# Cognitive Behavior Therapy With and Without Narrative Assessment and Suicide Attempts: A Systematic Review and Meta-Analysis

## TL;DR

Adding narrative assessment to cognitive behavior therapy may reduce the risk of suicide attempts more effectively than therapy without it.

## Contribution

This study is the first to show that narrative assessment in CBT significantly reduces suicide attempts compared to CBT without it.

## Key findings

- CBT with narrative assessment reduced suicide attempts by 32% compared to controls.
- CBT without narrative assessment showed no significant reduction in suicide attempts.
- Interventions with narrative assessment had older participants and lower risk of bias.

## Abstract

Are cognitive behavioral interventions that include a narrative assessment associated with a greater reduction in the risk of suicide attempts than those without?

In this meta-analysis of 23 randomized clinical trials with 3262 participants, interventions incorporating a narrative assessment were associated with reduced suicide attempts, while those without were not.

These findings suggest that including a narrative assessment may enhance the effectiveness of interventions in preventing suicide attempts.

This systematic review and meta-analysis of randomized clinical trials examines the association between cognitive behavioral interventions with vs without a narrative assessment and risk of suicide attempt.

There is currently no evidence-based method to identify the forces that may drive someone to attempt suicide.

To examine whether cognitive behavior therapy (CBT) interventions that incorporate a narrative assessment are associated with a greater reduction in suicide attempts than comparable interventions without this component.

Studies were identified through version 25.0.1 of the Metapsy Suicide Prevention Database, which includes randomized clinical trials published up to April 2025 retrieved through PubMed, Embase, Web of Science, Scopus, and Cochrane Central, including unpublished studies and references from relevant articles.

Included studies were randomized clinical trials of CBT interventions reporting suicide attempts as an outcome. Studies using waiting list controls, reporting only suicidal ideation, or lacking information on the type of assessment used were excluded.

Two reviewers independently extracted data and assessed risk of bias using the Cochrane Risk of Bias 2 tool. Meta-analyses were conducted using 3-level models with robust variance estimation. Relative risks (RRs) were pooled using the Mantel-Haenszel method. Analyses followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. Data were pooled using a random-effects model.

The primary outcome was the incidence of suicide attempts. Interventions were grouped by presence or absence of a narrative assessment component.

Twenty-three studies with 3262 participants met inclusion criteria. CBT interventions including a narrative assessment were associated with a significantly reduced risk of suicide attempt compared with controls (RR, 0.68; 95% CI, 0.53-0.87; 1764 participants across 14 studies), whereas CBT interventions without this component were not associated with risk of suicide attempt (RR, 1.17; 95% CI, 0.63-2.20; 1498 participants across 9 studies). Subgroup comparison indicated a significant difference between groups (Q1 = 7.27; P = .007; I2 = 86%). Studies without a narrative assessment had significantly younger participants, a lower event rate, and slightly higher risk of bias.

In this systematic review and meta-analysis, CBT interventions including a narrative assessment were associated with a reduced risk of suicide attempt, while CBT without this component did not have an association with risk of suicide attempt. Age differences between study populations may partly explain this finding, as interventions in younger populations often show smaller and more inconsistent effect sizes. 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. Causal conclusions require direct head-to-head trials.