Post on 22-Aug-2020
NOVEL APPROACHES
FOR HIGH-RISK
SUICIDAL
VETERANS
MARIANNE GOODMAN, M.D.
K. NIDHI KAPIL-PAIR, PH.D.
SARAH SULLIVAN, M.S., MHC-LP
ANGELA P. SPEARS, B.S.
RACHEL E. HARRIS, M.A.
James J. Peters VA Medical Center, Bronx, NY
Mental Illness Research, Education and Clinical Center
Suicide Prevention and Treatment Research Program
To address critical gaps in suicide treatment,
our clinical research group has developed
three novel interventions:
1. PLF - Project Life Force
2. SAFER - Safe Actions for Families to
Encourage Recovery
3. Using TELEHEALTH to improve outcomes
in Veterans at risk for suicide.
NOVEL INTERVENTIONS
Question: Of all living US citizens, what percentage
are Veterans?
?
Map of total US population and distribution
BACKGROUND: Q & A
Answer: Of all living US citizens, 7.3 percent have
served in the military at some point in their lives
(SAMSHA).
92.7%
7.3%
% Veterans in the United States
Civilians Veterans
Map of total US population and distribution
Q & A
Question: How many Veterans live in NY state?
?
Map of total US population and distribution
Q & A
Answer: 806,827 Veterans are currently living in NY
state.
806,827
20,392,192
# OF VETERANS IN NEW YORK STATE
NY VeteransVeterans living in other states
Map of total US population and distribution
Q & A
Question: How many Veterans kill themselves
every day?
Q & A
Answer: 20
Q & AOnly 6 of the 20
Veterans who die
by suicide each day
receive services at
the VA
93 Civilians, also die by
suicide each day
This is in spite of enhanced suicide prevention resources.
Suicide prevention is the #1 clinical priority in the VA.
Veterans account for 18% of
all suicide deaths in US
adults.
THE PROBLEM: VETERAN SUICIDE
SUICIDE SAFETY PLAN (SSP)
The Suicide Safety Plan (SSP) is a
written, prioritized list of coping
strategies and resources for
reducing suicide risk.
It is a prevention tool, developed
collaboratively by patient and
clinician (Stanley & Brown, 2008).
In 2008, the VA mandated that
clinicians oversee the construction of
an individualized SSP for every
patient who is identified at “high risk”
for suicide.
The patient takes the SSP home for
his/her use at the onset of (or during)
a suicidal crises.
(Stanley & Brown, 2008)
1. Warning signs
2. Internal coping strategies
3. People and social settings that provide distraction
4. People whom I can ask for help
5. Professionals or agencies I can contact during a crisis
6. Making the environment safe
BREAKDOWN OF SSP
VA USE OF THE SSP
• There are currently no recommended guidelines or
mechanisms for refinement of the SSP beyond its initial
development.
• There are no recommended guidelines for involving family
members or friends in the implementation of, or use of, the
SSP.
To address these critical gaps, our clinical research group has
developed two novel interventions:
SAFER - Safe Actions for Families to Encourage Recovery
PLF – Project Life Force
Please Note: These interventions are adjunctive to standard
outpatient mental health care at the James J. Peters VA Medical
Center.
PROJECT LIFE FORCE
PLFKeeping High-Risk Veterans Alive Through a
Group Safety Planning Intervention
Funding : VA SPiRE RR&D
VA MERIT, CSRD
RCT:
6-month
DBT vs. TAU
in 93 high-risk
suicidal Veterans:
Negative study:
Both groups
improved in all
outcome
measures
ORIGINS OF PLF- DBT NEGATIVE RCT
DIALECTICAL BEHAVIOR THERAPY (DBT) TRIAL IN SUICIDAL VETERANS (GOODMAN ET. AL, 2016)
PERSONAL ANECDOTE WITH SUICIDAL VETERAN
Findings notable for:
Wide range of use (none to several times daily)
Importance of clinician collaboration
Barriers/obstacles to use
Problems/obstacles:
Lack of social network
Social withdrawal/depression
Avoidant style of coping
Burden too great to carry out plan alone
Facilitators of use of the plan:
Sharing of plan with significant others
Mobile formats of the plan
Individualized plans
20 Veterans interviewed after SSP construction and 1 month later
QUALITATIVE STUDY OF SUICIDE SAFETY PLAN
(SSP) USE (KAYMAN ET AL., 2015)
Findings notable for:
Wide range of use (none to several times daily)
Importance of clinician collaboration
Barriers/obstacles to use
Problems/obstacles:
Lack of social network
Social withdrawal/depression
Avoidant style of coping
Burden too great to carry out plan alone
Facilitators of use of the plan:
Sharing of plan with significant others
Mobile formats of the plan
Individualized plans
20 Veterans interviewed after SSP construction and 1 month later
PLF aims to address these concerns
PLF incorporates:
1) Teaching of distress
tolerance and emotion
regulation skills applied to
individual steps of the SSP,
2) Introduces use of a mobile
SSP Application,
3) Helps Veterans identify
individuals they can call for
help, and practice asking for
help,
4) Aims to develop detailed,
personalized and meaningful
SSPs,
5) Delivered in a group
context offering support.
QUALITATIVE STUDY OF SUICIDE SAFETY PLAN
(SSP) USE (KAYMAN ET AL., 2015)
PROJECT LIFE FORCE
PROJECT LIFE FORCE (PLF) is a manualized, 90-minute
group therapy for 10 sessions, lasting 3 months.
• Combines psychoeducation and emotion regulation skills with suicide
safety planning development and implementation.
Group Psychotherapy
Emotion Regulation Skills
Psychoeducation
Suicide Safety Planning
Technologic integration
THE SOLUTION:
PLF Session 2:
Emotion
Recognition
SkillsPLF Session 3:
Distress Tolerance
Skills
PLF Session 4-5:
Interpersonal
Communication
Skills with
Family PLF Session 6:
Interpersonal
Communication
Skills with Clinical
TeamPLF Session 1:
Crisis
Prevention
Services
PLF Session 7:
Means Restriction
GROUP SUICIDE SAFETY PLANNING & SKILLS
INTERVENTION
1) PLF=manualized, weekly 90-minute
group treatment lasting 10 weeks.
2) Each session of PLF corresponds to
a step of the safety plan and teaches
skills to maximize the use of that
particular step of the plan.
3) PLF is augmented with education
pertaining to suicide risk, means
restriction and suicide prevention mobile
applications.
4) A manual with 84 pages of session
handouts has been developed & tested.
5) Designed to meet VA mandated
monitoring and permit immediate
access.
6) Capitalizes on group support & is
cost effective.
Project Life Force Session Outline
Session Focus Skill Covered
1
Introduction, psychoeducation about
suicide, SSP step #5 - crisis
numbers, meet local SPC
Crisis Management Skills
Urge Restriction
2SSP step #1 - Identification
of Warning Signs
Emotion, Thought or Behavior
Recognition skills
3SSP step #2 - Internal
Coping StrategiesDistraction Skills
4SSP step #3 - Identifying
people to help distractMaking Friends Skills
5SSP step #4 - Sharing SSP with
Family
Interpersonal Skills/Practicing
Asking for Help
6SSP step #5 -
Professional Contacts
Skills to Maximize Treatment
Efficacy & Adherence
6SSP step #6 - Making
the Environment Safe
Means Restriction,
Psychoeducation About Methods
7 Improving Access to the SSPUse of Safety Planning Mobile
Apps and Virtual Hope Box
8 Physical Health ManagementDecreasing Vulnerability to
Negative Emotion
9 Building a Meaningful LifeBuilding Meaning and Reasons
for Living
10 Recap/Review
**PLF is one of the only manualized outpatient
group treatments for suicidal individuals.
PLF SKILLS AND SAFETY PLANNING IN A GROUP
PLF is one of the only manualized outpatient group
treatments for individuals at high risk for suicide.
This is surprising given that groups:
1. Diminish social isolation and increasing social
support/social connectedness, a protective factor against
suicide;
2. It’s cost effectiveness and maximizing staff time;
3. The peer movement among those who have experienced
suicidal crises is strong and growing; and
4. Veterans and military service members are familiar with
working as a unit, with team approach to problems.
PLF = SAFETY PLANNING IN A
GROUP FORMAT
OPEN LABEL PILOT
Initial effectiveness in
depression, suicidal symptoms,
hopelessness.
Feedback on each session from
patient and PLF therapist.
Test feasibility and tolerability of
intervention on 50 Veterans.
Plus post-intervention
feedback from treating
clinician(s).
After 10 weeks of PLF, Veterans had:
>40% suicide symptom severity/ideation
>30% depression,
>20% hopelessness
PROJECT LIFE FORCE - OUTCOMES
CSSRS= Columbia Suicide Severity Rating Scale;
BDI= Beck Depression Inventory;
BHS= Beck Hopelessness Scale;
BSS= Beck Suicide Ideation Scale
Feasibility/Acceptability Pilot
Data (N=45)
• <2.0 total hours/week per
clinician
• Veteran satisfaction 4.7 out
of 5 point likert scale
• 5.0 of 5 rating on
recommending the
treatment to others
• <17% attrition
• 100% of participants
developed updated safety
plans and increased use
patterns.
PROJECT LIFE FORCE - OUTCOMES
More Effective Use of
Safety Plan
“Going through each step
in depth makes it a living
document, instead of just
filling it out on the fly and
never using it.”
QUALITATIVE FEEDBACK ON PLF
Hope/Improved Depressive and Suicidal Feelings
“I wake up wanting to live now.”
More Effective Use of
Safety Plan
“Going through each step
in depth makes it a living
document, instead of just
filling it out on the fly and
never using it.”
QUALITATIVE FEEDBACK ON PLF
Hope/Improved Depressive and Suicidal Feelings
“I wake up wanting to live now.”
Increased Connection &
Sense of Belongingness.
Lessened Loneliness
“To actually connect with my
brothers in this fight was
powerful. It’s another battle
we are facing.”
More Effective Use of
Safety Plan
“Going through each step
in depth makes it a living
document, instead of just
filling it out on the fly and
never using it.”
QUALITATIVE FEEDBACK ON PLF
Keeping High-Risk Veterans Alive Through a
Group Safety Planning Intervention
Greg Brown, PhD
University of Pennsylvania
Philadelphia VA
Michael Thase MD
University of Pennsylvania
Philadelphia VA
Barbara Stanley, PhD
Columbia University
Psychiatric Institute
Hanga Galfalvy, PhD
Columbia University
Psychiatric Institute
Marianne Goodman, M.D.
Icahn School of Medicine,
Mount Sinai
James J. Peters VAMC
PROJECT LIFE FORCE RCT
SESSION 9:
IN SESSION ACTIVITY
“Together we want to start to list all the big and little
reasons to keep on living.
We have listed some samples from other people, in
order to jumpstart your own list.
As we read together the following items, try and think
of the aspects of your life that you take for granted.
We want to write them down as reminders of the
beautiful and wonderful things in life.”
EXAMPLES OF
REASONS FOR LIVING
Watching someone
talk about
something they’re
passionate about.
The first
snowfall of the
season.
Fresh baked
cookies.
Stepping on
crunchy
leaves.
Splashing in
puddles.
Traveling
around the
world
Your future
children, pets,
spouses, or
friends
HOMEWORK
Add reasons for
living to your safety
plan.
Special Design Features:
1) Multi-site RCT, n=265 suicidal
Veterans
2) Co-investigators Drs. Brown
and Stanley are creators of the
VA suicide safety plan
3) Rigorous multi-method
assessment of suicidal
behaviors with follow-up out to 1
year.
4) Assessment training and
adherence monitoring performed
by 3rd site.
5) Examining impact on suicide
safety planning quality
6) Explore “group cohesion” as
mediator
Study Assessments, Schedule and Purpose
Domain Measure Description Source
Study
Contac
t
(Month
)
Study
Purpose
Suicidal
Behavior and
Ideation
Columbia Suicide
Severity Rating
Scale–current &
since last visit
version
Interim history of suicide
related behaviors; severity
of ideation; intensity of
ideation subscales
Interview0, 3,
6,12
Primary
Outcome;
Suicidal
Ideation and
Behavior
Suicidal behavior,
Suicidal intention
Identification of suicidal
ideation and behavior in
medical record
Chart
abstraction12
Primary
Outcome
Suicide Death by suicide Death by suicide
Death
Certificates
NVDRS
12Primary
Outcome
DepressionBeck Depression
ScaleDepression
Self-
Report
0, 3,
6,12
Secondary
Outcome
HopelessnessBeck
Hopelessness
Scale
Hopelessness
Positive and Negative
Beliefs about the future
Self-
Report
0, 3,
6,12
Secondary
Outcome
Mental Health
Services
Self-report log
based on the
Modified Cornell
Services Index
MCSI
Use of mental health
services, SOC contacts
determined from medical
record
Log
maintained
by subject
& research
staff
3, 6,12
Secondary
Outcome
Safety PlanBrief Survey of
Safety Plan
Utilization
Subject self-report of using
the safety plan prior to
baseline assessment or
during follow-up and which
components were used
Self-report0, 3,
6,12
Secondary
Outcome
Suicide-
Related
Coping
Suicide-Related
Coping Measure
Report of coping behaviors
identified on the SPI and
confidence in managing
suicidal feelings.
Self-report0, 3,
6,12
Secondary
Outcome
Group
Cohesion
Group
Psychotherapy
Process Measure
Group Process Outcomes Self-report1,5,10
(weeks)Mediator
Demographic
and Medical
History
Information
Demographic
Information and
History of
Psychiatric,
Substance Use,
Medical
Information
MSRC Common Data
ElementsInterview 0,3 Descriptive
DiagnosisMini-International
Psychiatric
Interview
Axis I diagnosis Interview 0 Descriptive
Methodology
Merit
SAFE ACTIONS FOR FAMILIES
TO ENCOURAGE RECOVERY
SAFER RCTFUNDING: VA MERIT, RR&D
RATIONALE FOR FAMILY INVOLVEMENT
Psychological models of suicidality
emphasize the role of social factors in the
development and intensification of suicidal
thoughts and behavior:
• feeling like a burden on family and friends,
• feelings of isolation and not belonging,
• “unloveability” and
• perceptions of diminished support from
one’s family and social network
(Brenner et al, 2008; Farrell et al, 2015; Johnson et al, 2008; Joiner et
al, 2015, Owen et al, 2015; Ellis et al., 2015)
RATIONALE FOR FAMILY INVOLVEMENT
2015 VA Behavioral Health Autopsy Program
(BHAP) Report based on interviews with 114
family members recommended:
1) educating families about suicide warning signs;
2) improving communication between the veteran and
family member;
3) involving the family in the veterans’ treatment to
enhance support and trust;
4) providing families with coaching on how to assist their
loved one to seek help.
RATIONALE FOR FAMILY INVOLVEMENT
Treatments targeting Family Members
Currently, the only family based group treatment available is
called Family Connections (FCs; Hoffman et al., 2005, Hoffman,
Fruzzetti, & Buteau, 2007).
Depression
Patients of family members also show improvement and feel more
validated after FC.
Burden
Grief
QUALITATIVE INTERVIEWS:
RATIONALE FOR FAMILY INVOLVEMENT
Our Pilot Qualitative Study:
Family Themes
1) Fear of triggering urges, “I never know how he’ll react”
2) Feeling unsupported, “There’s no real support” and
3) Feeling overwhelmed, ”I didn’t know what to do”
Veterans felt alone and afraid to reach out to family members.
PROTOCOL SUMMARY
SAFER is a novel, 4-
session manualized
intervention.
Through the use of psychoeducation,
disclosure and development/revision of
both the Veteran and a complementary
family member safety plan, SAFER
provides the tools and structure to support
family involvement in suicide safety
planning for Veterans at moderate risk for
suicide.
(Stanley & Brown, 2008)
WHERE SAFER FITS IN…
SAFER INTERVENTION
SAFER is a novel, manualized, weekly, 90-minute, individual
joining + 3-session family-based treatment.
Session
#Focus Homework
Individual
Joining
• Introductions, assess Veteran and family
interaction around suicide, review individual
concerns, motivation.
• Clarify intervention goals, ensure commitment.
1
• Review of barriers to Safety Planning and family
involvement.
• Review Veteran Safety Plan.
Veterans and family
members construct a list of
“reasons for living.”
2
• Construction of family member’s safety plan.
Practice using communication skills to facilitate
use of Veteran and family member plans.
• Review Reasons for Living homework.
Try to implement safety
plan in your life.
Booster • Review of Safety Plan use for dyad.
• Address implementation problems.
ELIGIBILITY - VETERAN
Inclusion Criteria:
1. Moderate risk for suicide, defined as:
• evidence of current (within the past week) suicidal ideation, plan or intent on the
Columbia Suicide Severity Rating Scale (C-SSRS),
• Scoring < 4 on the C-SSRS Behavior Scale, and without history of suicide
attempt in the last three months.
2. Inclusion criteria also include the availability of a consenting, qualifying family member
or partner.
Exclusion criteria:
1. Alcohol or drug abuse or dependence.
2. For romantic couples, “severe” intimate-partner violence as defined by the revised 20-
item Conflict Tactics Scale Short Form (CTS2S) (Straus & Douglas, 2004);
3. Limited English proficiency.
ELIGIBILITY- VETERAN
Inclusion Criteria:
Family members/friends must meet at least three (two for nonrelatives) of five criteria
established by (Pollak & Perlick, 1991):
1. Spouse, co-habiting significant other or parent;
2. More frequent contact than any other caregiver
3. Helps to support the Veteran
4. Contacted by treatment staff for emergencies;
5. Involvement in the patient’s treatment.
Exclusion criteria:
1. Alcohol or drug abuse or dependence
2. For romantic couples, “severe” intimate-partner violence as defined by the revised 20-item
Conflict Tactics Scale Short Form (CTS2S) (Straus & Douglas, 2004);
3. Limited English proficiency.
ELIGIBILITY- CAREGIVER
PARTICIPANTS
0
5
10
15
20
25
30
35
40
Consented Baselines Randomized Post Post-3
Veterans Caregivers
PARTICIPANTS
Veteran Race
White
Black
Native American
Other/Unknown
Multi-Racial
Native Hawaiian
Veteran Age Range: 35-84
Veteran Gender: 3 Females, 30 Males
Veteran Hispanic: 13/33
Caregiver Age Range: 24-66
Caregiver Gender: 11 Females, 9 Males
Caregiver Hispanic: 8/20
Caregiver Race
White
Black
Other/Unknown
Multi-Racial
Native Hawaiian
QUALITATIVE FEEDBACK
“Having
someone to
reach out with
such as Dr. XX.”
“We need more
doctors, like Dr. XX,
that listen instead of
constantly
speaking.”
“SAFER helped me
keep my SSP
constantly in my head
and helped me go to
my safety zones.”
“Knowing that
we are not
alone.”
“To have a
plan that is
useful.”“I liked best finding
different ways to
help my husband.”
“Reaching out to
others that are going
through what my
husband is going
through is helpful.”
VETERANS
CAREGIVERS
Caregivers are VERY burdened and the SAFER intervention
may be further burdening them.
• Length of SAFER intervention?
Veterans often do not have many people in their live.
Veterans who do have people in their lives often do not
want to participate.
• Is there a way to better engage caregivers?
Veterans are reluctant to ask for help, and hesitant to admit
vulnerability to family.
INTERIM LESSONS LEARNED
Using TELEHEALTH to
Improve Outcomes In
Veterans at Risk for
Suicide
Gretchen Haas, Ph.D.
VA Pittsburgh Health Care System
Marianne Goodman, M.D.
James J. Peters VA Medical
Center, Bronx, NY
Adam Wolkin, M.D.
VA New York Harbor Health Care System
Funded by: Linked Standard Research Grant
American Foundation for Suicide Prevention (AFSP)
TECHNOLOGY AND SUICIDE PREVENTION
Telehealth technology has become more interactive,
less money and, more available to healthcare
providers as a means of treating chronic medical
diseases.• Approximately 50% of >3.4 billion smartphone/tablet
users have downloaded mHealth apps as of 2018.
• Surveys from psychiatric out-patients reported that 69%
of people, and 80% of those ages <45, have a desire to
use mobile apps to track mental health.
• However, there is a lack of comprehensive evidence-
base for mobile apps.
• There is a complete lack of outcome data on the
efficacy of mHealth interventions for suicidal
behavior.
TECHNOLOGY AND SUICIDE PREVENTION
Crisis Text Line
Caring contacts via text message/emails
Automatic detection of suicidality from social media content (FB & Twitter)
Mobile Applications
Daily interactive monitoring systems
Examples:
PILOT DATA
Three separate randomized pilot trials (n = 117 Veterans) were conducted.
Diagnoses of Veterans included Major Depressive Disorder or Schizophrenia/Schizoaffective Disorders.
No completed suicides and only 1 suicide attempt.
Demonstrated that the Telehealth intervention leads to decreased suicidal ideation within three months.
Preliminary data from these veteran cohorts demonstrated high acceptability rates.
Initial device used in pilot
studies
INTERACTIVE VOICE RESPONSE SYSTEM (IVR)
Length of callsis 5-8
minutes
Daily Calls
Responses automatically
upload to online portal
Nurses monitor
responses every 4 hours
Voice & keypad
responses
2 scripts for participants:
Depression & Schizoprehnia
Have you been
acting in a way
that disregards
your safety?
TELEHEALTH IVR SYSTEM
TELEHEALTH IVR SYSTEM
Five Suicide Questions:
1. Have you been acting in a way that disregards your safety?
2. Have you felt today that life is not worth living?
3. Have you thought today that you would be better off dead?
4. Have you had thoughts today of wanting to harm yourself even if
you have not intended to do it?
5. Do you have any intent to take your own life today or have you
been thinking about a plan to do it?
Nursing staff contacts site PI: Dr. Goodman
TELEHEALTH STUDY GOALS
Test the effectiveness of telehealth
interventions on suicidal ideation
and suicidal behaviors
(exploratory).
Test if the telehealth system
decrease risk factors and increase
protective factors.
Sustain connections with
healthcare providers during the
three months following
hospital discharge.
Allows for a longitudinal view
of suicidal risk information.
TELEHEALTH PROTOCOL SUMMARY
Daily telehealth monitoring
includes questions for participants
about suicide, depressive
symptoms and medication
adherence.
Participants will be randomized into
either: Interactive Voice Response
System (IVR) or Treatment As Usual
(TAU).
3 month intervention will have
clinical assessments at 2, 4, 8,
and 12 weeks post-discharge.
Recruitment:
In-patient unit
40 participants per site.
POTENTIAL BENEFITS
• The daily check-in provides: • participants with hope & a sense of being
listened to
• reminders to focus on their mental health, which
may improve medication adherence
• consistency & a sense that one is
not alone
• a friendly voice
• a way to catch symptoms before they are too
severe
POTENTIAL OBSTACLES
• Participants don’t answer their
phone, don’t have minutes on their
phone or charge their phone
• Participants don’t like the IVR voice or
scripts and inability to engage in
conversation
• Participants turn off their phone
when depressed
• IVR System feels too mechanical,
too repetitive and inflexible
Sarah R. Sullivan, M.S., MHC-LPClinical Research Coordinator
718-584-9000 x5149
Sarah.Suillivan@va.gov
Marianne Goodman, M.D.
James J. Peters Veterans Affairs Medical Center
Associate Director, VISN 2 Mental Illness, Research, Education, Clinical
Center (MIRECC)
Director, Suicide Prevention and Treatment Research Program
Clinical Professor Psychiatry, Icahn School of Medicine
Past President, North American Society for the Study of Personality
Disorders (NASSPD)
718-584-9000 x5188
Marianne.Goodman@va.gov
K. Nidhi Kapil-Pair, Ph.D.
Clinical Psychologist, Postdoctoral Fellow
718-584-9000 x5231
Kalpana.Kapil-Pair@va.gov
Angela P. Spears, BS
Clinical Research Assistant
718-584-9000 x3021
Angela.Spears2@va.gov
Rachel E. Harris, MA
Clinical Research Coordinator
718-584-9000 x3718
Rachel.Harris6@va.gov
Presenter Contact
Information
THANK YOU!!