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Spotlight on Suicide Prevention

September 2021

September is Suicide Prevention Month  - Reach Out

Introduction

According to the 2019 National Veteran Suicide Prevention Annual Report, an average of 16.8 Veterans die by suicide every day. This is 1.5 times the rate for non-Veteran adults in the US1. Many recently discharged servicemembers have difficulty with personal relationships or their transition back to civilian life. Aging, homelessness, chronic health conditions stemming from military service, underlying mental health conditions including substance use disorders, in some cases aggravated by military service, all increase Veterans’ risk of suicide2.

In June 2019, VA and the White House announced the creation of a task force to develop a national roadmap to prevent suicide among Veterans. The President’s Roadmap to Empower Veterans and End the National Tragedy of Suicide (PREVENTS) seeks to change the culture surrounding mental health and suicide prevention through better community integration, prioritized research efforts, and implementation strategies that emphasize Veterans’ overall health and well-being3.

Because significant VA resources are devoted to preventing suicide among Veterans, those treated in VA are significantly less likely to follow through than Veterans outside the VA health care system. VA researchers are working to identify risk factors for suicide among Veterans and prevent suicide by directly responding to a Veteran’s individual risk profile. They are building new tools to help manage risk factors, identify more effective prevention strategies, and better ensure the successful transition of Veterans into the VA healthcare system4.

Below are some examples of current HSR&D funded research to help prevent Veteran suicide.


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Two Ongoing Studies Investigating Sleep and Suicide

Study 1: Longitudinal Assessment of the Sleep-Suicide Link in Veterans Discharged from Inpatient Psychiatric Care

Implications:

This study will assess Veteran sleep and suicide during the period following psychiatric hospitalization. The primary objective will be to examine how sleep impacts suicidal ideation and behavior and to determine which specific sleep parameters influence suicidal ideation.

Overview:

Veterans and military personnel account for 18% of all known suicides in the United States, with 20 Veterans dying each day of suicide and 900 attempting suicide monthly. While multiple risk factors have been implicated in suicide behavior, insufficient sleep is consistently associated with elevated suicide risk. Since sleep difficulties often drive Veterans into treatment, sleep problems may be an optimal target for suicide prevention. Unfortunately, the exact link between inadequate sleep and suicide risk is unclear, and research is mixed regarding which specific types of sleep problems are associated with suicide and which mechanisms are driving the sleep-suicide link.

The goal of this ongoing study (August 2020 – July 2024) is to examine the link between sleep and suicidal ideation and related behaviors in a sample of high-risk Veterans. One hundred and forty Veterans will be recruited during inpatient hospitalization and followed over six months following hospital discharge. Sleep and suicide will be assessed using a combination of actigraphy and Ecological Momentary Assessment (EMA). EMA will assess mechanisms hypothesized to drive the relationship between sleep and suicide including emotional reactivity and impulsivity. EMA devices will be able to capture daily changes in the hypothesized mechanisms, sleep parameters, and suicide thoughts and behaviors.

Principal Investigators: John E McGeary, PhD and Jennifer Primack, PhD are psychologists and investigators at the VA Providence Healthcare Center, Providence, RI.

Study 2: Improving Sleep as a Strategy to Reduce Suicide Risk among at-Risk Veterans: A Real World Clinical Trial

Implications:

By treating insomnia, a common problem that is both a risk factor for suicide and highly prevalent in common conditions associated with suicide such as depression and post-traumatic stress disorder (PTSD), investigators expect to reduce the severity of suicidal ideation (SI) among Veterans experiencing SI, insomnia and a co-occurring condition.

Overview:

Suicide is the tenth leading cause of death in the U.S., occurs at elevated rates among Veterans, and is a VA priority. Veterans with common chronic conditions such as PTSD and depression are at increased risk for suicide. Although evidence-based treatments exist for these conditions, a significant number of Veterans do not engage in or complete such treatments, leaving them at higher risk for suicide.

This study seeks to establish the feasibility and effectiveness of treating insomnia in the primary care environment as a suicide prevention strategy. It builds on HSR&D funded pilot work that demonstrated the feasibility of delivering a brief version of cognitive-behavioral therapy for insomnia (CBT-I) within primary care to Veterans experiencing SI. The pilot data suggest that the brief, primary care-based insomnia treatment delivered by the research team was acceptable to Veterans and associated with significant reductions in insomnia and depression symptoms as well as reduced SI intensity. The next stage of this program of research is to implement delivery of the insomnia treatment by primary care-mental health integration (PC-MHI) clinicians and to establish its effectiveness.

Study investigators are conducting a randomized clinical trial among 240 Veterans experiencing either co-occurring depression or PTSD. Of these Veterans, those who also endorsed SI and insomnia, were randomized to receive either a brief course of CBT-I or a sleep hygiene intervention of similar length. Assessments of suicidal thoughts and behaviors, insomnia, depression, and PTSD will be conducted at baseline, post-treatment, and every six weeks thereafter until six months post-treatment. Investigators will then determine how improvements in sleep and other symptoms (e.g. depression, PTSD) contribute to reductions in SI severity. In addition, investigators will collect and analyze participant and provider feedback to assess barriers and facilitators of implementation in real-world clinical practice.

Principal Investigator: Wilfred R. Pigeon, PhD is Executive Director of the VA Center of Excellence (CoE) for Suicide Prevention in Canandaigua, New York.




Implementing Caring Contacts for Suicide Prevention in Non-Mental Health Settings

Implications:

Caring Contacts is one of the only suicide prevention interventions shown to have reduced death by suicide in randomized controlled trials. Studies have demonstrated significant reductions in suicide deaths, attempts, and ideation at one and two-year follow-up. The treatment has been found to be feasible and acceptable with military and Veteran populations and helpful with active duty Soldiers and Marines.

Overview:

Suicide rates for Veterans are higher than the general population and suicide prevention is a high priority for VA. Most suicide deaths occur within 30 days after discharge from the hospital or emergency department (ED), making this an important event for a suicide prevention intervention to target. The Implementing Caring Contacts for Suicide Prevention in Non-Mental Health Settings QUERI Partnered Implementation Initiative is implementing and evaluating an evidence-based suicide prevention intervention—Caring Contacts—in VA EDs and urgent care centers. Caring Contacts (CC) involves sending brief, non-demanding expressions of care and concern to Veterans at risk for suicide at specified intervals over a year or more. The goal of this Partnered Implementation Initiative is to implement and evaluate CC in emergency department and urgent care settings to reach Veterans who may not engage with mental health services.

Implementation:

  • The research team adapted CC for Veterans and the ED setting, developed an implementation process and tools, and piloted implementation at the Central Arkansas Veterans Healthcare System in Little Rock, AR.
  • In the first year, 375 Veterans received Caring Contacts from the ED at the Central Arkansas Veterans Healthcare System. Many voiced positive views.
  • The CC intervention is currently being implemented and evaluated in 28 VA medical centers across VISNs 5, 6, 10, 12, 16, 17, 19, 22, and 23.

Principal Investigator: Sara J. Landes, PhD, is the Associate Director for the Behavioral Health QUERI, and a psychologist and researcher at the Central Arkansas Veterans Healthcare System. She also serves as the Co-Director of the South Central MIRECC Psychology Fellowship.




Improving Uptake of the VA Suicide Risk Identification Strategy

Implications:

This QUERI partnered evaluation project both tailors and adapts quality improvement strategies in order to advance implementation of population-based suicide risk screening and evaluation across the VA healthcare system. It is expected to help VA healthcare facilities address implementation challenges related to VA Risk ID. The goal is to ensure that more Veterans are screened and evaluated for suicide risk, which is the basis of effective, patient-centered suicide risk management. Moreover, since the implementation intervention “dose” is determined by monitoring facility performance over time, the project allows for individualized resource deployment, with the program office determining when and where resources are most needed.

Overview:

Emerging evidence indicates that many individuals who die by suicide are not identified as having psychiatric disorders, and often present for non-behavioral healthcare prior to their death. Current research also suggests that early and accurate detection of suicide risk among all Veterans presenting for VA care is a critical component of reducing suicide rates among Veterans. In October 2018, VA developed a system-wide, multi-staged strategy for standardized, evidence-based screening of suicide risk, and structured methods for the subsequent evaluation of those who screen positive for suicide risk (VA Risk ID).

Ongoing evaluation of VA Risk ID as well as interventions to improve its implementation are needed in order to facilitate continuous quality improvement. Working with VA’s Office of Mental Health and Suicide Prevention, the Examining the Effectiveness of an Adaptive Implementation Intervention to Improve Uptake of the VA Suicide Risk Identification Strategy QUERI Partnered Evaluation Initiative aims to develop an adaptive implementation strategy to improve the implementation of Risk ID among patients receiving care in ambulatory care settings. The focus on an adaptive implementation strategy provides an opportunity to vary the level and type of implementation support provided to VA healthcare facilities based on performance. This is important because facilities will differ with respect to VA Risk ID uptake and implementation barriers.

Using a randomized trial (SMART), this project will evaluate the effectiveness of two evidence-based implementation strategies in multiple phases:

  • The run-in phase will begin with implementation as usual. During this phase, all facilities will have access to resources provided through the Risk ID program (e.g., education & training, technical assistance).
  • In phases one and two – 1) Audit and Feedback (A/F), and 2) Audit and Feedback plus External Facilitation (A/F+EF) – facilities facing challenges in meeting implementation adherence goals will receive a sequence of implementation boosters. Investigators will evaluate the impact of these strategies on changes in VA Risk ID performance over time.

In addition, QUERI investigators will examine whether the uptake of VA Risk ID contributes to greater use of other suicide risk management practices, such as safety planning.

Principal Investigator: Nazanin Bahraini, PhD is a Clinical Research Psychologist and Director of Education at the Rocky Mountain MIRECC for suicide prevention, Denver CO.




Public Messaging to Increase Treatment Seeking Among Veterans at Risk for Suicide During Transition from Military Service

Implications:

Completion of the study will result in a portable data-driven intervention that can be deployed at low cost to effectively reach and engage the target population in need of mental health services. If the intervention is found effective, study investigators will use findings to improve current Veteran suicide communication, and work with the VA Suicide Prevention Program to include messages in future suicide prevention outreach to Veterans.

Overview:

Despite a great need for treatment, more than half of returning Veterans at risk for suicide do not initiate mental health services. Such findings underscore the urgent need for strategies to increase treatment seeking among recently separated Veterans vulnerable to self-directed violence and resistant to initiating mental health care. VA has embarked on the regular use of communication campaigns as part of a public health communication approach designed to reach the larger Veteran population with messages promoting help seeking. What types of messages effectively change beliefs and behaviors for at-risk Veterans is unclear.

The main objective of this study is to develop and test the use of public messaging to increase treatment seeking among Veterans at risk for suicide and resistant to seeking mental health care following separation from military service. Specific aims are:

  • Develop public messaging to increase the likelihood for treatment seeking among recently separated Veterans at risk for suicide and resistant to initiating mental health care.
  • Conduct a trial testing the public messaging.
  • Examine facilitators and barriers of message use to identify methods for effectively reaching and engaging Veterans at risk for suicide in the first year following separation from service.

Investigators will conduct structured interviews based on the Theory of Planned Behavior to guide the design of effective public messages that will be subsequently tested in a two-arm trial. Messages will be disseminated to Veterans during the trial by a smartphone app. Research staff will collect assessments by telephone at baseline, 1- and 2- months post-randomization.

Potential participants will be identified using data available from the VA/DoD Identity Repository (VADIR) and recruited by invitational mailing and follow-up telephone calls. Veterans 18 and older who separated from military service in the past 12 months, are experiencing suicidal ideation with low intent to seek help, and are willing and able to provide consent and download/use the app on a smartphone will meet inclusion criteria.

Principal Investigator: Elizabeth Karras-Pilato, PhD, is Co-Research Director of the Center of Excellence (CoE) for suicide prevention at the VA Finger Lakes Healthcare System, Canandaigua, NY.




References

  1. 2019 National Veteran Suicide Prevention Annual Report. [Internet]. Washington (DC): US Department of Veterans Affairs; 2020. [cited 2021 Aug 5]. Available from: https://www.mentalhealth.va.gov/docs/data-sheets/2019/2019_National_Veteran_Suicide_Prevention_Annual_Report_508.pdf
  2. VA research on Suicide Prevention. [Internet]. Washington (DC): US Department of Veterans Affairs; 2021. [cited 2021 Aug 5]. Available from: https://www.research.va.gov/topics/suicide.cfm#intro
  3. [Internet]. Washington (DC): US Department of Veterans Affairs; 2021. [cited 2021 Aug 5]. Available from: https://www.va.gov/prevents/
  4. New, Ongoing, and Published Research. [Internet]. Washington (DC): US Department of Veterans Affairs; 2021. [cited 2021 Aug 5]. Available from: https://www.research.va.gov/topics/suicide.cfm#research
  5. Veterans Crisis Line. [Internet]. Washington (DC): US Department of Veterans Affairs; nd. [cited 2021 Aug 5]. Available from:  https://www.veteranscrisisline.net/get-help/hotline

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