Brief interventions for short-term suicide risk reduction in military populations

Transcription

1 Brief interventions for short-term suicide risk reduction in military populations Craig J. Bryan, PsyD, ABPP National Center for Veterans Studies The University of Utah

2 Research Team NCVS / University of Utah Craig Bryan, PsyD, ABPP (PI) M. David Rudd, PhD, ABPP (Co-I) Tracy Clemans, PsyD (Fellow) AnnaBelle Bryan, BSPH (Res. Mgr) Sharon Stone, LCSW (Therapist) Kim Arne, LMSW (Therapist) Sean Williams, LMSW (Evaluator) Jennifer Amicone, MSW (Therapist) Erica Armstrong (RA) UTHSCSA Jim Mintz, PhD (Co-I, Stats) Ray Aguilar (Database) Paul Gruenwald (Database) Deanne Hargita (Regulatory) Fort Carson Travis Bruce, MD (Site PI) MAJ Trent Elliott, PsyD (Collab)

3 Study Background/Rationale NATIONAL CENTER Active duty hospitalizations for suicidal ideation, Medical Surveillance Monthly Report, Vol. 18 (4), April 2011.

4 Study Background/Rationale Results of RCT of 12-session BCBT vs. TAU for suicide attempts among military personnel: Suicide attempts reduced by 50% in BCBT Significant reductions in PTSD symptoms in BCBT No differences in depression, anxiety, suicidal ideation Crisis response planning and reasons for living anecdotally observed to be important interventions

5 Study Background/Rationale Suicidal individuals experience cognitive rigidity & failed problem solving Overestimate likelihood of negative/undesirable outcomes 2 Anticipate fewer positive events will occur in future 3 Impaired ability to consider reasons for why undesirable events will not occur Suicidal & nonsuicidal indiv. can list equal no. of reasons 2 Suicidal individuals take longer to generate the first reason 2 When reasons are listed, hopelessness drops 4 2. MacLeod. (1994) 3. MacLeod et al. (1993)

6 Study Background/Rationale Crisis Response Plan (CRP) Problem solving tool that outlines crisis management steps Collaboratively developed by clinician and patient Now widely used in military mental health settings, especially triage Potential problems with CRPs in triage: Not originally designed as a single-session intervention Fidelity of intervention is low Does not explicitly target suicidal intent or desire

7 Study Background/Rationale Most suicidal individuals experience both desire for life and desire for death simultaneously Reasons for living associated with lower suicidal intent and perception of suicide as solution 5 Reasons for living associated with suicidal ambivalence Suicidal ambivalence is associated with death by suicide 6 Enhancing suicidal patients reasons for living can reduce risk for suicidal behaviors Suicidal patients can list reasons for living, but take a long time to generate the first item 5. Kovacs & Beck (1977) 6. Brown et al. (2005)

8 Research Question(s)/Hypotheses NATIONAL CENTER 1. The crisis response plan with reasons for living (CRP+RFL) intervention will contribute to significantly decreased risk for suicide attempts and hospitalization during follow-up relative to the crisis response plan alone (CRP) and treatment as usual (TAU). 2. The CRP+RFL intervention will contribute to greater ambivalence about suicide and faster recall of reasons for living relative to the CRP and TAU interventions. 3. Greater ambivalence about suicide and faster recall of reasons for living will mediate the relationship between intervention and reduced risk for suicide attempt during follow-up.

9 Design and Methodology Treatment As Usual (TAU) Crisis Response Plan (CRP) Crisis Response Plan + Reasons for Living (CRP+RFL) Suicide risk assessment Suicide risk assessment Suicide risk assessment Supportive listening Supportive listening Supportive listening Identify warning signs Identify self-mgt skills Identify social support Identify warning signs Identify self-mgt skills Identify reasons for living Identify social support Crisis mgt education Crisis mgt education Crisis mgt education Referrals to treatment & community resources Referrals to treatment & community resources Referrals to treatment & community resources

10 Design and Methodology Primary outcome: Suicide attempt (SASII) Suicidal ambivalence (BSSI Items 1 & 2) Hospitalization Secondary outcomes: Suicidal ideation (BSSI, DSI-SS) Subjective suicidal intent (SBQ-R) Proposed mediator:: Reasons for living (speed of identification)

11 Design and Methodology Subjects 360 active duty Soldiers recruited from Ft. Carson triage Inclusion: 18+ y/o; active duty; speaks English; current suicidal ideation and/or recent suicide attempt Exclusion: inability to consent due to medical or psychiatric condition (psychosis, mania, etc.) Staff 2 therapists, 1 evaluator Embed therapists into 5 mental health teams Follow-up assessments completed by blind evaluator

12 Ineligible / Exclude Baseline Assessment Randomize Past suicide attempts Suicidal ideation Depression / mood Hopelessness Suicidal beliefs Hope / optimism Meaning in life Reasons for living Suicidal ambivalence TAU CRP CRP+RFL Immediate Immediate Immediate Mood Reasons for Living Suicidal ambivalence 1 month 3 months 6 months 1 month 3 months 6 months 1 month 3 months 6 months Suicide attempts Hospitalization Suicidal ideation Depression / mood Hopelessness Suicidal beliefs Hope / optimism Meaning in life Reasons for living Suicidal ambivalence

13 Baseline Assessment (n = 103) Randomized (n = 49) 54 Declined or Ineligible 26 Ineligible 28 Declined TAU (n = 17) CRP (n = 17) CRP+RFL (n = 15)

14 Planned Analyses 1. Between treatment differences Suicide attempt, hospitalization: survival curve using log-rank and Wilcoxon statistics Ambivalence, suicidal ideation, suicide intent: mixed effects regression with repeated measures 2. Speed of RFL recall Mixed effects regression with repeated measures and pairwise comparisons 3. Mediation of RFL recall speed Sobel test and test of indirect effects using bootstrapping method 4. Fundamental voice frequency analysis Cross-lagged actor-partner interdependence models (APIMs)

15 Questions? Craig J. Bryan, PsyD, ABPP