Article

Effect of Crisis Response Planning on Patient Mood and Clinician Decision Making: A Clinical Trial With Suicidal U.S. Soldiers

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Abstract

Objective: The study examined the immediate effect of crisis interventions on the emotional state of acutely suicidal soldiers and clinician decision making. Methods: Soldiers (N=97) presenting to a military emergency department or behavioral health clinic were randomly assigned to receive a contract for safety (N=32), standard crisis response plan (S-CRP; N=32), or enhanced crisis response plan (E-CRP; N=33). Soldiers completed self-report scales before and after the intervention. Clinicians blinded to treatment group assignment rated participants' suicide risk level and made a decision about inpatient psychiatric admission. Results: Larger reductions in negative emotional states occurred in S-CRP and E-CRP. Larger increases in positive emotional states occurred in E-CRP. Clinician suicide risk ratings did not differ across treatment groups. Participants in E-CRP were less likely to be psychiatrically admitted. Conclusions: The CRP immediately reduces negative emotional states among acutely suicidal soldiers. Discussing a patient's reasons for living during a CRP also reduces the likelihood of inpatient psychiatric admission.

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... (m = 68.2) representing moderate-high quality evidence. See Table 2. S-SSP and E-SSP interventions included in this category were called "crisis response plans" (Bryan et al., 2017(Bryan et al., , 2018a(Bryan et al., , 2018bRozek et al., 2019) and "safety plans" (Green et al., 2018;Stanley et al., 2015Stanley et al., , 2020. S-SSPs included identification of warning signs, self-management and coping strategies, and social supports and healthcare professionals who could help during a suicide crisis. ...
... S-SSPs included identification of warning signs, self-management and coping strategies, and social supports and healthcare professionals who could help during a suicide crisis. Four of these plans also included identifying crisis services (Bryan et al., 2017(Bryan et al., , 2018a(Bryan et al., , 2018bRozek et al., 2019), three included a component of reducing access to lethal means (Green et al., 2018;Stanley et al., 2015Stanley et al., , 2020, and one included a component of identifying places that could serve as a distraction (Green et al., 2018). E-SSPs included the components included in S-SSPs, while also including verbal contracts for safety and identifying reasons for living (Bryan et al., 2017(Bryan et al., , 2018a(Bryan et al., , 2018bRozek et al., 2019). ...
... Four of these plans also included identifying crisis services (Bryan et al., 2017(Bryan et al., , 2018a(Bryan et al., , 2018bRozek et al., 2019), three included a component of reducing access to lethal means (Green et al., 2018;Stanley et al., 2015Stanley et al., , 2020, and one included a component of identifying places that could serve as a distraction (Green et al., 2018). E-SSPs included the components included in S-SSPs, while also including verbal contracts for safety and identifying reasons for living (Bryan et al., 2017(Bryan et al., , 2018a(Bryan et al., , 2018bRozek et al., 2019). ...
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Background. Suicide safety planning (SSP) is a suicide prevention approach that involves developing a collaborative plan between a service provider such as an occupational therapist and a person who is at risk of suicide. Purpose. To synthesize effectiveness studies on SSP. Method. Using the Joanna Briggs Institute methodology, we conducted a systematic review of effectiveness studies including a: (1) title and abstract screening; (2) full-text review; (3) critical appraisal; and (4) narrative synthesis. Findings. We included 22 studies. Critical appraisal scores ranged from 38.5 to 92.3 (m = 63.7). The types of interventions included were: standard and enhanced SSP (n = 11); electronically delivered SSP (n = 5); and SSP integrated with other approaches (n = 6). Only three studies identified meaningful activity as a component of SSP. Evidence across a range of studies indicates that SSP is effective for reducing suicide behavior (SB) and ideation (SI). While some studies have demonstrated effectiveness for reducing symptoms of mental illness, promoting resilience and service use, the number of studies exploring these outcomes is currently limited. Implications. Occupational therapists support individuals expressing SI, and SSP is a necessary skill for practice.
... The CRP is a brief intervention in which a clinician and an individual collaboratively identify personal indicators or warning signs of an emotional crisis, self-management strategies, reasons for living, sources of social support, and sources of professional and crisis support (6,28). Several clinical trials support the efficacy of the CRP and SPI for reducing suicide attempts (29) and other suicidal behaviors (30) as compared to treatment as usual. ...
... Typically, these suicide-focused interventions are administered to individuals with a history of suicide attempts or ideation, however, there is consideration that completing a CRP may be a prevention tool in the development of suicidal thoughts and behaviors in a non-clinical sample. Preliminary research suggests the CRP may lead to short-term increases in positive emotional states including hope (28) and optimism (31) when the intervention was enhanced with a brief discussion about suicidal persons' reasons for living. The CRP may also serve individuals in creating a plan to navigate and reduce the impact of emotional distress based on self-reported warning signs that may or may not be suicide specific. ...
Article
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Background Assessing for and identifying those at imminent risk for suicide continues to present challenges, especially as many who die do not interact with specialty mental health treatment preceding suicide. Suicide-specific interventions in healthcare settings have been found to improve suicide-related outcomes, yet little is known about the confluence of behavioral, cognitive, emotional, and physiological indicators of emotional distress as they correspond to other key risk characteristics and high-risk groups like gun owners.AimThe purpose of this content analysis was to examine self-identified warning signs of distress between gun owners and non-owners through crisis response planning (CRP).Methods Participants completed a collaborative CRP. Warning signs were categorized as being either behavioral, cognitive, emotional, or physiological in nature. Bivariate logistic regression models were used to examine associations between firearm ownership and variables of interest. Participants were evenly split between men (n = 44) and women (n = 44) and were predominantly white (67.1%) with a mean age of 35.9 (SD = 13.6).ResultsEmotional warning signs of distress (68.2%) were reported slightly more often than behavioral (65.9%) followed by physiological (52.3%), and cognitive (46.6%). Firearm owners were significantly more likely to be male (OR = 2.5, 95%CI [1.07–6.0]). All participants were about a fourth as likely to report both a behavioral and physiological warning sign concurrently (OR = 0.26, 95% CI [0.09–0.67]).Conclusion Similarities and departures in warning signs of emotional distress may inform future research exploring both self-reported warning signs and related self-management strategies identified through suicide-specific interventions, particularly among high-risk groups such as gun owners.
... Just over half (56%) of participants had a history of suicide attempts at baseline. Additional details about study participants can be found elsewhere (Bryan, Mintz et al., 2017). ...
... Approval for the current study was received from the Madigan Army Medical Center's Institutional Review Board. Additional details about the overall study design can be found elsewhere (Bryan, Mintz et al., 2017, and https://www.clinicaltrials. gov; #NCT02042131). ...
Article
Background and Aim: The Suicide Cognitions Scale (SCS) was developed to assess a broad range of suicide-related cognitions. Research to date supports the scale's factor structure, internal consistency, and construct validity. The present study tested the scale's prospective validity for suicide attempts among 97 military personnel presenting to an emergency department or psychiatric outpatient clinic for an unscheduled walk-in evaluation. Method: Cox regression and receiver operator characteristic analyses were conducted to test the prospective validity of the SCS. Results: Results supported the prospective validity of the SCS (area under the curve [AUC] = 0.69) and indicate the scale's performance is comparable to an empirically supported measure of suicide ideation (AUC = 0.75). The SCS performance was not reduced by removing items containing the word suicide. Limitations: Homogeneous sample comprised of US soldiers, predominantly male, with recent suicidal ideation. Conclusion: Results support the SCS as an indicator of subsequent risk for suicidal behavior when used in acute care settings, and suggest the scale's performance is similar to more traditional suicide risk screening methods that depend on honest self-disclosure of suicidal thoughts.
... Peer mentors also receive training in crisis response planning and lethal means counseling to ensure they are prepared for face-to-face meetings with individual service members who may be experiencing heightened emotional distress and/or an acute suicidal episode. The crisis response plan (CRP) is a brief suicide prevention strategy that reduces the incidence of suicide attempts among military personnel by 76% and leads to faster reductions in suicide ideation and emotional distress as compared to typical suicide risk management strategies [5,40]. Typically handwritten on an index card, the CRP is a collaboratively developed plan that includes several key sections: personal warning signs that serve as indicators of emerging emotional distress, self-management strategies that work to reduce or distract from acute emotional distress, reasons for living or sources of meaning or purpose in life, sources of social support (e.g., peers, family members), and professional healthcare and/or crisis services. ...
Article
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In light of data indicating military personnel are more likely to reach out to peers during times of need, peer-to-peer (P2P) support programs have been implemented for military suicide prevention. Often designed to reduce suicidal thoughts and behaviors by reducing mental health symptom severity, existing data suggest that P2P programs have little to no effect on mental health symptoms. Conceptualizing suicide prevention from an occupational safety and injury prevention perspective to promote positive health-related behavior change at both the group and individual level may enhance the effectiveness of P2P programs and military suicide prevention efforts more broadly. To illustrate these concepts, the present article provides an overview of the Airman’s Edge project, a P2P program design based upon the occupational safety and injury prevention model of suicide prevention, and describes a program evaluation effort designed to test the effectiveness of this approach.
... Our results are consistent with findings that crisis response planning reduced suicide attempts during a 6-month follow-up period in high-risk active duty soldiers. 42 Crisis response planning is an abbreviated form of safety planning that uses 4 of 6 elements of the SPI (without social interaction as a means of distracting from suicidal thoughts and lethal means counseling). Our results are also consistent with past research 30 that found that a combination of in-person intervention using screening and a safety plan coupled with telephone phone follow-up reduced suicide attempts. ...
Article
Importance Suicidal behavior is a major public health problem in the United States. The suicide rate has steadily increased over the past 2 decades; middle-aged men and military veterans are at particularly high risk. There is a dearth of empirically supported brief intervention strategies to address this problem in health care settings generally and particularly in emergency departments (EDs), where many suicidal patients present for care. Objective To determine whether the Safety Planning Intervention (SPI), administered in EDs with follow-up contact for suicidal patients, was associated with reduced suicidal behavior and improved outpatient treatment engagement in the 6 months following discharge, an established high-risk period. Design, Setting, and Participants Cohort comparison design with 6-month follow-up at 9 EDs (5 intervention sites and 4 control sites) in Veterans Health Administration hospital EDs. Patients were eligible for the study if they were 18 years or older, had an ED visit for a suicide-related concern, had inpatient hospitalization not clinically indicated, and were able to read English. Data were collected between 2010 and 2015; data were analyzed between 2016 and 2018. Interventions The intervention combines SPI and telephone follow-up. The SPI was defined as a brief clinical intervention that combined evidence-based strategies to reduce suicidal behavior through a prioritized list of coping skills and strategies. In telephone follow-up, patients were contacted at least 2 times to monitor suicide risk, review and revise the SPI, and support treatment engagement. Main Outcomes and Measures Suicidal behavior and behavioral health outpatient services extracted from medical records for 6 months following ED discharge. Results Of the 1640 total patients, 1186 were in the intervention group and 454 were in the comparison group. Patients in the intervention group had a mean (SD) age of 47.15 (14.89) years and 88.5% were men (n = 1050); patients in the comparison group had a mean (SD) age of 49.38 (14.47) years and 88.1% were men (n = 400). Patients in the SPI+ condition were less likely to engage in suicidal behavior (n = 36 of 1186; 3.03%) than those receiving usual care (n = 24 of 454; 5.29%) during the 6-month follow-up period. The SPI+ was associated with 45% fewer suicidal behaviors, approximately halving the odds of suicidal behavior over 6 months (odds ratio, 0.56; 95% CI, 0.33-0.95, P = .03). Intervention patients had more than double the odds of attending at least 1 outpatient mental health visit (odds ratio, 2.06; 95% CI, 1.57-2.71; P < .001). Conclusions and Relevance This large-scale cohort comparison study found that SPI+ was associated with a reduction in suicidal behavior and increased treatment engagement among suicidal patients following ED discharge and may be a valuable clinical tool in health care settings.
... For example, a recent brief psychosocial intervention (a volitional helpsheet) which draws from the integrated motivational-volitional model of suicidal behavior offers promise in reducing risk of repeat self-harm in some individuals following a suicide attempt (Armitage et al., 2016;O'Connor et al., 2017). The recent focus on safety planning and crisis response planning interventions is also consistent with the ideation-to-action framework (Stanley and Brown, 2012;Bryan et al., 2018) and are welcome additions to the field. ...
Article
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Suicide and attempted suicide are major public health concerns. In recent decades, there have been many welcome developments in understanding and preventing suicide, as well as good progress in intervening with those who have attempted suicide. Despite these developments, though, considerable challenges remain. In this article, we explore both the recent developments and the challenges ahead for the field of suicide research and prevention. To do so, we consulted 32 experts from 12 countries spanning four continents who had contributed to the International Handbook of Suicide Prevention (2nd edition). All contributors nominated, in their view, (i) the top 3 most exciting new developments in suicide research and prevention in recent years, and (ii) the top 3 challenges. We have synthesized their suggestions into new developments and challenges in research and practice, giving due attention to implications for psychosocial interventions. This Perspective article is not a review of the literature, although we did draw from the suicide research literature to obtain evidence to elucidate the responses from the contributors. Key new developments and challenges include: employing novel techniques to improve the prediction of suicidal behavior; testing and applying theoretical models of suicidal behavior; harnessing new technologies to monitor and intervene in suicide risk; expanding suicide prevention activities to low and middle-income countries; moving toward a more refined understanding of sub-groups of people at risk and developing tailored interventions. We also discuss the importance of multidisciplinary working and the challenges of implementing interventions in practice.
... Clinically, leveraging WTL versus WTD ambivalence has been a successful therapeutic technique used to foster patient motivation, engagement in therapy, and self-determined restorative action out of suicidal crises (Jobes, 2012(Jobes, , 2016. Identifying and attending to "reasons for living" is also used to help address suicide risk in Dialectical Behavioral Therapy (Linehan et al., 2006) and Enhanced Crisis Response Planning (Bryan et al., 2018). The results of the current study suggest a potential cognitive mechanism for these therapeutic effects. ...
Article
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The “Death/Life” Implicit Association Test (d-IAT) is a reaction-time task which has been associated with past and future suicidal behavior; in some work, the association has been incremental to explicit self-report of suicide risk. Proposed mechanisms for this association relate to one’s unwillingness or inability to completely disclose or be introspectively aware of implicit risk. This study investigated moderators of implicit-explicit concordance as well as predictors of d-IAT score unexplained by self-reported suicidal thoughts and behaviors among an online sample of 382 adults with higher demographic suicide risk (i.e., military service members and veterans, men over age 50, and LGBTQ young adults). Before and after controlling for current explicit report, results replicated the finding of a significant relationship between d-IAT score and severity of past suicidal behavior, and additionally indicated that suicide attempt history and wish to live moderated the association between d-IAT score and explicit report. Furthermore, results suggest that poor introspective awareness, rather than deception, may account for differences between implicit and explicit risk assessment. Continuing investigation of moderators and mechanisms of the d-IAT is needed to improve the utility and validity of using implicit suicide risk assessment as a clinical tool.
... A conceptual "cousin" of the SPI is the "Crisis Response Plan" (CRP), which was first developed by Rudd, Joiner, and Rajab [25] and further elaborated and rigorously studied by Bryan and colleagues [26][27][28][29][30]. The CRP has the patient note on an index card, in their own written words, various triggers, coping strategies, resources, and oftentimes their reasons for living. ...
Article
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While the existence of mental illness has been documented for centuries, the understanding and treatment of such illnesses has evolved considerably over time. Ritual exorcisms and locking mentally ill patients in asylums have been fundamentally replaced by the use of psychotropic medications and evidence-based psychological practices. Yet the historic roots of mental health management and care has left a certain legacy. With regard to suicidal risk, the authors argue that suicidal patients are by definition seen as mentally ill and out of control, which demands hospitalization and the treatment of the mental disorder (often using a medication-only approach). Notably, however, the evidence for inpatient care and a medication-only approach for suicidal risk is either limited or totally lacking. Thus, the “one-size-fits-all” approach to treating suicidal risk needs to be re-considered in lieu of the evolving evidence base. To this end, the authors highlight a series of evidence-based considerations for suicide-focused clinical care, culminating in a stepped care public health model for optimal clinical of suicidal risk that is cost-effective, least-restrictive, and evidence-based.
... Research has shown that the CRP, used as a one-time intervention, reduces suicidal behavior by 76%, reduces suicidal ideation, decreases the number of psychiatric inpatient days, and increases optimism as compared to treatment as usual (TAU; Bryan et al, 2017a, Bryan et al., 2017b. Additionally, the CRP has been integrated into treatment protocols including brief cognitive behavioral therapy for suicide prevention (BCBT), which has been shown to reduce suicide attempts by 60% compared to TAU (Bryan & Rudd, 2018;Rudd et al., 2015). ...
Article
Objective: Posttraumatic stress disorder (PTSD) and suicidal thoughts and behaviors are common in military members and veterans and produce anxiety for many clinicians. Although there are separate interventions for PTSD and elevated suicide risk, there is not much guidance on how to integrate these approaches. Crisis response planning (CRP) is an evidence-based tool used to prevent suicide attempts that can easily be integrated into trauma-focused therapies for patients with PTSD. Method: Given the high frequency of suicidal thoughts among patients with PTSD, the current paper discusses how CRP can be integrated into trauma-focused therapy. A clinical case example is provided to demonstrate how the CRP can be integrated into cognitive processing therapy for a suicidal veteran diagnosed with PTSD. Results: Using CRP within a cognitive processing therapy treatment program reduced both PTSD and suicidal ideation. Conclusions: Suicide specific treatments can be integrated effectively into trauma-focused treatments.
... 198). TAPS staff are trained to explore coping strategies and to use various intervention skills like Applied Suicide Intervention Skills Training (ASIST) (LivingWorks, 2020) and Crisis Response Planning (CRP) (Bryan et al., 2018) to assess risk and the need for professional care. Special care is taken to connect survivors with professionals versed in military culture, bereavement, and suicide risk. ...
Article
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The TAPS Suicide Postvention ModelTM is a three-phase approach to suicide grief that offers a framework for survivors and providers in the aftermath of a suicide. This framework proposes guidance on how to build a foundation for an adaptive grief journey and creates a research-informed, proactive, intentional pathway to posttraumatic growth. The Model follows the Tragedy Assistance Program for Survivors’ peer-based model of care and has supported more than 16,000 military suicide loss survivors over the past decade. The Model is applicable to anyone grieving a suicide loss or coping with any associated trauma.
... On the other hand, it could be found that during the crisis intervention, in the initial phase, 9 patients showed aggressive behavior, like shouted and screaming (I am feeling hot, go way, I am bored). Study by Bryan and team concluded that patients began to subside their negative symptoms after several times were given crisis interventions 31 . Secondary outcomes of improving Brøset were comprised of elaboration of the sentences and providing example actions at each stage; there were suggested that the items have relatively high internal consistency. ...
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Background: The Crisis intervention program is very crucial to reduce the violence of emergency and acute mental illness. In the present research, an adjusted violence scale instrument through the implementation of a crisis intervention program that was combined with antipsychotic medicine was proposed for acute mental illness patients. Methods and Material: The Brøset’s violence risk scale instrument was utilized to measure the patients' behavior with intervention; after that, it was refined (mixed method with concurrent embedded strategy) to adapt the measuring scales. Each patient was given a crisis intervention program and received similar antipsychotic medication that comprised of Chlorpromazine 300 mg/day, Haloperidol 15 mg/day, and Trihexyphenidyl 6 mg/day; then, the response was recorded for 7 to 12 days in an acute inpatient psychiatric unit. The instrument was adjusted to satisfy the changes in patients' behaviors throughout an intervention. Then, a trial procedure, verification, and validation were performed on the content of the instrument. Results: The results revealed that a paired-samples t-test comparison of the panic level of 72 patients' violence was t=-7617 and probability 0.000. The proportion of agreement Cohen's kappa (κ) can range from -1 to +1. It means that the kappa (κ) equal to 0.667 represents a moderate agreement. Furthermore, since Probability was very low ( P < 0.05). Conclusions: It can be concluded that there was different levels of patients' violence before and after the crisis intervention. The interrater statistical results confirmed that the majority of nurses had similar perceptions towards items of modified Brøset’s violence risk scales.
... CRP has been shown to reduce suicide attempts by 76% compared to usual treatment. 31,32 Owing to its efficacy, CRP is recommended for use with suicidal veterans in the VA/DoD Clinical Practice Guideline as a standard care practice. Secondary aims include the determination of whether there were pre-to post-intervention changes in measures of suicide risk, mindfulness, and emotional regulation. ...
Article
Introduction This study was a preliminary evaluation of a manualized, brief mindfulness-based intervention (MB-SI) for veterans with suicidal ideation (SI), admitted into an inpatient psychiatric unit (IPU). Materials and Methods A randomized, controlled pilot study of 20 veterans aged 18-70 years with SI, admitted into a psychiatric unit, assigned to treatment as usual (TAU) or MB-SI groups. Outcome data were collected at three time points: preintervention (beginning of first session), postintervention (end of last session), and 1-month postintervention. Primary outcomes were safety and feasibility. Secondary outcome measures were SI and behavior, mindfulness state and trait, cognitive reappraisal, and emotion regulation. Additionally, psychiatric and emergency department admissions were examined. Data analysis included Generalized Linear Models, Wilcoxon Signed-Rank, Mann–Whitney U, and Fisher’s exact tests for secondary outcomes. Results Mindfulness-based intervention for suicidal ideation was feasible to implement on an IPU, and there were no associated adverse effects. Mindfulness-based intervention for suicidal ideation participants experienced statistically significant increase in Toronto Mindfulness Scale curiosity scores 1-month postintervention compared to preintervention and greater Toronto Mindfulness Scale decentering scores 1-month postintervention compared to TAU. Emotion Regulation Questionnaire Reappraisal scores significantly increased for the MB-SI group and significantly decreased for TAU over time. IPU and emergency department admissions were not statistically different between groups or over time. Both TAU and MB-SI participants experienced a significant reduction in Columbia-Suicide Severity Rating Scale-SI scores after the intervention. MB-SI participants experienced a higher increase in Five-Facet Mindfulness Questionnaire scores postintervention compared to TAU. Conclusions Mindfulness-based intervention for suicidal ideation is feasible and safe to implement among veterans during an inpatient psychiatric admission with SI, as it is not associated with increased SI or adverse effects. Preliminary evidence suggests that MB-SI increases veterans’ propensity to view experiences with curiosity while disengaging from experience without emotional overreaction. Further, more rigorous research is warranted to determine efficacy of MB-SI. Trial registration The clinicaltrials.gov registration number is NCT04099173 and dates are July 16, 2019 (initial release) and February 24, 2022 (most recent update).
... In the future, we may be able to use information about suicidal subtypes to explore moderators of treatment response, such that some subtypes may demonstrate greater response to certain evidence-based treatments than others. Given that evidence-based treatments such as Safety Planning [59] and Crisis Response Planning [60] are associated with significant reductions in future suicidal behavior, it will important to eventually evaluate whether subgroups of participants have more favorable outcomes in these treatments. Finally, this study will improve our understanding of the effect of PTSD and insomnia treatment on suicide risk over time. ...
Article
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Objectives Several recent studies have demonstrated that posttraumatic stress disorder (PTSD) and insomnia treatments are associated with significant reductions in suicidal ideation (SI) among service members. However, few investigations have evaluated the manner in which suicide risk changes over time among military personnel receiving PTSD or insomnia treatments. This paper describes the study protocol for a project with these aims: (1) explore potential genetic, clinical, and demographic subtypes of suicide risk in a large cohort of deployed service members; (2) explore subtype change in SI as a result of evidence-based psychotherapies for PTSD and insomnia; (3) evaluate the speed of change in suicide risk; and (4) identify predictors of higher- and lower-risk for suicide. Methods Active duty military personnel were recruited for four clinical trials (three for PTSD treatment and one for insomnia treatment) and a large prospective epidemiological study of deployed service members, all conducted through the South Texas Research Organizational Network Guiding Studies on Trauma and Resilience (STRONG STAR Consortium). Participants completed similar measures of demographic and clinical characteristics and subsets provided blood samples for genetic testing. The primary measures that we will analyze are the Beck Scale for Suicide Ideation, Beck Depression Inventory, and the PTSD Checklist for DSM-IV. Discussion Results from this study will offer new insights into the presence of discrete subtypes of suicide risk among active duty personnel, changes in risk over time among those subtypes, and predictors of subtypes. Findings will inform treatment development for military service members at risk for suicide.
... Three of these components address administrative best practices in managing change, including leadership, training, and measuring outcomes and conducting quality improvement. Four additional components reflect established best practices in suicide care, namely, suicide screening and risk assessment (18)(19)(20)(21); use of systematic suicide care protocols that include safety planning and lethal means reduction (22)(23)(24)(25)(26)(27)(28)(29); evidence-based treatment to address suicidal thoughts and behaviors directly, in addition to other mental health issues (30)(31)(32)(33)(34); and provision of support during care transitions, with follow-up after discharge from acute care settings such as "caring contacts" (35)(36)(37). ...
Article
Objective: This study tested the hypothesis that fidelity of clinics to Zero Suicide (ZS) organizational practices is inversely related to suicidal behaviors of patients under clinical care. Methods: Using cross-sectional analyses, the authors examined the fidelity of 110 outpatient mental health clinics to ZS organizational best practices and suicidal behaviors of clinic patients in the year before a large-scale Zero Suicide implementation. Fidelity to ZS organizational best practices was assessed over a 1-year period with an adapted version of the ZS Organizational Self-Study instrument (17 items self-rated on a Likert scale of 1-5). Suicidal behaviors of patients were identified by extracting information on suicide attempts and deaths from a mandated statewide incident-reporting system database. Clinics were dichotomized into any or no suicide incidents during the year of observation. Logistic regression analyses were used to adjust for clinic census and population type (majority child or adult). Results: The clinics (N=110) served 30,257 patients per week. Clinics' total average fidelity score was 3.1±0.6 (range=1.41-4.12). For each point increase in fidelity, clinics had a significantly reduced likelihood of having a suicide incident (adjusted odds ratio=0.31, 95% confidence interval=0.14-0.69). Exploratory analysis identified significant differences for seven of 17 ZS organizational practices, with the largest effect sizes for suicide-specific quality improvement policies and activities (η2=0.097) and lethal means reduction (η2=0.073). Conclusions: These findings support an association between clinics' use of ZS organizational best practices and lower suicidal behaviors of patients under their care. Findings also support the validity of the ZS Organizational Self-Study instrument.
... One example is ketamine, a glutamatergic modulator that has been associated with rapid reductions in suicidal thoughts within hours (11). Another new treatment approach is crisis response or safety planning, an outgrowth of cognitive behavioral therapy for suicide prevention that is associated with rapid changes in suicidal thoughts within hours (12) and decreased risk of suicide attempt within months (13,14). ...
Article
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Rapid-acting interventions for the suicide crisis have the potential to transform treatment. In addition, recent innovations in suicide research methods may similarly expand our understanding of the psychological and neurobiological correlates of suicidal thoughts and behaviors. This review discusses the limitations and challenges associated with current methods of suicide risk assessment and presents new techniques currently being developed to measure rapid changes in suicidal thoughts and behavior. These novel assessment strategies include ecological momentary assessment, digital phenotyping, cognitive and implicit bias metrics, and neuroimaging paradigms and analysis methodologies to identify neural circuits associated with suicide risk. This review is intended to both describe the current state of our ability to assess rapid changes in suicide risk as well as to explore future directions for clinical, neurobiological, and computational markers research in suicide-focused clinical trials.
... Three of these components address administrative best practices in managing change, including leadership, training, and measuring outcomes and conducting quality improvement. Four additional components reflect established best practices in suicide care, namely, suicide screening and risk assessment (18)(19)(20)(21); use of systematic suicide care protocols that include safety planning and lethal means reduction (22)(23)(24)(25)(26)(27)(28)(29); evidence-based treatment to address suicidal thoughts and behaviors directly, in addition to other mental health issues (30)(31)(32)(33)(34); and provision of support during care transitions, with follow-up after discharge from acute care settings such as "caring contacts" (35)(36)(37). ...
Article
Objective: This study tested the hypothesis that fidelity of clinics to Zero Suicide (ZS) organizational practices is inversely related to suicidal behaviors of patients under clinical care. Methods: Using cross-sectional analyses, the authors examined the fidelity of 110 outpatient mental health clinics to ZS organizational best practices and suicidal behaviors of clinic patients in the year before a large-scale Zero Suicide implementation. Fidelity to ZS organizational best practices was assessed over a 1-year period with an adapted version of the ZS Organizational Self-Study instrument (17 items self-rated on a Likert scale of 1-5). Suicidal behaviors of patients were identified by extracting information on suicide attempts and deaths from a mandated statewide incident-reporting system database. Clinics were dichotomized into any or no suicide incidents during the year of observation. Logistic regression analyses were used to adjust for clinic census and population type (majority child or adult). Results: The clinics (N=110) served 30,257 patients per week. Clinics' total average fidelity score was 3.160.6 (range=1.41-4.12). For each point increase in fidelity, clinics had a significantly reduced likelihood of having a suicide incident (adjusted odds ratio=0.31, 95% confidence interval=0.14-0.69). Exploratory analysis identified significant differences for seven of 17 ZS organizational practices, with the largest effect sizes for suicide-specific quality improvement policies and activities (h 2 =0.097) and lethal means reduction (h 2 =0.073). Conclusions: These findings support an association between clinics' use of ZS organizational best practices and lower suicidal behaviors of patients under their care. Findings also support the validity of the ZS Organizational Self-Study instrument.
... The World Health Organization (WHO) statistics show that every year, 1 million people die from suicide, and suicide attempts are 20 times more than this rate. [6][7] Fakhari showed that people with a suicide attempt have poorer relationships, problem-solving, roles, affective responses, and social interactions. www.ghanamedj.org ...
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Objective: Stress and life changes such as ageing, spouse’s death, divorce, marriage, job loss, retirement, illness, interpersonal relationships and a history of suicide ideation or attempt may be considered risk factors for suicide attempts. This study aimed to investigate the relationship between stress and suicide.Design: Case-controlled and retrospective study.Participants: Patients referred to the Emergency Poisoning Unit of Yazd, were used as a case group and other ad-mitted patients with various plans and etiologies were a control group, matched on age, gender, marital status and place of residence.Settings: Patients were asked to fill out a questionnaire including age, gender, economic status, marital status, place of residence, a background of suicide, and history of family members’ suicide as well as the Holmes-Rahe scale. SPSS 16, chi-square and t-test were used for analyzing data.Results: Comparing the Holmes-Rahe stress scale’s scores of the case group (312.9±84.60) and control group (224.62±85.57) showed a significant statistical difference (P<0.0001). Regarding stress intensity, the score in the case group showed 6% mild stress, 40% moderate stress, 54% severe stress, and in the control group, 13%, 61% and 26%, respectively. Holmes-Rahe stress scale score of stress intensity showed a significant statistical difference be-tween groups (P<0.0001).Conclusion: The results of this study suggest that stress was associated with increased suicide attempts.
... Specifically, CRP has shown to reduce suicide attempts among active duty military personnel by 76% compared with typical suicide risk-management strategies [16]. It also contributes to significantly faster reductions in suicide ideation [16], as well as immediate reductions in emotional distress and suicidal intent [39]. To more directly target suicidal ideations, WET-S was developed to combine CRP for suicide prevention with WET. ...
Article
Studies of active duty service members have shown that military personnel who screen positive for posttraumatic stress disorder (PTSD) are more than twice as likely to make a suicide attempt. Evidence-based PTSD treatments can reduce suicidal ideation; however, it can be challenging to provide evidence-based, trauma-focused, PTSD treatment to high-risk patients on an acute psychiatric inpatient unit because the priority of care is stabilization. Treatment for PTSD requires more time and resources than are typically afforded during inpatient hospitalizations. Written Exposure Therapy is an evidence-based, five-session, trauma-focused treatment for PTSD that may overcome the implementation challenges of providing PTSD treatment in an acute inpatient psychiatric treatment setting. This paper describes the design, methodology, and protocol of a randomized clinical trial. The goal of the study is to determine if five 60-min sessions of Written Exposure Therapy enhanced with Crisis Response Planning for suicide risk reduces the presence, frequency, and severity of suicidal ideation, suicidal behavior, rehospitalization, and non-suicidal, self-injurious behaviors. The study also will determine if Written Exposure Therapy for Suicide reduces posttraumatic stress symptom severity among military service members, veterans, and other adult military beneficiaries admitted to an acute psychiatric inpatient unit for comorbid suicide ideation or attempt and PTSD symptoms compared with Treatment as Usual. The study is designed to enhance the delivery of care for those in acute suicidal crisis with comorbid PTSD symptoms.
... Identifying and discussing reasons for living also provides a useful platform for identifying and implementing interventions that can enhance cognitive flexibility and undermine the negative cognitive bias that characterizes suicidal states (12). Recent research further suggests that including a patient's reasons for living as a component of their crisis response or safety plan may lead to faster reductions in suicidal ideation, promote protective psychological states like hope and optimism, and support effective emotion regulation (31)(32)(33). As Brown et al. (34) noted, identifying a suicidal individuals' reasons for dying and reasons for living allows the clinician a mechanism to translate their ambivalence in concrete fashion, essentially a weighted value, coupled with the ability to actively engage their expressed ambivalence clinically, strategically intervene to move it in the direction of living (i.e., adding to the reasons for living list), and subsequently track it over the course of clinical care. ...
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Research in clinical suicidology continues to rapidly expand, much of it with implications for day-to-day clinical practice. Clinicians routinely wrestle with how best to integrate recent advances into practice and how to do so in efficient and effective fashion. This article identifies five critical domains of recent research findings and offers examples of simple questions that can easily be integrated into a clinician's existing suicide risk assessment interview and related protocol helping inform the risk formulation process.
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Accumulating evidence supports the efficacy of cognitive behavioral therapy for suicide prevention (CBT‐SP) as an empirically supported treatment approach for suicidal patients. In light of these findings, several procedures pulled from CBT‐SP have been recommended for standard care with suicidal patients. The present article provides an overview of the procedures used in CBT‐SP and discusses how these procedures meet, or even exceed, standard of care expectations for outpatient mental healthcare clinicians. Finally, the relevance of clinician fidelity to the CBT‐SP model when evaluating standard of care expectations is discussed.
Article
1 Background Previous research supports the efficacy of the crisis response plan (CRP) for the reduction of suicidal behaviors as compared to treatment as usual (TAU). Patient perspectives and use of the CRP, and their relationship to later suicidal thoughts, remain unknown. 2 Methods A secondary analysis of a randomized clinical trial comparing a standard CRP (S‐CRP), a CRP enhanced with reasons for living (E‐CRP), and TAU in a sample of 97 active‐duty U.S. Army personnel was conducted. Participants were asked about their use, perceptions, and recall of each intervention. Generalized estimating equations were used to test the conditional effects of intervention use, perceptions, and recall on severity of suicide ideation during follow‐up. 3 Results Across all treatment groups, over 80% of participants retained their written CRP up to 6 months later, but less than 25% had the written plan in their physical possession at the time of each assessment. Participants in S‐CRP and E‐CRP were more likely to recall self‐management strategies and sources of social support. Participants in TAU were more likely to recall use of professional healthcare services and crisis management services. All three interventions were rated as highly useful. More frequent use of the E‐CRP and recall of its components were associated with significantly reduced suicide ideation as compared to TAU. 4 Conclusions Both CRPs have high acceptability ratings. The effect of both CRPs on reduced suicide ideation is associated with patient recall of components. More frequent use of the E‐CRP is associated with larger reductions in suicide ideation.
Article
Aim This study examined the short‐term effects of a brief crisis intervention on optimism of acutely suicidal soldiers. Methods U.S. Soldiers (N = 97) presenting for an emergency mental health appointment in a military emergency department or behavioural health clinic were randomly assigned to treatment as usual standard crisis response plan, or enhanced crisis response plan (E‐CRP). This study is used a subsample of the original clinical trial (n = 64) for those who completed self‐report measures of optimism (Life Orientation Test‐Revised) prior to receiving any intervention and a secondary self‐report assessment one‐month following the intervention. Results Results indicate that individuals with low baseline optimism who received the E‐CRP had significant increases in optimism 1 month post‐intervention. Conclusion This provides evidence that discussing a patient's reasons for living during a CRP increases optimism in those high‐risk patients with the lowest baseline optimism.
Article
Aim: This study examined the short-term effects of a brief crisis intervention on optimism of acutely suicidal soldiers. Methods: U.S. Soldiers (N = 97) presenting for an emergency mental health appointment in a military emergency department or behavioural health clinic were randomly assigned to treatment as usual standard crisis response plan, or enhanced crisis response plan (E-CRP). This study is used a subsample of the original clinical trial (n = 64) for those who completed self-report measures of optimism (Life Orientation Test-Revised) prior to receiving any intervention and a secondary self-report assessment one-month following the intervention. Results: Results indicate that individuals with low baseline optimism who received the E-CRP had significant increases in optimism 1 month post-intervention. Conclusion: This provides evidence that discussing a patient's reasons for living during a CRP increases optimism in those high-risk patients with the lowest baseline optimism. K E Y W O R D S crisis response plan, military, suicide 1 | INTRODUCTION Suicide is a leading cause of death among active duty service members in the United States (Schoenbaum et al., 2014). Development of early interventions specific to the prevention of suicide is imperative and accumulating evidence supports the effectiveness of brief interventions for suicidal behaviour in this population (eg, Rudd et al., 2015). Crisis response planning (CRP), a personalized problem-solving tool used to promote the use of individual-specific coping strategies during an acute crisis, is one such intervention with demonstrated efficacy (Bryan et al., 2017). CRP has been associated with 1) a 76% reduction in suicide attempts, 2) significantly faster reduction in suicidal ideation, 3) a reduction in psychiatric inpatient days in comparison to treatment as usual (TAU; Bryan, Mintz, Clemans, Leeson, et al., 2017), and 4) reduced negative mood states (Bryan et al., 2017). In the initial clinical trial of CRP efficacy as a brief intervention for suicidal behaviour, Bryan, Mintz, Clemans, Leeson, et al. (2017) compared 2 versions of CRPs to TAU. Standard CRP (S-CRP) involved identification of warning signs of distress, coping skills, sources of social support, and professional resources. Enhanced CRP (E-CRP) included an additional module focused on identifying reasons for living (RFL; Bryan, Mintz, Clemans, Leeson, et al., 2017). In the RFL module , the therapist and patient collaboratively identified the patient's reasons for living and explicitly wrote them on the plan. This list often directly contradicted the patient's original view of not having any reasons for living and seeing suicide as the only option, creating flexibility in thinking. Results from the initial trial indicated that both versions of
Article
Introduction: Several protective factors for mitigating suicidal ideation (SI) such as positive affect, reasons for living, purpose in life, meaning in life, gratitude, grit, optimism, social support, and hope have been identified and received empirical support. However, few studies have examined the interrelationships of these protective factors and the identification of protective factors most closely linked to lower levels of SI may be useful for both theory-building initiatives and improvement of suicide-specific interventions. Network analysis offers an approach for testing the relation among these constructs, SI, and suicide risk factors. Methods: A sample N¼557 undergraduate students oversampled for lifetime SI completed a cross-sectional, online survey. The data was used to estimate an undirected, cross-sectional network of the aforementioned protective factors. Results: The resulting inferred network implicates strong negative influence of suicide cognitions, but not recent SI, and the strong positive influence of presence of meaning in life, trait hope, and low negative affect. Conclusions: Implications for dimensionality of SI versus suicide cognitions, targeting presence of meaning in life, trait hope, and negative affect in treatment, and cross-cultural variations in reasons for living are discussed. The study is limited by the cross-sectional and convenience sampling methodology.
Article
Objective: The interpersonal theory of suicide has contributed to advances in the understanding and prevention of suicidal behavior, with over a decade of empirical examination. Few studies, however, have used a longitudinal design with repeated short-term follow-ups to examine the temporal trajectories of perceived burdensomeness, thwarted belongingness, and suicidal ideation, nor have any studies to our knowledge investigated the propositions of the interpersonal theory of suicide using a dynamic systems theory approach. The present study examined the temporal dynamics of perceived burdensomeness, thwarted belongingness, and suicidal ideation, as moderated by capability for suicide, using dynamic systems modeling analyses in a sample of 91 adults at high risk for suicide (Mage = 27.03 years, SD = 8.64; 53.8% female, 44.0% male, 1.1% nonbinary, 1.1% transgender female). Method: Participants completed brief online self-report measures at 6 time-points, each 3 days apart. Results: Results were generally in support of the interpersonal theory of suicide: perceived burdensomeness, thwarted belongingness, and suicidal ideation exhibited patterns of temporal stability that were accentuated at high levels of capability for suicide; perceived burdensomeness and thwarted belongingness exhibited a reciprocal temporal pattern, as did perceived burdensomeness and suicidal ideation. However, thwarted belongingness did not have an incremental influence on suicidal ideation. Conclusions: Overall, these findings provide additional information about the nature of suicidal ideation and interpersonal risk factors over time and point to nonlinear dynamic systems modeling as an analytic technique that may prove useful in understanding trajectories of suicidal thoughts and behaviors.
Chapter
Suicide rates for US active-duty military members and Veterans have steadily increased following the attacks against America on 9/11. In response to the troublingly high rate of suicide among this population, the Department of Defense began implementing efforts to understand and reduce suicide risk for service members and Veterans. Various suicide prevention programs and policies have been developed, both within the military and the Veterans Health Administration, with the aim of identifying at-risk individuals and preventing suicidal behavior. While these efforts are commendable, the suicide rate among service members and Veterans has yet to meaningfully decline. Nonetheless, nascent and innovative developments in suicidology have yielded improved techniques for identifying at-risk individuals (e.g., machine-learning-based predictive models) and more effective psychotherapeutic interventions for ameliorating suicidality (e.g., Brief Cognitive Behavioral Therapy). Such advancements in the identification and treatment of suicidality are ongoing and represent great promise for the reduction of suicide rates among service members and Veterans. This chapter provides a broad overview of these advancements, with a particular emphasis on Veterans. An overview of the epidemiology of suicide among service members and Veterans will be presented, followed by a review of current evidence-based methods for identifying, treating, and preventing suicide among Veterans. Some recommendations for future efforts are proposed in the conclusion of the chapter. Despite laudable progress, there remains an urgent need for more widespread adoption of evidence-based practice and further research into what underlies, sustains, and prevents suicide risk in service members and Veterans.
Article
Veterans with posttraumatic stress disorder (PTSD) are at elevated risk for engaging in suicidal self-directed violence (S-SDV). Safety Planning has been widely implemented in the Veterans Health Administration to prevent S-SDV; however, limited guidelines exist regarding considerations for Safety Planning with veterans with PTSD. In this article, we discuss clinical considerations to guide health care providers in customizing each step of Safety Planning for veterans with PTSD. Proposed considerations include challenges establishing an appropriate baseline (Step 1); risky behaviors and substance use (Step 2); PTSD-related avoidance, beliefs, distrust, and isolation (Steps 3 and 4); stigma and distrust of providers and institutions (Step 5); and hypervigilance, safety beliefs, firearms, substances, and numbing (Step 6). Strategies for addressing these are provided for each step of the Safety Plan, such as delineating trauma-related warning signs, anticipating avoidance, and incorporating PTSD-related resources. In addition, methods of implementing the Safety Plan into evidence-based PTSD treatments disseminated within the Department of Veterans Affairs (e.g., cognitive processing therapy, prolonged exposure therapy) are discussed. Continued examination of Safety Planning in veterans with PTSD, including empirical investigation, is needed.
Article
The Beck Scale for Suicide Ideation (BSS) is one of the most used and empirically supported suicide risk assessment measures for behavioral health clinicians and researchers. However, the 19-item BSS is a relatively long measure and can take 5 to 10 minutes to administer. This study used Item Response Theory (IRT) techniques across two samples of mostly U.S. military service members to first identify ( n 1 = 1,899) and then validate ( n 2 = 757) an optimized set of the most informative BSS items. Results indicated that Items 1, 2, 4, 6, and 15 provided a similar-shaped test information curve across the same range of the latent trait as the full-length BSS and showed reliable item functioning across participant characteristics. The sum score of these five items showed a linear score linkage with the full-scale score, ρ > 0.87, and was equally as sensitive as the full scale for prospectively predicting near-term suicidal behavior at 74% with a cut score ≥1 (equivalent to full-scale score ≥6). Results are consistent with those from civilian samples. In time- or length-limited assessments, using these five BSS items may improve administration efficiency over the full BSS, while maintaining classification sensitivity. This study suggests that summing Items 1, 2, 4, 6, and 15 of the Beck Scale for Suicide Ideation (BSS) is an acceptable approach for shortening the full-length measure.
Article
Safety planning has been shown to reduce suicide risk and days in inpatient care among adults, but few studies have investigated how safety planning influences suicide-related outcomes among at-risk children and adolescents. This lack of research presents several avenues of research for researchers to explore. Aiming to establish a research agenda for safety planning research among youth, this paper outlines three areas of need in the research literature: 1) Facilitators and barriers influencing the use of safety plans among youth; 2) Parental involvement and parent-professional collaboration; and 3) Novel methods for safety planning development, modification, and application.
Article
Suicide risk screening depends heavily on accurate patient self-report. However, past negative experiences with mental health care may contribute to intentional nondisclosure of suicide risk during screening. This study investigated among 282 men older than age 50 whether likelihood for current explicit risk nondisclosure was associated with previous highest level of mental health care received. This sample was selected post hoc out of a larger sample of participants from higher risk and lower help-seeking populations (i.e., military service members and veterans, men older than age 50, and lesbian gay bisexual, transgender, and queer young adults), however, the other groups were underpowered for analysis. Among these men, history of psychiatric hospitalization was significantly associated with likelihood for explicit nondisclosure of current suicide risk, while history of receiving only outpatient therapy for suicidal thoughts or behaviors was significantly associated with likelihood for full reporting of suicide risk. Severity of suicidal ideation and internalized stigma against mental illness were significant indirect contributors to the effect. Although causality could not be determined, results suggest that a potential cost to consider for psychiatric hospitalization may be future nondisclosure of suicide risk. Conversely, outpatient interventions that appropriately manage suicidal thoughts or behaviors may encourage future full reporting of suicide risk and improve screening detection.
Article
Objective: The purpose was to examine temporal associations among meaning in life and suicide risk across suicide-focused interventions. Methods: A secondary analysis was conducted using data from a randomized clinical trial testing the efficacy of a standard crisis response plan (S-CRP) and a CRP enhanced with a discussion about the patient's reasons for living (E-CRP) as compared to treatment as usual (TAU). A total of 97 active duty U.S. Army personnel presenting to military emergency departments and outpatient behavioral health clinics with active suicide ideation or a lifetime history of suicide attempts were enrolled between January 2013 and February 2016. Meaning in life and suicide risk were assessed at baseline and 1, 3, and 6 month follow-ups. Results: The association of meaning in life with time-lagged suicide risk significantly differed across treatment groups (p = .024). In TAU, meaning in life was not significantly associated with later reductions in suicide risk. In S-CRP, a stronger desire to establish meaning in life was significantly associated with later reductions in suicide risk (p < .001). In E-CRP, a stronger sense of purpose and meaning in life was significantly associated with later reductions in suicide risk (p < .001). Discussion: Faster reductions in suicide risk observed among patients who receive a CRP are attributable in part by the effects of strengthened meaning in life. Different facets of meaning in life contribute to reduced suicide risk in unique ways across treatments with varying components. Clinical Trials Registration: Data used in this secondary analysis came from ClinicalTrials.gov identifier NCT02042131.
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Objective: Analyze responses to a national request for information (RFI) to uncover gaps in policy, practice, and understanding of veteran suicide to inform federal research strategy. Data source: An RFI with 21 open-ended questions generated from Presidential Executive Order #1386, administered nationally from July 3 to August 5, 2019. Study design: Semi-structured, open-ended responses analyzed using a collaborative qualitative and text-mining data process. Data extraction methods: We aligned traditional qualitative methods with natural language processing (NLP) text-mining techniques to analyze 9040 open-ended question responses from 722 respondents to provide results within 3 months. Narrative inquiry and the medical explanatory model guided the data extraction and analytic process. Results: Five major themes were identified: risk factors, risk assessment, prevention and intervention, barriers to care, and data/research. Individuals and organizations mentioned different concepts within the same themes. In responses about risk factors, individuals frequently mentioned generic terms like “illness” while organizations mentioned specific terms like “traumatic brain injury.” Organizations and individuals described unique barriers to care and emphasized ways to integrate data and research to improve points of care. Organizations often identified lack of funding as barriers while individuals often identified key moments for prevention such as military transitions and ensuring care providers have military cultural understanding. Conclusions: This study provides an example of a rapid, adaptive analysis of a large body of qualitative, public response data about veteran suicide to support a federal strategy for an important public health topic. Combining qualitative and text-mining methods allowed a representation of voices and perspectives including the lived experiences of individuals who described stories of military transition, treatments that worked or did not, and the perspective of organizations treating veterans for suicide. The results supported the development of a national strategy to reduce suicide risks for veterans as well as civilians.
Article
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Suicides within the U.S. Armed Forces remain elevated. Brief cognitive behavioral therapy for suicide prevention (BCBT) has demonstrated preliminary efficacy as a psychotherapeutic intervention that reduces suicide attempts among U.S. Army Soldiers. The generalizability of BCBT's effects in other military groups and its underlying mechanisms of action remain unknown, however. The Marine Suicide Prevention and Intervention REsearch (M-SPIRE) study is designed to test the efficacy of BCBT for the prevention of suicide attempts among active duty U.S. Marines with recent suicidal ideation or attempts and to identify potential mechanisms of change contributing to BCBT's effects. In this protocol paper, we describe M-SPIRE's rationale and methods with a particular emphasis on measuring treatment fidelity and BCBT's hypothesized mechanisms of action.
Article
Firefighters are chronically exposed to trauma as well as occupational and relational stressors. Furthermore, firefighters are faced with cultural and structural barriers in accessing psychological treatment services. Symptoms of posttraumatic stress disorder, depression, anxiety, and alcohol use disorder are prevalent, and suicidal ideation and behavior pose a significant public health concern. Awareness of fire culture is necessary for developing and enhancing evidence-based treatment services and increasing treatment initiation and adherence in this resilient, vulnerable, and understudied population. An overview of the mental health landscape of the fire service is provided, and major assessment and treatment issues are explored.
Article
Psychosocial interventions, such as Cognitive Behavioural Therapy (CBT), are often recommended in UK clinical guidelines to reduce suicidality and self-harm in service users with serious mental health problems, but the effectiveness of these interventions in acute mental health inpatient settings is not established. The aim of this study is to examine the types, and effectiveness of psychosocial interventions in inpatients settings in reducing the risk of self-harm and suicidality. A systematic review and meta-analysis was conducted of randomised controlled trials (RCTs) examining the efficacy of suicide and self-harm focused inpatient psychosocial interventions on suicidality (primary outcome), depression, hopelessness and suicide attempts (secondary outcomes). A total of ten studies met eligibility criteria were included in this review. All had low to moderate risk of bias for majority of the indicators, except for blinding of participants where all studies had high risk of bias. All studies examined psychosocial interventions for suicide reduction and none examined a psychosocial intervention for self-harm. The majority of the psychosocial interventions were CBT and Dialectical Behavioural Therapy (DBT). The interventions were no more effective than control treatments in reducing suicidality, depression, hopelessness or suicide attempts post-therapy and at follow-up. However, the majority were small pilot or feasibility RCTs. In conclusion, the findings from this review suggests that psychosocial interventions are not any more effective in reducing suicidality in acute mental health inpatient settings than control interventions. However, a large-scale RCT examining a psychosocial intervention for suicide is needed to provide conclusive findings. There were also no identified RCTs examining self-harm interventions indicating a need to conduct research in this area.
Article
Rapid‐acting treatments for suicidal thoughts are critically needed. Consequently, there is a burgeoning literature exploring psychotherapeutic, pharmacologic, or device‐based brief interventions for suicidal thoughts characterized by a rapid onset of action. Not only do these innovative treatments have potentially important clinical benefits to patient populations, they also highlight a number of methodological considerations for suicide research. First, while most clinical trials related to suicide risk focus on suicide attempts, new clinical trials that use suicidal thoughts as the primary outcome require a number of slight modifications to their clinical trial design. Second, the rapid onset of these new interventions permits an experimental therapeutics approach to suicide research, in which psychological and neurobiological markers are embedded into clinical trials to better understand the underlying pathophysiology of suicidal thoughts. The following review discusses these methodological innovations in light of recent research using the N‐methyl‐D‐aspartate (NMDA) receptor antagonist ketamine, which has been associated with rapid effects on suicidal thoughts. We hope that “lessons learned” from the ketamine literature will provide a blueprint for all researchers evaluating rapid‐acting treatments for suicidal thoughts, whether pharmacologic or psychotherapeutic.
Article
The advent of rapid-acting suicide-focused interventions and longitudinal research designs employing high-frequency, repeated measurement of suicide risk has resulted in a need to quantify suicide risk during very brief windows of time (e.g., minutes, hours, days). This has rapidly outpaced traditional methods for assessing suicide risk, which often focus on measuring indicators of suicide risk during much broader intervals of time (e.g., weeks to months). Valid and practical methods for rapidly assessing suicide risk during small time intervals are therefore needed. This study reports a preliminary examination of the Suicide Visual Analog Scale (S-VAS) and the Perceived Burdensomeness Visual Analog Scale (PB-VAS) in a clinical sample of suicidal adults. Results support the convergent validity, predictive validity, responsiveness, and clinical utility of both scales, suggesting the S-VAS and PB-VAS are valid methods for rapidly quantifying two dimensions of suicide risk.
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This study explored the factors psychiatrists considered in deciding on hospitalization for a large sample of suicide attempters in the emergency department of a general hospital in Madrid, Spain, between 1996 and 1998. Psychiatrists assessed 509 patients who had attempted suicide; 196 of these (39 percent) were hospitalized in the psychiatric unit, and 313 (61 percent) were discharged from the emergency department. The assessment included Beck's Suicidal Intent Scale (SIS) and a checklist of 47 clinical variables. Of the 32 clinical variables significantly associated with hospitalization that were introduced in a logistic regression model, 11 remained significant. Six variables were associated with an increased odds of hospitalization: intention to repeat the attempt, plan to use a lethal method, low psychosocial functioning before the suicide attempt, previous psychiatric hospitalization, a suicide attempt in the past year, and planning that nobody would try to save their life after they had attempted suicide. Five variables decreased the odds: a realistic perspective on the future after the attempt, relief that the attempt was not effective, availability of a method to kill oneself (that was not used), belief that the attempt would influence others, and family support. Models based on the SIS total score and individual SIS items had lower specificity and sensitivity. Psychiatrists appear to rely on patients' self-report in deciding on hospitalization rather than focus on demographic, diagnostic, or psychosocial issues. If the findings of this study were replicated in other hospital settings, the implication would be that the guidelines for assessing suicide attempts need to encourage thorough and detailed assessment of the attempt and the future plans.
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The authors describe the development of the Suicide Attempt Self-Injury Interview (SASII), an instrument designed to assess the factors involved in nonfatal suicide attempts and intentional self-injury. Using 4 cohorts of participants, authors generated SASII items and evaluated them with factor and content analyses and internal consistency statistics. The final measure was assessed for reliability and validity with collateral measures. The SASII assesses variables related to method, lethality and impulsivity of the act, likelihood of rescue, suicide intent or ambivalence and other motivations, consequences, and habitual self-injury. The SASII was found to have very good interrater reliability and adequate validity.
Article
Importance: Suicide is a leading cause of deaths in the United States. Although the emergency department (ED) is an opportune setting for initiating suicide prevention efforts, ED-initiated suicide prevention interventions remain underdeveloped. Objective: To determine whether an ED-initiated intervention reduces subsequent suicidal behavior. Design, setting, and participants: This multicenter study of 8 EDs in the United States enrolled adults with a recent suicide attempt or ideation and was composed of 3 sequential phases: (1) a treatment as usual (TAU) phase from August 2010 to December 2011, (2) a universal screening (screening) phase from September 2011 to December 2012, and (3) a universal screening plus intervention (intervention) phase from July 2012 to November 2013. Interventions: Screening consisted of universal suicide risk screening. The intervention phase consisted of universal screening plus an intervention, which included secondary suicide risk screening by the ED physician, discharge resources, and post-ED telephone calls focused on reducing suicide risk. Main outcomes and measures: The primary outcome was suicide attempts (nonfatal and fatal) over the 52-week follow-up period. The proportion and total number of attempts were analyzed. Results: A total of 1376 participants were recruited, including 769 females (55.9%) with a median (interquartile range) age of 37 (26-47) years. A total of 288 participants (20.9%) made at least 1 suicide attempt, and there were 548 total suicide attempts among participants. There were no significant differences in risk reduction between the TAU and screening phases (23% vs 22%, respectively). However, compared with the TAU phase, patients in the intervention phase showed a 5% absolute reduction in suicide attempt risk (23% vs 18%), with a relative risk reduction of 20%. Participants in the intervention phase had 30% fewer total suicide attempts than participants in the TAU phase. Negative binomial regression analysis indicated that the participants in the intervention phase had significantly fewer total suicide attempts than participants in the TAU phase (incidence rate ratio, 0.72; 95% CI, 0.52-1.00; P = .05) but no differences between the TAU and screening phases (incidence rate ratio, 1.00; 95% CI, 0.71-1.41; P = .99). Conclusions and relevance: Among at-risk patients in the ED, a combination of brief interventions administered both during and after the ED visit decreased post-ED suicidal behavior.
Article
Objective: To evaluate the effectiveness of crisis response planning for the prevention of suicide attempts. Method: Randomized clinical trial of active duty Army Soldiers (N=97) at Fort Carson, Colorado, presenting for an emergency behavioral health appointment. Participants were randomly assigned to receive a contract for safety, a standard crisis response plan, or an enhanced crisis response plan. Incidence of suicide attempts during follow-up was assessed with the Suicide Attempt Self-Injury Interview. Inclusion criteria were the presence of suicidal ideation during the past week and/or a lifetime history of suicide attempt. Exclusion criteria were the presence of a medical condition that precluded informed consent (e.g., active psychosis, mania). Survival curve analyses were used to determine efficacy on time to first suicide attempt. Longitudinal mixed effects models were used to determine efficacy on severity of suicide ideation and follow-up mental health care utilization. Results: From baseline to the 6-month follow-up, 3 participants receiving a crisis response plan (estimated proportion: 5%) and 5 participants receiving a contract for safety (estimated proportion: 19%) attempted suicide (log-rank χ(2)(1)=4.85, p=0.028; hazard ratio=0.24, 95% CI=0.06-0.96), suggesting a 76% reduction in suicide attempts. Crisis response planning was associated with significantly faster decline in suicide ideation (F(3,195)=18.64, p<0.001) and fewer inpatient hospitalization days (F(1,82)=7.41, p<0.001). There were no differences between the enhanced and standard crisis response plan conditions. Conclusion: Crisis response planning was more effective than a contract for safety in preventing suicide attempts, resolving suicide ideation, and reducing inpatient hospitalization among high-risk active duty Soldiers.
Article
IMPORTANCE: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multicomponent study designed to generate actionable recommendations to reduce Army suicides and increase knowledge of risk and resilience factors for suicidality. OBJECTIVES: To present data on prevalence, trends, and basic sociodemographic and Army experience correlates of suicides and accident deaths among active duty Regular Army soldiers between January 1, 2004, and December 31, 2009, and thereby establish a foundation for future Army STARRS investigations. DESIGN, SETTING, AND PARTICIPANTS: Analysis of trends and predictors of suicide and accident deaths using Army and Department of Defense administrative data systems. Participants were all members of the US Regular Army serving at any time between 2004 and 2009. MAIN OUTCOMES AND MEASURES: Death by suicide or accident during active Army service. RESULTS: The suicide rate rose between 2004 and 2009 among never deployed and currently and previously deployed Regular Army soldiers. The accident death rate fell sharply among currently deployed soldiers, remained constant among the previously deployed, and trended upward among the never deployed. Increased suicide risk was associated with being a man (or a woman during deployment), white race/ethnicity, junior enlisted rank, recent demotion, and current or previous deployment. Sociodemographic and Army experience predictors were generally similar for suicides and accident deaths. Time trends in these predictors and in the Army’s increased use of accession waivers (which relaxed some qualifications for new soldiers) do not explain the rise in Army suicides. CONCLUSIONS AND RELEVANCE: Predictors of Army suicides were largely similar to those reported elsewhere for civilians, although some predictors distinct to Army service emerged that deserve more in-depth analysis. The existence of a time trend in suicide risk among never-deployed soldiers argues indirectly against the view that exposure to combat-related trauma is the exclusive cause of the increase in Army suicides.
Article
Past suicidal behaviors including ideation and attempts have been identified as significant risk factors for subsequent suicidal behavior. However, inadequate attention has been given to the development or validation of measures of past suicidal behavior. The present study examined the reliability and validity of a brief self-report measure of past suicidal behavior, the Suicidal Behaviors Questionnaire-Revised (SBQ-R). Participants included psychiatric inpatient adolescents, high school students, psychiatric inpatient adults, and undergraduates. Logistic regression analyses provided empirical support for the usefulness of the SBQ-R as a risk measure of suicide to differentiate between suicide-risk and nonsuicidal study participants. Receiver operating characteristic (ROC) analyses indicated that the most useful cutoff scores on the SBQ-R were 7 for nonsuicidal samples, and 8 for clinical samples. Both the single SBQ-R Item 1 and SBQ-R total scores are recommended for use in clinical and nonclinical settings.
Armed Forces Health Surveillance Center: Surveillance snapshot: hospitalizations for suicidal ideation, active component, US Armed Forces
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Detecting and Treating Suicide Ideation in All Settings
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