Which PTSD clusters and symptoms are central to reducing suicidal ideation? A network and cross-lagged analysis among individuals receiving cognitive processing therapy

Background: Posttraumatic stress disorder (PTSD) is associated with suicidal ideation (SI) and SI tends to improve over the course of evidence-based psychotherapy for PTSD. However, it remains unclear which PTSD clusters and symptoms are central to changes in SI throughout treatment.Objective: To use (1) network analysis to identify the PTSD clusters and symptoms most uniquely related to SI (at baseline and post-treatment); and (2) cross-lagged analyses to examine whether these PTSD clusters and symptoms prospectively predicted decreases in SI over the course of cognitive processing therapy (CPT).Method: Participants were 188 individuals with PTSD receiving CPT as part of an implementation-effectiveness trial. At each session, DSM-IV PTSD clusters and symptoms were assessed using the PTSD Checklist and SI was assessed using the Outcome Questionnaire-45.Results: Multi-staged cross-sectional network analyses indicated that at baseline and post-treatment the avoidance and reexperiencing clusters were uniquely associated with SI. Within these clusters, the symptoms uniquely associated with SI were recurrent thoughts and dreams of trauma, restricted range of affect, and sense of foreshortened future at baseline; and sense of foreshortened future, restricted range of affect, recurrent dreams of trauma, feelings of detachment from others, memory impairment, avoidance of reminders of trauma, and psychological cue reactivity at post-treatment. Multilevel cross-lagged analyses indicated that the avoidance cluster and the restricted range of affect and sense of foreshortened future symptoms, uniquely predicted next-session decreases in SI.Conclusions: These findings suggest that reductions in SI within treatment may be due to direct targeting of avoidance, affect, and future-related cognitions. Further research remains necessary to determine whether the present findings extend to DSM-5 PTSD clusters and symptoms.