Significance: The suicide rate among Veterans rose 35.9% from 2001 to 2019, leading to VA to make suicide prevention a top clinical priority. We developed an intervention, which includes the VHB app and its enhanced facilitation (VHB-EF), with the aim of reducing Veteran suicide attempts. Developing and implementing effective strategies to reduce suicide attempts post-hospitalization is also a research priority within this RFA. Innovation/Impact: We developed VHB-EF to provide awareness, active engagement, and support of VHB with the aim of reducing suicide attempts post-hospitalization. This study will be the first to test the effectiveness of VHB-EF on suicide attempts and may improve safety after discharge. It will examine potential intervention mechanisms, according to self-efficacy theory and the theory of planned behavior, while also considering ultimate implementation and scalability of the VHB-EF through provider and Veteran feedback. Specific Aims: Aim 1: Determine the effectiveness of VHB-EF for reducing suicide attempts. Aim 2: Examine the intervention mechanisms by measuring the effects of VHB-EF on 1) reasons for living, and 2) self-efficacy to (a) cope and (b) refrain from suicide attempts. Exploratory Sub-aim 2: Examine whether higher reasons for living and self-efficacy partially mediate the effect of VHB-EF on suicide attempts over 6 months. Aim 3: Assess the determinants (barriers and facilitators) of VHB-EF adoption to inform future implementation and sustainability of VHB-EF across the VA. Methodology: A randomized effectiveness-implementation Hybrid Type I trial will be conducted at two VHA inpatient mental health units. We will randomize 928 Veterans hospitalized after a suicidal crisis to either VHB- EF or Enhanced Usual Care (EUC). The VHB-EF includes a single session on the unit that educates Veterans on app purpose for suicide prevention, loads the app on their personal phone, provides practice of each app component, and discusses strategies to enhance app usage after hospital discharge. It also includes a remote- delivery phase which includes 2 phone calls after discharge to monitor risk, review/revise VHB content, and support app use and outpatient treatment engagement. The EUC arm consists of reviewing a community resources list. We will assess how VHB-EF (vs. EUC) impacts suicide attempts, as well as potential mediators, across follow-up assessments (6 weeks and 3- and 6- months post-randomization). Qualitative interviews with providers and Veterans will focus on barriers and facilitators of adoption. Next Steps/Implementation: The VHB is already accessible in VA, but active intervention is needed to engage high-risk suicidal Veterans, and additional effectiveness evidence is needed to support its incorporation into treatment guidelines for suicide prevention. Through qualitative interviews we will examine the determinants (barriers and facilitators) of VHB-EF adoption to inform future implementation and sustainability of this approach across the VA. Broader implementation of the intervention will be coordinated with Office of Mental Health and Suicide Prevention who supports the proposal.

Significance: The proposed project directly addresses VHA's top clinical priority, suicide prevention. In addition, this proposal aligns with VA HSR&D's high priority foci of suicide prevention and health equity as well as VHA National Strategic Plan Objectives 2.1 and 2.3 which focus on ensuring Veterans receive equitable, comprehensive suicide prevention services to support their recovery. VHA Office of Health Equity and VHA Office of Mental Health and Suicide Prevention also highlight in their strategic plans the need for supporting equitable, suicide-related care for all Veterans. Innovation and Impact: The proposed project is the first evaluation of suicide-related care quality among BIPOC Veterans with SDV. In addition, no research to date has determined areas to improve suicide-related care quality for BIPOC Veterans. Use of national VHA- and non-VHA administrative data triangulated with BIPOC Veteran and mental health clinician qualitative data will result in a richer conceptualization of current factors impacting suicide-related care and inform future strategies for enhancing care. Specific Aims: Aim 1) Evaluate suicide-related care quality among BIPOC Veterans; Aim 2) Conduct qualitative interviews with BIPOC Veterans and VA clinicians to better understand factors impacting suicide-related care quality for BIPOC Veterans; Aim 3) Explore associations between health care systems-level factors and suicide- related care quality indicators for BIPOC Veterans; Exploratory Aim) Explore the relationship between suicide- related care quality among BIPOC Veterans and suicide outcomes. Methodology: Aim 1 will identify BIPOC Veterans with SDV (FY18-FY22) utilizing VHA databases. Data from the VHA Corporate Data Warehouse for suicide-related care quality outcomes as well as sociodemographic and clinical variables will be linked. Data will be analyzed using generalized estimating equations. Aim 2 will involve interviews with at least 40 BIPOC Veterans and at least 40 VHA mental health clinicians about their beliefs and experiences with suicide-related care which will be analyzed using thematic analysis. Aim 3 will link data from Aim 1 to health care systems factors at the station level. For the Exploratory Aim will link data from mortality data sources to explore associations with mortality outcomes. Next Steps/ Implementation: The proposed project will increase our understanding of factors impacting suicide- related care quality among BIPOC Veterans. Findings from this project will inform future proposals focused on intervention development to enhance suicide-related care quality among BIPOC Veterans.

Significance: This study will increase our understanding of suicide risk during Veteran reintegration and will support development of prevention efforts tailored for women Veterans during this period. These data are needed to inform recent executive orders and VA initiatives calling for increased suicide prevention efforts among reintegrating Veterans; findings from this study will identify subgroups of reintegrating Veterans most in need of valuable resources and which reintegration challenges are especially problematic and when "“ enabling VA to develop selective prevention approaches within this important population. Innovation & Impact: This study moves the field beyond cross-sectional studies of suicide risk among Veterans of recent eras and is carefully designed to study gender differences in suicide risk, building on the body of research and theory in suicide prevention and emerging findings of gender differences in suicide risk. Furthermore, this study is innovative in its linking of VA-DoD datasets to identify a national sample of newly separated Veterans at increased risk of suicide who are not necessarily engaged in VA healthcare. Specific aims: The specific aims of this study are to: 1) Model the trajectories of reintegration challenges of at- risk Veterans to identify population subgroups (e.g., stable, deteriorating, improving) and examine gender differences in reintegration experiences, 2) Identify associations between trajectories identified in Aim 1 and suicide-risk-related predisposing factors among women and men, and 3) Identify associations between trajectories identified in Aim 1 and development, or worsening, of suicide risk (suicidal ideation, suicide cognitions, suicide attempts) and any effect measure modification by gender. Methodology: This is a national cohort survey study. We will enroll a cohort of 2,000 Veterans separating from service in the prior six months, identified using the VA-DoD Veteran Identity Repository (VADIR) data. We will oversample for women to enroll a cohort that is approximately half women. We will also oversample for risk indicators available in Department of Defense (DoD) healthcare data available through DaVINCI (i.e., prior mental health inpatient/outpatient visit, emergency department visit, other outpatient visit). After completing the baseline survey, participants will complete 6 additional surveys over the course of a 36 month follow up period. Surveys will include measures that assess functioning in the six core domains of reintegration challenges (mental and physical heath, identity/role negotiation, relationship quality, financial well-being, spirituality) as well as predisposing factors associated with increased risk for suicide and measures assessing suicide risk (suicidal ideation, suicide cognitions, suicide attempts). Main analyses will identify the reintegration trajectories, including any gender differences, examine the suicide-related predisposing factors associated with deteriorating trajectories, and examine suicide risk outcomes associated with reintegration trajectories. Next steps: Data gathered in this study will directly inform the many VA initiatives, legislation, and recent executive orders calling for increased suicide prevention efforts among reintegrating Veterans by providing the necessary data to identify subgroups of Veterans at increased risk of suicide and their respective needs directing valuable resources. The VA Office of Mental Health and Suicide Prevention and the VA Office of Social work are strong partners in these efforts and will support dissemination and implementation of findings.

Objectives: The goal of VHA’s Health Services Research and Development (HSRD) COnsortium of REsearch (CORE) initiative is to accelerate research that will lead to improvements to care delivered to Veterans. The mission of the “Suicide Prevention Research Impact NeTwork (SPRINT)” CORE is to accelerate health services Suicide Prevention (SP) research that will lead to improvements in care and result in reductions in suicide behaviors among Veterans. The proposed suicide prevention clinical resource center (SP-CRC) is responsive to CSRD's solicitation of applications from VA research facilities to establish an SP-CRC that will serve suicide prevention investigators by providing highly critical research resources to facilitate programmatic and scientific needs. The mission of our SP-CRC, the Center for Harmonizing and Improving Interventions to Prevent Suicide (CHIIPS), will be to advance a precision medicine approach to suicide prevention research. CHIIPS content area hubs will include Predictive Analytics, Biomarkers, Identification, Screening, Assessment, Social Determinants/Disparities, Interventions, and (v) Training and Education Innovation and Impact: By establishing a VA SP-CRC with an explicit focus on promoting precision medicine for suicide prevention, we will improve individual suicide prevention outcomes, address unsatisfactory response rates for standardized treatments, promote the incorporation of diverse patient presentations, characteristics, and needs into treatment plans and suicide prevention research, improve system and population-level outcomes, and increase efficient use of finite resources (staff, funds, infrastructure). Resources Delivered: At the completion of this project, we will have provided several resources to the VA suicide prevention research community including: 1) a portfolio review of VA suicide prevention research portfolio projects on precision medicine, 2) a dataset repository for use by VA suicide prevention researchers to conduct secondary analyses, 3) the establishment of precision medicine suicide prevention research postdoctoral fellowships, 4) creation and dissemination of several recommendations for clinical trials methodology and safety protocols for suicide prevention research, 5) various precision medicine related educational resources for suicide prevention researchers to promote competent precision medicine suicide prevention research, 6) a statistical and research design consultation service, 7) funding for precision medicine suicide prevention pilot studies or supplemental funding for ongoing studies, 8) a literature review of all precision medicine suicide prevention research to date. Coordination with SPRINT: CHIIPS will work closely with the Suicide Prevention Research Impact Network (SPRINT) PIs and hubs to optimize synergies and avoid duplication of effort between the two centers. Our goal is to enhance current SPRINT activities, by leveraging their network and infrastructure to focus on precision medicine approaches. Together, SPRINT and CHIIPS will help VA Office of Research and Development create a vision and set priorities for as well as build a precision medicine suicide prevention research portfolio that will advance the state of the science and help VA achieve its mission of significantly reducing the number of Veteran suicides.

Significance: Rehabilitation is relevant to the reintegration of all TSMVs, who share the goal of adapting to post- military life roles. This CDA-1 will deliver recommendations for assessing reintegration and yield critical insights for identifying TSMVs prone to reintegration difficulty. These are essential steps for detecting intervention targets that promote positive functional outcomes and disrupt suicide risk trajectories. Identifying modifiable predictors of reintegration difficulty will inform a future CDA-2 application focused on developing targeted interventions to address those factors. This CDA-1 is aligned with priorities outlined by the White House's National Strategy for Preventing Veteran Suicide and the VA's National Roadmap to Empower Veterans and End Suicide. This project is also responsive to RR&D's request for suicide prevention research that involves Veterans not currently receiving VA healthcare. Innovativeness: The proposed research represents the first comprehensive psychometric evaluation of the M2CQ in a longitudinal sample of TSMVs. Second, by incorporating the construct of personality functioning, it suggests new ways of thinking about reintegration difficulty and its relationship to suicide risk. Third, the longitudinal design includes pre- and post-transition timepoints, which provide a unique opportunity to directly evaluate temporal changes in reintegration difficulties as a function of co-occurring personality functioning problems and the major life event of separation from service. Specific Aims: Aim 1 is (a) to investigate the M2CQ's structural validity, reliability, and item-level properties; (2) evaluate how well M2CQ scores/items detect meaningful and expected change in functioning over time; (3) to determine whether total scores and items have particularly strong associations with negative clinical outcomes. Aim 2 is to evaluate personality functioning as a potentially modifiable individual difference factor that is associated with reintegration difficulties. Aim 3 is to examine alternative hypotheses about the roles of reintegration difficulty, personality functioning, and psychopathology in predicting future suicidal thoughts and behavior during the military transition period. Methodology: This CDA-1 will use a longitudinal sample of TSMVs who participated in two ongoing community reintegration peer-sponsorship programs. Four waves of data were collected over a one-year period (n = ~ 515): 6- and 2-months before separation; 2- and 6-months post-separation. Statistical analyses include factor analysis, item response theory, and latent growth curve modeling. Next Steps/Implementation: Research results and recommendations for assessing reintegration difficulty will be shared with the VA research and clinical community.

Significance/Impact: This CDA will use enhanced causal inference methods to provide robust evidence to inform VA programs. Few VA researchers are using causal inference methods to examine VA's virtual care or mental health initiatives. My quantitative background, prior research, and operational ties position me well to provide such robust evidence to VA and share lessons from using novel causal inference and mixed methods.

Innovation: The CDA will evaluate three recent telehealth initiatives that have not been evaluated previously at a large scale with novel and rigorous methods. It will offer advances in methods for observational evaluations across VA through its: 1) use of mixed methods to transparently inform sophisticated causal inference methods, innovatively expanding both mixed methods and causal inference fields and 2) use of machine learning with an equity lens to improve causal inference, offering long-term benefits for using machine learning methods. Specific Aims: I will further develop my causal inference skills and augment them through the incorporation of qualitative methods, suicide prevention expertise, and a health equity lens. I will examine the suicide prevention and disparities impact of three recent telehealth initiatives aimed at increasing Veterans' access to care: 1) VA's Anywhere to Anywhere (A2A) policy which enabled virtual care provision across state lines; 2) VA's expansion of video care; and 3) VA's distribution of video-enabled tablets. I will pursue the following aims: Aim 1: Examine the impact of telehealth across state lines, via VA's Anywhere to Anywhere (A2A) policy, on psychotherapy frequency, suicide outcomes (suicide-related ED visits, hospitalizations, deaths), and costs. Aim 2: Examine the impact of video vs. in-person or phone therapy on suicide outcomes and care costs. Aim 3: Examine the impact of VA tablets on the frequency of suicide risk screens and on suicide outcomes. Methodology: For each aim, I will use an exploratory sequential mixed methods design. In Aims 1a, 2a, and 3a, I will conduct interviews with Veterans and providers in rural and urban areas about factors affecting their use of out-of-state therapy, video therapy and VA tablets. Rapid qualitative analyses will inform causal inference study designs, variable selection, secondary analyses and interpretation of results in Aims 1b, 2b, and 3b. In Aims 1b, 2b, and 3b, I will leverage difference-in-difference (DiD) study designs which can account for selection bias due to unobserved reasons for patient/provider selection into VA telehealth initiatives. I will innovatively use causal decomposition methods with machine learning to highlight the extent to which health disparities are explained through observed variables vs. unexplained or due to potentially inequitable treatment of disadvantaged groups. Next Steps/Implementation: I will work with my operational partners in VA's Office of Connected Care, Office of Rural Health and Office of Mental Health & Suicide Prevention to ensure that my research aligns with their implementation priorities. Aim 1 will inform how to leverage out-of-state therapy relationships to improve access in under-resourced areas. Aims 2 and 3 will inform OMHSP's decisions on how to integrate VA's video telehealth and tablets with VA's routine suicide prevention efforts to improve suicide risk detection and reduce suicides. Aims 2 and 3 will also inform OCC's and ORH's decisions on whether and how to expand VA's tablet program.

Significance: There is a critical gap in knowledge about how to treat PTSD among individuals at high risk for suicidal behavior. As a result, VA/DoD Clinical Practice Guidelines do not specify indicated treatment strategies for this population. Experts have recommended two approaches to facilitate the safe and effective use of EBPs for PTSD with individuals at elevated acute suicide risk, including combining these treatments with suicide-focused EBPs or augmenting them with suicide risk management strategies. This project will help to fill this critical gap by rigorously evaluating these two approaches among Veterans with SDV. The results will provide important information to inform guidelines about indicated treatments for this high-risk population. Innovativeness: This will be the first large-scale RCT to evaluate treatments for PTSD among Veterans who have engaged in SDV, an HSR&D high priority group. The DBT + DBT PE intervention is the first treatment designed to address both SDV and PTSD, and results will indicate if this novel treatment improves outcomes compared to the current VHA gold standard of care. To facilitate more rapid implementation of these findings into clinical practice, implementation barriers and facilitators for both treatments will also be evaluated. Specific Aims: This study will randomize 200 Veterans with PTSD, recent and repeated SDV, current suicidal ideation, and emotion dysregulation to DBT + DBT PE (intervention) or PE + SRM (control). Aim 1 will test the hypothesis that DBT + DBT PE will be superior to PE + SRM in improving clinical outcomes and engagement in trauma-focused treatment. Exploratory analyses will examine Veteran characteristics that may predict better engagement and outcomes in DBT + DBT PE versus PE + SRM. Aim 2 will examine barriers and facilitators to implementation of both treatments.

Methods: This is a multi-site hybrid type 1 effectiveness-implementation trial. Veterans will be treated in outpatient settings at three VA sites and assessed at 5 points over 18 months. A mixed-methods approach will be used to evaluate barriers and facilitators to implementation, including conducting interviews with 45 key stakeholders (Veterans, providers, and leadership). Primary Outcomes/Endpoints: Primary outcomes will be reductions in SDV episodes at 18-month follow-up and reductions in PTSD severity at post-treatment.

Implementation/Next Steps: This project will provide much-needed information about how to safely and effectively treat PTSD among Veterans at elevated acute risk for suicide. If one or both treatments are found effective, Aim 2 will provide vital information about how to maximize future implementation success. Future implementation activities would be coordinated with our national operational partners.

Significance: Suicide is the number one cause of death for LGBQ+ Veterans age 18-29 and is ranked 5th for LGBQ+ Veterans of all ages. Transgender Veterans' risk of suicide is 20 times higher than other Veterans, with as many as one in three attempting suicide in their lifetime. Despite heightened risks, VA's National Strategy for Preventing Veteran Suicides does not include any solutions tailored specifically to LGBTQ+ Veterans. Effective interventions are urgently needed in clinical settings to reduce these health inequities. Innovation & Impact: Through a partnership with the VA Innovation Ecosystem and VA Central Office partners, Pride groups rapidly spread to 65 VA sites from 2017-2023. This intervention: 1) is the first manualized group tailored for LGBTQ+ Veterans; 2) is not a mental health group and does not require a diagnosis for inclusion; and 3) is supported by evidence-based implementation strategies. Yet important research questions remain about the effectiveness and implementation of this program before enterprise-wide implementation will be supported. This study is the first: 1) to evaluate Pride using a control group; 2) to examine adoption, sustainment, and cost of any LGBTQ+ Veteran intervention in VA; and 3) the first known hybrid type 2 study to use retrospective structured data to examine intervention effectiveness on suicide risk. Specific Aims: Aim 1: Evaluate effectiveness of the Pride group on LGBTQ+ Veteran outcomes and service utilization over time compared to matched LGBTQ+ Veteran controls that did not attend the group. Pride group Veterans will have lower rates of suicidal ideation (primary outcome), lower risk of suicide attempts and deaths, and greater reduction in depression and anxiety scores in the 12-months after baseline than the control group. Pride group Veterans will also have higher rates of preventive care service use and lower use of emergency services. Aim 2. Evaluate site-level variability in implementation progress and sustainment. Aim 3. Conduct a budget impact analysis to determine resources required to implement Pride at national and local levels. Methodology: This 4-year hybrid type 2 effectiveness-implementation study will leverage VA administrative data and a controlled interrupted time series design (Aim 1) followed by a prospective mixed-methods examination of implementation and cost (Aims 2 and 3). A propensity matched control group of LGBTQ+ Veterans will be compared to Veterans that attended Pride between 2017-2023 for 1 year before and after the intervention. Informed by RE-AIM and health-equity implementation frameworks, mixed methods will be used to examine adoption (primary), reach, implementation, and maintenance at newly trained VA sites (N = 30). Qualitative interviews with VA staff will increase understanding at sites that fail to adopt Pride within 6-months and among existing sites with evidence of sustainment (>1 year). Time tracking by the implementation facilitation team and local delivery sites will inform budget impact analyses for future decision-making. Next Steps/Implementation: Partners in the VA Offices of Mental Health and Suicide Prevention, LGBTQ+ Health, and Health Equity -- among others -- have met quarterly as a Pride Steering Committee for the past 3 years. These relationships have resulted in tangible investments and a readiness to support next steps.

Objectives: The proposed continuation project builds on significant progress during Years 1-3 to provide MBCT-S to rural Veterans at risk for suicide. The following objectives describe the projects progression towards overcoming rural barriers to suicide prevention care, provider barriers to adopting telehealth suicide prevention, and to set the stage for wide-scale dissemination and implementation. • Objective 1 (Year 1-2)—Develop practice guidelines for telehealth delivery of MBCT-S and provide to 60 Veterans at risk for suicide. • Objective 2 (Year 2-3)— Develop telehealth MBCT-S dissemination framework including training and consultation. • Objective 3 (Year 2-4)—Implement MBCT-S at VA facilities serving rural Veterans • Objective 3a—VA NYH serving rural Veterans in Upstate NY (45 Veterans annually). • Objective 3b—VA Houston serving rural Veterans in Eastern TX (45 Veterans annually). • Objective 4 (Years 1-4)—Evaluate implementation and effectiveness outcomes using RE AIM Framework (Reach [%reached], Effectiveness [e.g., reduced suicidal ideation, depression] Adoption (# providers referring & delivering), Implementation (barriers & facilitators; training effectiveness, fidelity); Maintenance (site sustainment indicators). Long-term Impact: The proposed project will set the stage for wide-scale implementation of MBCT-S to rural Veterans. The resulting dissemination package will allow MBCT-S to be implemented at other rural VA facilities throughout the U.S. The RE-AIM framework will be utilized to monitor and improve implementation, as well as gather “lessons learned” to guide future expansion of this innovation.

Significance/Impact: Veterans who have been homeless have high rates of depression and opioid use disorder and barriers to accessing traditional primary care services. It is important to determine effective models of MHSA services integration at this time when Veterans have more options for care in VA and community settings. VA’s homeless patient aligned care team (H-PACT) program, implemented in over 60 VA facilities, offers a natural laboratory to determine optimal approaches of MHSA services integration to advance Veteran health. My research will impact Veteran health by determining the effectiveness of H-PACT for providing high quality MHSA care and mitigating adverse MHSA outcomes among homeless-experienced Veterans; and by determining the unique and potentially modifiable aspects of H-PACT and other patient aligned care teams (PACTs) that could be scaled to achieve superior MHSA outcomes for homeless-experienced Veterans in specialized and non-specialized PACT settings. This research strongly aligns with VA research priorities of mental health and primary care, and legislative priorities related to addiction recovery and community care.

Innovation: While prior studies suggest H-PACT improves primary care utilization and Veteran experiences with care, there is less research focused on determining what features of H-PACT are successful. We lack data on clinical process measures and outcomes for Veterans empaneled in H-PACTs, information on aspects of MHSA services integration that exists within H-PACTs and traditional PACTs caring for homeless-experienced Veterans, and the barriers and facilitators that contribute to MHSA quality for homeless-experienced Veterans. Specific Aims: My CDA-2 has three primary aims: 1) Compare MHSA services quality of care (e.g., clinical performance measures for depression, opioid use disorder) and outcomes (e.g., psychiatric hospitalization, opioid-related overdose, suicide) for homeless-experienced Veterans empaneled in H-PACTs versus other PACTs in the same facilities; 2) Measure levels and features of MHSA services integration (e.g., coordination with community services, co-location of providers, full integration) for homeless-experienced Veterans in H- PACTs and other PACTs; and 3) Evaluate MHSA service practices and barriers in 4 facilities ranked low and 4 ranked high on measures of MHSA services quality for homeless-experienced Veterans. I will work with my mentors to develop the expertise to study MHSA services quality in primary care settings, and to augment my foundational training with new skills in survey design, qualitative methods and implementation science. Methodology: I aim to 1) use VA administrative data to operationalize MHSA services quality of care based on VA performance measures and established definitions; 2) adapt an organizational survey of H-PACT structures to survey providers from H-PACTs and PACTs about how MHSA services integration is achieved for homeless-experienced Veterans, and; 3) conduct stakeholder interviews in low and high performing facilities to identify barriers to delivering high quality MHSA services for homeless-experienced Veterans. Next Steps/Implementation: Findings will provide information to VA providers, operational partners, and leadership about the effectiveness of the H-PACT initiative, and targets for intervention to bolster lower performing H-PACTs. My pre-implementation research findings and training experiences will inform my future work focused on MHSA outcomes in specialized PACT settings, including an HSR&D effectiveness- implementation study (IIR) application to improve MHSA services quality for homeless Veterans in PACTs.

Significance: The solicitation to which this proposal responds (HX-21-024) prioritizes learning about "benefits and harms of tapering and/or discontinuation." At present, several federal agencies have declared a commitment to averting suicide during opioid taper. But thus far, we lack a deep understanding as to why the suicides occur, which makes preventive and mitigating action difficult to plan. The next logical step in preparing a health system response is in-depth study of the events themselves. Innovation and Impact: Whereas much research has gone toward discerning statistical associations between prescription opioid change and outcomes (including suicide), this project takes a different approach, by applying techniques of psychological autopsy. The pre-requisite challenge to such research is the ability to recruit bereaved survivors who may perceive stigma and who often harbor distrust of health care systems. Our team has invested years in building connections to the community, and allying with suicidologists, so that recruitment becomes possible. Also, by assessing differences between Veteran and non-Veteran suicides, we are positioned to assist VA of its unique assets and liabilities, with the goal of mitigating the latter. Specific Aims: Aim 1. Characterize the patient and clinical context factors associated with suicide among 100 persons (50 Veterans and 50 non-Veterans) who have died by suicide in the context of opioid transition (stoppage or reduction) through survey, structured interview of bereaved family members, and medical record review. Aim 2. Identify factors that may be unique to suicides following opioid transition in Veterans as opposed to non-Veterans, with attention to differences in experience for Veterans in and outside of VA care. Methodology: We will recruit, from the public, family survivors of Veterans and non-Veterans with pain who have died by suicide in the context of an opioid transition. We will work with survivors to solicit medical records from within or outside VA, to review them, and to carry out structured interviews traditional for psychological autopsy. From review of the resulting reports, a multidisciplinary research team (including experts in opioid taper, suicide, addiction, health services research and medical anthropology) will apply the Social-Ecological Framework to identify common personal and contextual factors, to identify aspects of clinical interaction that appear salient to these events, and to identify notable contrasts between those suicides occurring among Veterans as opposed to non-Veterans during opioid transition. Next Steps/Implementation: We intend to present findings quarterly to our patient/family Stakeholder Team and to VA partners (Office of Mental Health and Suicide Prevention, VA National Program Director for Pain Management), so that early and actionable insights are triaged for action. The collation of our research findings and our stakeholder response and feedback allows this project to serve as the first step of the Intervention Mapping process ("Needs Assessment"), which leads in turn to design of preferred outcomes, intervention design and testing.

Innovation: Suicide prevention is the top clinical priority for VA/DoD. The importance of including family members in Veterans suicide-related care is a critical component of the National Strategy for Preventing Veteran Suicides 2018-2028 and key finding from VA/DoD patient focus groups conducted for the 2019 VA/DoD Clinical Practice Guidelines for the Assessment and Management of Patients at Risk for Suicide. Innovative aspects of this CDA-2 proposal directly address several components of national reports and include: 1) The first couples-based suicide-specific intervention and the first suicide-specific intervention to target interpersonal functioning factors identified by suicide theories and rehabilitation psychology (i.e., effective communication and interpersonal engagement); 2) Veteran-centric choice between home-based telemental health and office-based care in order to increase access; and 3) Improved data analytic quality of Veteran suicidality by examining both Veteran and partner reports of suicide related risk factors (the first suicide- specific treatment study to do this). Methodology: The proposed 5-year study consists of two phases. Phase 1: treatment refinement with 10 couples (N=20) and Phase 2: pilot Randomized Controlled Trial (RCT) of TR&ST compared to VA Standard Suicide Intervention with 60 couples (N=120). The intervention period is 13 weeks and the entire study period is approximately 7 months. Couples in both phases will be quantitatively assessed at baseline, mid-treatment, post-treatment, and 3-months post-treatment (and qualitatively interviewed following each TR&ST module). The primary outcome to be evaluated is change in suicidal ideation severity. Secondary outcomes concern changes in interpersonal functioning. Aims: Aim 1 (Phase 1): Refine TR&ST in a population of Veterans with active suicidal ideation. Aim 2 (Phase 2): Evaluate treatment feasibility and acceptability of TR&ST. Aim 3 (Phase 2): Compare TR&ST vs. VA Standard Suicide Intervention on suicidal ideation severity and interpersonal functioning (i.e., communication, bonding, relationship satisfaction, and belonginess and burdensomeness) over 7 months. Next Steps: This Career Development Award is the first step toward developing a vital program of research within VHA focused on enhancing interpersonal functioning and suicide-related care by involving family members in treatment. If Aims are achieved, future work includes 1) an adequately powered RCT of TR&ST vs. VA Standard Suicide Intervention 2) a more direct evaluation of telehealth for couples-based or family involvement in suicide-specific interventions, and 3) examination of moderators or groups of interest (such as women Veterans).

Significance: Depression affects 1 in 5 Veterans and is a leading cause of suicidality and disability. It contributes substantially to the current pandemic-related mental health crisis. Depression symptoms, including suicidal thoughts/behaviors, and related functional impairment have increased since COVID onset. Partnering with Primary Care, Mental Health, and Connected Care leaders, we propose to study pandemic-related service disruptions for depression, which may help to mitigate acute care use and mortality in the Veteran population. We apply established depression quality indicators from our prior research to a broad national scale at a critical time. We will also obtain feedback to improve current hybrid (virtual/in-person) care models from VA providers and Veterans who screened positive, including those who were not detected to have depression. Specific Aims: To improve virtual and in-person services for the VA primary care population during recovery, this proposal will examine how the pandemic disrupted depression care delivery mechanisms, including expanded telehealth, and patient outcomes. Our Specific Aims are: 1) To examine engagement in guideline- concordant care for depression (virtual or in-person) following screening, before and during the pandemic; 2) To compare psychiatric emergency/hospital visits and mortality from suicide between Veterans who screened positive and were detected versus not detected to have depression by clinicians; 3) To understand VA patients' and providers' current perspectives on addressing new depressive episodes using virtual and in-person modalities during the pandemic and eventual recovery. Methodology: Given hypothesized care disruption (lowered care quality) during COVID-19, Aim 1 proposes to extend our preliminary VISN methods nationally to assess the VA population's trajectory from a new positive depression (and suicide-risk) screen to appropriate treatment (i.e., medication, therapy) in FY19-22/23. We will also examine the changing mix of virtual and in-person depression care delivered. Aim 2 will use interrupted time series analyses to explore the extent to which acute care use may be mitigated by clinician detection of depression nationally. We will also compare mortality rates between patients detected and not detected to have depression. Sub-analyses will reveal where (e.g., clinics with low PC-MHI access) and for whom (e.g., minorities) detection does not systematically occur, and downstream negative sequelae, to guide future intervention. Finally, Aim 3 will interview (1) 40 Veterans who were detected and not detected to have depression per Aims 1 & 2 about care-seeking behavior change, digital divide, etc. and (2) 40 VA primary care and PC-MHI providers about staffing shortage, telehealth adoption, etc. across three VAs (GLA, Syracuse, and Durham). In addition to contextualizing disrupted care findings, qualitative data will help isolate best practices on patient-to-provider and provider-to-provider (e.g., handoffs) interactions in hybrid depression care models. Next Steps/Implementation: The COVID-19 pandemic provides the VA with an opportunity to improve upon a system-wide proactive response to depression and suicide, one that is conceptualized to care for the entire Veteran population. This proposed research will provide the basis for testable hypotheses (e.g., acceptable virtual depression treatments in primary care), and clinical recommendations (e.g., satisfactory virtual provider- to-provider handoffs for new patient referrals), to improve virtual and in-person VA depression services.

Significance: This study will provide foundational information on an understudied risk factor for suicide in a cohort of Veterans at increased suicide risk post 9/11 Veterans within six years following military separation. It will provide information to inform suicide postvention strategies that target the population of suicide bereaved post-9/11 Veterans as well as those targeting women and American Indian/Alaskan Native (AI/AN) Veterans. Innovation and Impact: (1) Use of VA data to provide the most reliable prevalence estimates for suicide exposure among Veterans to date; (2) Oversampling of vulnerable but understudied populations -- Women and AI/AN Veterans; (3) inclusion of two comparison groups to elucidate the common and unique contribution of suicide exposure to health outcomes and patterns of VA service utilization; and (4) Assessment of the formal and informal supports Veterans receive for mental health problems associated with suicide using both survey and VA healthcare utilization data. Specific Aims: (1) Evaluate differences in the prevalence of posttraumatic stress disorder (PTSD), prolonged grief disorder (PGD), and in suicidal ideation, attempts and planning among Veterans exposed to suicide compared with those exposed to other causes of sudden death and with unexposed Veterans. We will also evaluate differences by sex and race. (2) Identify modifiable moderating factors for the association between suicide exposure and negative outcomes and modifiable moderating factors for the association between suicide or sudden death exposure and negative outcomes relative to those with neither exposure. (3) Describe treatment experiences, interests, reported suicide attempts, and patterns of VA service utilization among those exposed to a suicide death compared to Veterans exposed to other sudden deaths and to unexposed Veterans. (4) Contextualize quantitative findings through interviews with a purposive sample of Veterans exposed to suicide. The interviews will focus on modifiable factors at each level of the socio-ecological model of suicide prevention to better understand targets for intervention. Methodology: This explanatory sequential mixed methods study examines outcomes associated with suicide exposure in a nationally representative sample of post-9/11 Veterans enrolled in VA healthcare. We will collect data in three waves. Wave 1 will implement a national population probability sample using a brief survey to assess exposure history (suicide, other sudden death, neither) and exposure characteristics (e.g., time since exposure) among 11,400 Veteran respondents. Wave 2 will survey Wave 1 respondents, stratified by exposure history (suicide, sudden death, neither), to assess outcomes and variables of interest among 4,500 Veterans (1,500 respondents per exposure group). Wave 3 involves interviews with a purposive subsample of 32 Waves 2 survey responders who have been exposed to suicide but differ in outcomes. Quantitative analysis is the priority of the study; the qualitative component will contextualize the quantitative findings. Next Steps/ Implementation: This work will direct VA and the field towards an understanding of the most critical outcomes among veterans exposed to suicide, the mechanisms that may lead to deleterious outcomes, and lay a foundation for understanding the effective treatments and supports needed for Veterans who experience a suicide loss, including women and AI/AN Veterans.

Objectives: The overall goal of this project is to enhance our family member intervention specifically for those who support a Veteran recently discharged from psychiatric hospitalization and demonstrate the feasibility and scalability of the approach. Objective 1: Engage experts and stakeholders, including those VA Medical Center providers involved in psychiatric hospitalization and post-discharge supports, to develop the aspect of the CIC+SP intervention manual for family members of Veterans recently discharged from psychiatric hospitalization. Objective 2: Develop several strategies to identify and engage family member supporters of Veterans planned or recently leaving psychiatric inpatient treatment. Objective 3: Enhance and adapt website educational materials in the worriedaboutaveteran.org (WAV) website specifically for family member of Veterans in the post-hospitalization phase, partnering with the developers of the website. Objective 4: Conduct a pilot open trial of our new CIC+SP manual for this population.

Significance: This project addresses VA's top clinical priority (suicide prevention), an overarching priority of the Office of Research and Development (clinical trials), and multiple Health Service Research and Development priority areas, including social determinants of health, aging, access to care, mental health, suicide prevention, and population/whole health. The impact of this project is very high because it will advance scientific understanding of key gaps related to the mechanisms and outcomes of Caring Contacts, while also evaluating a timely, pragmatic, low-cost, and scalable intervention for Veterans affected by lack of social connection and treatment engagement. If effective, it will have applicability as a response to treatment disengagement and future disasters. Innovation and Impact: We have taken an empirically-grounded suicide prevention intervention and adapted it for Veterans with poor treatment engagement in VA outpatient care. This study is innovative in testing an intervention responsive to the COVID-19 pandemic and its aftermath, and unique in using a health services intervention strategy to target loneliness. The intervention's peer support component is highly novel for its low resource demands and potential for scalability. Specific Aims: The overarching objective of this project is to evaluate "Crisis Caring Contacts" (CCC), an adaptation of Caring Contacts tailored to reduce loneliness in the context of the pandemic. To reach this objective we will achieve these aims: 1) Among older Veterans with poor treatment engagement, evaluate the effectiveness of Crisis Caring Contacts in decreasing loneliness, compared to enhanced usual care; 2) Evaluate the effect of Crisis Caring Contacts on other important outcomes, including treatment engagement and suicidal ideation; 3) Explore potential moderators of treatment response to Crisis Caring Contacts; and 4) Explore the effect of Crisis Caring Contacts on all-cause mortality and suicide attempts. Methodology: Our approach is to conduct a multisite, pragmatic randomized controlled trial of CCC. We will target Veterans age 60 and over with active psychiatric or medical diagnoses who have had limited treatment engagement in VA outpatient care. Those in the CCC treatment arm will be sent 10 postcards over 10 months by a Peer Support Specialist. Those in the enhanced usual care arm (control) will be sent non-personalized, general health resource information. We will examine self-report and administrative data outcomes over 24 months of follow-up. Next Steps/Implementation: We will collect pre-implementation data from our study sites and share this with our operational partner, the Office of Mental Health and Suicide Prevention (OMHSP). Crisis Caring Contacts is highly suited to future implementation due to its scalability, ease of creating an operational dashboard to identify Veterans who could receive the intervention, and ability to add study materials to an implementation toolkit for VA Caring Contacts interventions.

Significance: This project evaluates an upstream public health approach to suicide prevention that is closely aligned with VA's National Strategy for Preventing Veteran Suicide. Suicide prevention remains VA's top clinical priority, and this project is highly responsive to multiple top VA priorities in research and clinical operations including studies testing outreach strategies to the families of Veterans and conducting clinical trials in suicide prevention. Innovation & Impact: Building upon a successful pilot randomized controlled trial of VA S.A.V.E., this randomized controlled effectiveness trial will be the first to rigorously evaluate the effectiveness of VA's signature suicide prevention skills training. Innovations include used of social media and digital outreach for upstream suicide prevention in Veterans not in VA care and use of standardized patient simulation as a method to assess participants' suicide prevention skills. Specific Aims: The primary objective of this study is to evaluate the effectiveness of VA S.A.V.E. and to explore factors impacting its potential widespread implementation. Specific Aims are: 1) Determine the effectiveness of VA S.A.V.E. in close supports of Veterans; 2) Evaluate mediators and moderators of response to VA S.A.V.E.; and 3) Using qualitative interviews and quantitative survey data, identify barriers to future implementation of VA S.A.V.E. and potential strategies for overcoming them in a diverse sample of close supports of Veterans. Methodology: We will conduct a randomized controlled effectiveness trial of VA S.A.V.E. using a targeted social media and digital ad campaign to recruit close supports likely to have interactions with Veterans at risk of suicide. Participants (N=710) will be randomized to VA S.A.V.E. versus an informational video (control). We will conduct follow-up surveys over 12 months. Our primary outcomes comprise use of gatekeeper behaviors (inquiring about suicidal ideation, recommending professional treatment, and providing suicide prevention hotline information). In a subgroup of participants split equally between treatment arms (n=50), we will also assess suicide prevention skills using a standardized patient simulation. Finally, guided by the Proctor taxonomy as an implementation framework, we will interview a subgroup of participants (n=32-48) to understand their experiences talking about suicide with at-risk Veterans and identify barriers and facilitators to implementation of the training in close supports. Next Steps/Implementation: The next step in this line of research would be a hybrid type 2 trial (equal focus on effectiveness and implementation). VA S.A.V.E. is free, brief, and accessible training, making it highly amenable to being rapidly taken to scale. Project findings can be used to quickly inform VA social media campaigns and other community-based efforts to disseminate VA S.A.V.E.

Significance: The proposed work has the potential to greatly improve our ability to identify high-risk individuals. If successful, early detection of Veterans at greater risk for suicidal behavior will allow for early intervention and lower suicide attempts and completions.

Innovation: Suicide rates are especially high among Veterans during the transition from inpatient to outpatient care, pointing to the need for improved suicide risk detection and prevention strategies for Veterans after discharge. The proposed research investigates suicide capability, a promising suicide prevention target given its role in the transition from suicidal thinking to suicide attempts. Neuroimaging and technology-based EMA methods will be leveraged to advance our understanding of suicide capability and facilitate future proposals evaluating biological interventions targeting suicide capability that may impede the progression from suicidal thinking to suicide attempts.

Significance: In the absence of comparative effectiveness, safety, or implementation data, VA facilities are currently split between which treatment they provide, and most provide neither treatment. This represents a gap in care in that many patients may be receiving a less effective or riskier treatment option, while others do not have access to either treatment, potentially due to the lack of data regarding which treatment to adopt. Innovation & Impact: This study represents the first head-to-head comparative effectiveness study of IV ketamine and IN esketamine. The emulated effectiveness-implementation study design is innovative in that it combines an emulated target trial approach to compare effectiveness and safety from observational data with qualitative and cost data to compare implementation aspects. Study findings will inform future adoption and sustained delivery of either or both treatments for Veterans with treatment-resistant depression (TRD). Specific Aims: Aim 1: Conduct a 2-arm emulated trial (N = 1,200) comparing the effectiveness of IV ketamine to IN esketamine on the primary outcome of Patient Health Questionnaire (PHQ9) symptom scores at 12 weeks post-treatment assignment among patients with TRD. Secondary outcomes will include suicidal ideation, suicide attempts, and psychiatric hospitalization. Aim 2: Compare adverse events leading to treatment discontinuation (AE-TDs) between the two arms at 12 weeks and explore differences in serious adverse events (SAEs) over 12 months. Potential AE-TD and SAE documentation will be extracted from medical records and confirmed by blinded physician review. Aim 3: Compare the Veteran patient experience, adoption and sustainment processes, and costs of IV ketamine and IN esketamine. Methodology: Aims 1 and 2 data will come from electronic medical records of eligible patients who have received either treatment at a VA facility that provides exclusively one of the treatments. Eligible patients will be those with major depressive disorder who have moderate or greater depression symptom severity following 3 or more prior oral antidepressant medication trials. PHQ9 depression symptom outcomes and adverse events will be manually extracted from medical records for 1,200 patients over 3 years. Inverse propensity treatment weighting will be used to emulate randomization. Primary analyses will compare longitudinal effectiveness and safety outcomes over the first 12 weeks of treatment. Aim 3 will apply qualitative analysis to data from up to 40 interviews of Veterans regarding their treatment experiences and up to 24 interviews of providers/champions regarding implementation processes. Qualitative data collection and analysis will be informed by the updated Consolidated Framework for Implementation Research. Staffing, pharmacy, supply, and facility costs will also be compared. Next Steps/Implementation: Findings will be used to generate an implementation playbook to inform VA policy and implementation. The playbook will be disseminated through operational partnerships with the Office of Mental Health and Pharmacy Benefits Management to local treatment providers and clinical leaders.