Preventing Veteran suicide has become the top clinical priority for the Veterans Health Administration (VHA). Rates of suicide among Veterans have increased since 2005, despite the VHA's comprehensive suicide prevention efforts. Also, data show that 80% of non-fatal suicide attempts among Veterans occurred within 4-weeks of having a VHA visit. Furthermore, research into new suicide prevention therapies remains limited in Veterans, as noted by a recent evidence brief (2018). These indicators all highlight the need for research that can expand the range of effective VHA suicide prevention interventions.
In response to this need, a randomized controlled trial evaluated Mindfulness-Based Cognitive Therapy for Suicide (MBCT-S). MBCT-S consists of 2 individual sessions and 8 group sessions. It was adapted from Mindfulness-Based Cognitive Therapy (MBCT) and incorporates suicide safety planning intervention. The study evaluated whether MBCT-S was more effective than treatment-as-usual (TAU) in reducing: 1) suicide events (defined broadly as actual attempt, aborted attempt, interrupted attempt, preparatory behavior, or suicide-related acute hospitalization or emergency department visit); 2) suicide attempts; and 3) suicidal ideation, depression and hopelessness.
Participants (N=140) were randomized to receive either MBCT-S+TAU (n=71) or TAU only (control; n=69) to compare the adjunctive value of MBCT-S to VA TAU for Veterans at high-risk for suicide. Inclusion Criteria: a) suicide risk last 30 days (i.e., attempt, ideation with intent, suicide-related acute hospitalization) AND b) placed on VA high-risk for suicide list OR had an actual, aborted, interrupted suicide attempt in the past year. Exclusion Criteria: a) clinically significant cognitive deficits; b) severe hallucinations or delusions; c) disorganized or disruptive behaviors; d) medical instability; and e) receipt of >=2 sessions of a mindfulness-based psychotherapy in past 12 months.
Participants received 5 assessments over 12 months: (a) Time 1 - baseline; (b) Time 2 - 5 weeks (mid-treatment); (c) Time 3 - 12-weeks (post-treatment); (d) Time 4 - 6-months; and (e) Time 5 - 12-months. Measures included the Columbia Suicide Severity Rating Scale (C-SSRS), the Beck Scale for Suicide Ideation, the Beck Depression Inventory and the Beck Hopelessness Scale. Data on suicidal behavior, acute hospitalizations, and emergency department visits were also obtained through electronic record review, permitting data gathering even among participants lost to follow-up. Analyses are utilizing an intent-to-treat approach, analyzing all participants regardless of follow-up status.
Of the 71 participants randomized to MBCT-S, 66 (92.9%) received the intervention ( 1 session) and 45 (63.4%) completed the intervention (defined as attending 1 individual sessions and 4 group sessions). Participants were 87.9% male with a mean age of 47 years. Race and ethnicity were reported as follows: White (45%), African American (27.9%), Latino (20.7%), and Other (6.4%). The most common psychiatric diagnoses were Major Depression (85%) and PTSD (60%). Substance use was also common at baseline (43.1% nonalcohol substance use; 34.1% alcohol binge drinking). History of actual suicide attempt reflected the high-risk nature of the sample, with 84.3% reporting at least one previous attempt and 55.7% reporting multiple attempts. All participants were receiving VA TAU, with 50.7% receiving VA residential treatment (i.e., PTSD, substance abuse, homelessness, serious mental illness), during the active treatment period of the study protocol (i.e., Time 1-Time3).
Kaplan Meier curves evaluated differences between the conditions in the amount of time until experiencing two key outcomes-1) suicide event (i.e., suicide attempts, preparatory behaviors, or suicidal ideation resulting in acute hospitalization or ED visit); and 2) any suicide attempt (actual, interrupted, or aborted suicide attempts). We focused on the first 100 days, as this time period coincided with the active treatment phase of MBCT-S (Time 1- Time 3) and this data is now complete (full 12-month follow-up data collection is ongoing).
At 100 days, there were no significant differences between the conditions on time to suicide event. When examining attempts, however, the MBCT-S condition showed a significant advantage over control on time to any suicide attempt. Specifically, Kaplan Meier Curve showed that by 100 days, 5 (7%) of MBCT-S participants made any suicide attempt, compared to 13 (18.8%) in the control group (log-rank 2=3.99, P=.046. The number of individuals needed-to-treat to prevent any suicide attempt was 9.74.
Finally, we capitalized on the fact that 50.7% of participants received VA residential care, during the active treatment period for MBCT-S (Time 1-Time 3) to evaluate how this important TAU context impacted MBCT-S outcomes. Analyses that stratified by residential treatment pointed to a stronger advantage for MBCT-S over control among participants receiving VA residential treatment. Specifically, among participants in a residential program, Kaplan Meier curves now showed a trend toward significance for reducing time to suicide event (log-rank 2=2.83, P=.093). For any suicide attempt, the Kaplan Meier curve showed a significant difference between MBCT and control only among participants receiving residential treatment, not among those seen as outpatients. Illustrating the greater benefit among those receiving residential care, 0 (0%) participants receiving MBCT-S had any suicide attempt at 100 days, compared to 9 (13.0%) of those in the control group (log-rank 2=8.65, P=.003).
Ongoing analyses are examining other outcome measures (Aim 3), as well as the 12-month results for suicide events and attempts.
The direct impact of the current study thus far has been a reduction of suicide attempts within 100 days among Veteran participants receiving MBCT-S. More broadly, a recent HSR&D evidence synthesis report noted the gap in suicide prevention studies targeting high-risk Veteran populations. The findings of this study directly address this area, showing promising outcomes for MBCT-S delivered to Veterans at high-risk for suicide. MBCT-S was tested and can be used adjunctively while Veterans receive other VA-suicide prevention interventions and services. Preliminary results for MBCT-S show promise for expanding the VHA's existing array of suicide prevention strategies and psychotherapies, particularly within VA residential programs.
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