Conclusions

The CARMS project did not evidence a significant treatment effect in that over 6 months reductions in the severity of suicidal ideation were not significantly greater for the treatment compared to the control group of the RCT component of the CARMS project. This was the case for both the primary and secondary suicide outcome variables. However, a planned mediation analysis showed that for those in the suicide-focused therapy group, at the 6-month time point, appraisals of social support and social connectedness improved, which, in turn, led to reductions in suicidal ideation severity. Qualitative findings allowed us to probe the types of disconnectedness that participants identified as key to their psychotic and suicidal experiences which centred on not mattering, and feeling of little value. It is vital that future work explores (1) factors characterising subgroups of participants who benefited most and least from our suicide-focused therapy (2) mechanisms underlying transitions from not mattering to mattering and disconnectedness to feeling connected (3) how therapy process variables such as the alliance, therapy ‘dose’ and formulation level impact pathways to suicidal experiences involving the potential for becoming connected and becoming supported and (4) how mental health professionals fulfilling diverse roles can be part of suicide-focused service delivery.