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PPO 10-247 – HSR&D Study

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PPO 10-247
Improving Outcomes in Suicidal Veterans with Schizophrenia
John W. Kasckow MD PhD MS
VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA
Pittsburgh, PA
Funding Period: March 2012 - February 2013

BACKGROUND/RATIONALE:
Suicide is a serious public health problem among Veterans with schizophrenia. Risk for suicidal behavior is elevated among this group of Veterans when they are discharged from the hospital following an admission for suicidal behavior. Many Veterans with schizophrenia have difficulty monitoring their symptoms and adhering to outpatient treatment.

To address this problem, we designed a home-based telehealth system using the Health Buddy monitoring device for Veterans with schizophrenia who were recently hospitalized for suicidality. While our previous pilot work demonstrated that our system helped patients better monitor their symptoms, it also identified problems which need to be addressed before initiating a randomized controlled trial. Specifically, some Veterans were not able to set up the system and some Veterans who were able to set up the system did not use it in a consistent and sustained manner.

OBJECTIVE(S):
The project aims were to: (1) evaluate and refine the telehealth system to optimize the utility of the intervention; (2) field test the refined system in a group of eligible Veterans at risk for suicide; and (3) establish project feasibility, refine and test study procedures, and obtain preliminary data for effect size and power calculations for the full scale randomized clinical trial to follow. Our overarching objective is to enhance, implement, and test the Health Buddy telehealth system in order to improve the outcomes of Veterans with schizophrenia and suicidality.

METHODS:
In collaboration with a panel of experts in suicide prevention, schizophrenia, substance abuse, recovery, and the use of telehealth applications for individuals with schizophrenia, we refined the telehealth dialogues for the Health Buddy system. The refined dialogues were then tested with 10 Veterans with a history of suicidal ideation or attempts and meeting DSM-IV criteria for schizophrenia/ schizoaffective disorder. Participants were read each question by a research assistant and their responses were recorded. The responses were then coded and a qualitative analysis was performed.

After refining the dialogues based on results obtained from the qualitative analysis, we recruited 25 Veterans currently hospitalized for recent suicide attempts or suicidal ideation, who met DSM-IV criteria for schizophrenia or schizoaffective disorder with a score of >1 on item 4 or 5 of the Beck Scale for Suicidal Ideation (BSS). At discharge, participants were randomly assigned to Usual Care (UC; control group) or UC + Health Buddy (HB) monitoring in which participants logged in daily to the HB device (intervention group). At baseline, the Mini Mental Status Exam and demographic information were collected. Baseline and follow-up assessments at 2, 4, 8, and 12 weeks included the Beck Scale for Suicidal Ideation (BSS), Calgary Depression Rating Scale, and Clinical Global Impressions (CGI) Scale. Analyses of 3 symptom measures were completed with mixed effect regression with the interaction of treatment group and time as the primary outcomes of interest.

FINDINGS/RESULTS:
Baseline demographic characteristics of the 10 Veterans that participated in the testing of the refined Health Buddy dialogues were as follows: age 57.40 9.24; 2 were African American and 8 were Caucasian; 2 were married/cohabitating. Clinical characteristics included a mean Mini Mental Status score of 28 and a mean Calgary Depression Rating Scale of 5.3. Qualitative analysis of the testing sessions revealed 4 main themes: (1) questions which focused on suicidality, family issues, and substance abuse elicited strong emotional responses; (2) patients were concerned about confidentiality of information pertaining to questions dealing with suicide, medication adherence, and substance use; (3) some questions were too vague and greater specificity was needed; and (4) there were words or phrases that were not well understood by the Veterans.

Among the 25 Veterans enrolled in our field test of study procedures, 15 were assigned to the intervention group and 10 to control group. Within 2 weeks of discharge, 4 subjects in the intervention group and 1 in the control group were unable to continue. Reasons for the 4 HB patients not continuing included: (1) 2 were no longer interested in participating; (2) 1 had worsening medical problems; and (3) 1 died from a medical problem. The 1 control patient dropped out because he was no longer interested in participating. As of 6/24/13, there are 6 subjects (3 in each group) still active in the study. Based on data available for 10 intervention and 7 control subjects, the BSS was significantly reduced over the course of the assessments for subjects in the intervention group but not in the control group (log-likelihood x2=0.02, df=4, p=0.02). The largest difference in means in BSS scores between the groups (0.6 for HB vs 7.8 for UC) was at the 12 week assessment. Since 6 more participants need to complete the protocol, these findings are preliminary and further analyses will be needed. In addition, over all participants, there were significant decreases in the Calgary depression measure and both CGI indices from baseline; however, there were no significant differences between the intervention and control groups in the pattern of change over time (all p values >0.5).

IMPACT:
We successfully refined the intervention to facilitate initial set-up and sustained use of the telehealth system among Veterans with schizophrenia at risk for suicide. We also initiated a related pilot study to adapt the telehealth dialogues for use among Veterans with major depression at risk for suicide. In addition, this pilot project was selected for inclusion on the VA Office of Mental Health Operations Strong Practices SharePoint site in recognition of its high potential for a positive impact on the lives of Veterans.

PUBLICATIONS:

Journal Articles

  1. Kasckow J, Zickmund S, Rotondi A, Welch A, Gurklis J, Chinman M, Fox L, Haas GL. Optimizing Scripted Dialogues for an e-Health Intervention for Suicidal Veterans with Major Depression. Community mental health journal. 2015 Jul 1; 51(5):509-12.
  2. Kasckow J, Gao S, Hanusa B, Rotondi A, Chinman M, Zickmund S, Gurklis J, Fox L, Cornelius J, Richmond I, Haas GL. Telehealth Monitoring of Patients with Schizophrenia and Suicidal Ideation. Suicide & Life-Threatening Behavior. 2015 Oct 1; 45(5):600-611.
  3. Kasckow J, Felmet K, Appelt C, Thompson R, Rotondi A, Haas G. Telepsychiatry in the assessment and treatment of schizophrenia. Clinical schizophrenia & related psychoses. 2014 Apr 1; 8(1):21-27A.
  4. Kasckow J, Zickmund S, Rotondi A, Mrkva A, Gurklis J, Chinman M, Fox L, Loganathan M, Hanusa B, Haas G. Development of telehealth dialogues for monitoring suicidal patients with schizophrenia: consumer feedback. Community mental health journal. 2014 Apr 1; 50(3):339-42.
  5. Rotondi AJ, Spring M, Grady J, Simpson R, Luther J, Abebe KZ, Hanusa BH, Haas GL. Use of a fractional factorial experiment to assess the e-healthcare application design needs of persons with dual diagnosis. Journal of Dual Diagnosis. 2012 Nov 8; 8(4):277-282.
Conference Presentations

  1. Kasckow J, Rotondi A, Hanusa B, Zickmund S, Chinman M, Gao S, Haas G. Monitoring suicidal Veterans with schizophrenia using telehealth. Presented at: American Psychiatric Association Institute on Psychiatric Services Annual Conference; 2014 Nov 1; San Francisco, CA.
  2. Kasckow JW, Rotondi AJ, Hanusa BH, Fox L, Zickmund SL, Chinman MJ, Gao S, Haas GL. Telehealth monitoring in suicidal Veterans with schizophrenia. Poster session presented at: American Psychiatric Association Annual Meeting; 2014 May 5; New York, NY.
  3. Kasckow JW, Zickmund SL, Walch A, Rotondi AJ, Chinman MJ, Fox L, Haas GL. Optimizing scripted dialogues for an e-health intervention for middle aged and older suicidal Veterans with schizophrenia. Paper presented at: American Association for Geriatric Psychiatry Annual Meeting; 2014 Mar 16; Orlando, FL.
  4. Kasckow JW, Zickmund SL, Walch A, Rotondi AJ, Chinman MJ, Fox L, Haas GL. Optimizing scripted dialogues for an e-health intervention for suicidal Veterans with major depression or schizophrenia: a ‘user design’ approach. Poster session presented at: American Psychiatric Association Institute on Psychiatric Services Annual Conference; 2013 Oct 11; Philadelphia, PA.
  5. Kasckow JW, Haas GL, Cornelius J, Luther J. Telehealth monitoring of suicidal ideation in patients with schizophrenia. Poster session presented at: International Congress on Schizophrenia Research; 2013 Apr 23; Orlando, FL.
  6. Kasckow JW, Luther J, Fox L, Loganathan M, Haas GL. Telehealth monitoring of older patients with schizophrenia at risk for suicide. Presented at: American Association for Geriatric Psychiatry Annual Meeting; 2013 Mar 15; Los Angeles, CA.
  7. Kasckow J, Mrkva A, Rotondi A, Chinman M, Fox L, Loganathan M, Haas G, Zickmund S. Optimizing scripted dialogues for an e-health intervention for suicidal Veterans with schizophrenia: a “user design” approach using qualitative methods. Poster session presented at: VA / Department of Defense Suicide Prevention Annual Conference; 2012 Jun 20; Washington, DC.


DRA: Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational
Keywords: Behavioral Therapy, Schizophrenia, Social Support, Telemedicine/Telehealth
MeSH Terms: none