attempts among high‑risk patients.
– BCBT’s brevity makes it attractive for deployment in constrained clinical settings; training programs and fidelity monitoring will be essential to maintain effectiveness during scale‑up.
– Given similar reductions in suicidal ideation across therapies, clinicians should recognize that reductions in self‑reported ideation may not equate to reduced risk of attempt; targeted behavioral interventions remain important.
– Implementation research should address training needs, telehealth delivery, integration with pharmacotherapy and case management, and cost‑effectiveness.
Conclusion
The MSPIRE randomized clinical trial demonstrates that brief cognitive behavioral therapy reduced suicide attempts among military personnel and veterans at high risk for suicidal behavior when compared with an active present‑centered psychotherapy. These findings replicate earlier work and suggest that targeted, skills‑based psychotherapies can prevent the transition from suicidal thoughts to attempts. Larger pragmatic trials, attention to diverse populations, and implementation studies will be key next steps to translate these results into routine clinical care.
Funding and trial registration
For details on funding sources and disclosures, see the original publication: Bryan CJ, et al. Brief Cognitive Behavioral Therapy for Suicidal Military Personnel and Veterans: The Military Suicide Prevention Intervention Research (MSPIRE) Randomized Clinical Trial. JAMA Psychiatry. 2025 Oct 8:e252850. Trial registration: ClinicalTrials.gov Identifier: NCT03769259.
References
1. Bryan CJ, Khazem LR, Baker JC, Brown LA, Taylor DJ, Pruiksma KE, Acierno R, Larick JG, Baucom BRW, Garland EL, Rudd MD. Brief Cognitive Behavioral Therapy for Suicidal Military Personnel and Veterans: The Military Suicide Prevention Intervention Research (MSPIRE) Randomized Clinical Trial. JAMA Psychiatry. 2025 Oct 8:e252850. doi: 10.1001/jamapsychiatry.2025.2850. PMID: 41060644; PMCID: PMC12509077.
2. Suicide. World Health Organization. Updated 2021. Available at: https://www.who.int/news-room/fact-sheets/detail/suicide (accessed 2025).
(higher‑level reviews and clinical guidelines should be consulted for implementation details and broader context.)
