national center for veterans studies brief interventions for short-term suicide risk reduction in...

NATIONAL CENTER FOR VETERANS STUDIES

Brief interventions for short-term suicide risk reduction in

military populations

Craig J. Bryan, PsyD, ABPPNational Center for Veterans Studies

The University of Utah


Research Team

NCVS / University of UtahCraig Bryan, PsyD, ABPP (PI)

M. David Rudd, PhD, ABPP (Co-I)

Tracy Clemans, PsyD (Fellow)

AnnaBelle Bryan, BSPH (Res. Mgr)

Sharon Stone, LCSW (Therapist)

Kim Arne, LMSW (Therapist)

Sean Williams, LMSW (Evaluator)

Jennifer Amicone, MSW (Therapist)

Erica Armstrong (RA)

UTHSCSAJim Mintz, PhD (Co-I, Stats)

Ray Aguilar (Database)

Paul Gruenwald (Database)

Deanne Hargita (Regulatory)

Fort CarsonTravis Bruce, MD (Site PI)

MAJ Trent Elliott, PsyD (Collab)


Study Background/Rationale

Active duty hospitalizations for suicidal ideation, 2005-20101

1. Medical Surveillance Monthly Report, Vol. 18 (4), April 2011.


Study Background/Rationale• Results of RCT of 12-session BCBT vs. TAU for suicide

attempts among military personnel:– Suicide attempts reduced by 50% in BCBT– Significant reductions in PTSD symptoms in BCBT– No differences in depression, anxiety, suicidal ideation

• Crisis response planning and reasons for living anecdotally observed to be important interventions



• Suicidal individuals experience cognitive rigidity & failed problem solving– Overestimate likelihood of negative/undesirable outcomes2

– Anticipate fewer positive events will occur in future3

• Impaired ability to consider reasons for why undesirable events will not occur– Suicidal & nonsuicidal indiv. can list equal no. of reasons2

– Suicidal individuals take longer to generate the first reason2

– When reasons are listed, hopelessness drops4

2. MacLeod. (1994)3. MacLeod et al. (1993)4. Schotte & Clum. (1982).



• Crisis Response Plan (CRP)– Problem solving tool that outlines crisis management steps– Collaboratively developed by clinician and patient– Now widely used in military mental health settings, especially

triage

• Potential problems with CRPs in triage:– Not originally designed as a single-session intervention– Fidelity of intervention is low– Does not explicitly target suicidal intent or desire


Study Background/Rationale• Most suicidal individuals experience both desire for life

and desire for death simultaneously– Reasons for living associated with lower suicidal intent and

perception of suicide as solution5

– Reasons for living associated with suicidal ambivalence– Suicidal ambivalence is associated with death by suicide6

• Enhancing suicidal patients’ reasons for living can reduce risk for suicidal behaviors– Suicidal patients can list reasons for living, but take a long time

to generate the first item

5. Kovacs & Beck (1977)6. Brown et al. (2005)


Research Question(s)/Hypotheses1. The crisis response plan with reasons for living (CRP+RFL)

intervention will contribute to significantly decreased risk for suicide attempts and hospitalization during follow-up relative to the crisis response plan alone (CRP) and treatment as usual (TAU).

2. The CRP+RFL intervention will contribute to greater ambivalence about suicide and faster recall of reasons for living relative to the CRP and TAU interventions.

3. Greater ambivalence about suicide and faster recall of reasons for living will mediate the relationship between intervention and reduced risk for suicide attempt during follow-up.


Design and MethodologyTreatment As Usual

(TAU)Crisis Response Plan

(CRP)Crisis Response Plan +

Reasons for Living(CRP+RFL)

Suicide risk assessment Suicide risk assessment Suicide risk assessment

Supportive listening Supportive listening Supportive listening

Identify warning signs Identify warning signs

Identify self-mgt skills Identify self-mgt skills

Identify reasons for living

Identify social support Identify social support

Crisis mgt education Crisis mgt education Crisis mgt education

Referrals to treatment & community resources




Design and MethodologyPrimary outcome:Suicide attempt (SASII)

Suicidal ambivalence (BSSI Items 1 & 2)

Hospitalization

Secondary outcomes: Suicidal ideation (BSSI, DSI-SS)

Subjective suicidal intent (SBQ-R)

Proposed mediator:: Reasons for living (speed of identification)


Design and MethodologySubjects

360 active duty Soldiers recruited from Ft. Carson triage• Inclusion: 18+ y/o; active duty; speaks English; current suicidal

ideation and/or recent suicide attempt• Exclusion: inability to consent due to medical or psychiatric

condition (psychosis, mania, etc.)

Staff

2 therapists, 1 evaluator• Embed therapists into 5 mental health teams• Follow-up assessments completed by blind evaluator


BaselineAssessment

Randomize

CRP

Immediate

1 month

3 months

6 months

TAU

Immediate

1 month

3 months

6 months

CRP+RFL

Immediate

1 month

3 months

6 months

Ineligible / Exclude

Past suicide attemptsSuicidal ideationDepression / moodHopelessnessSuicidal beliefsHope / optimismMeaning in lifeReasons for livingSuicidal ambivalence

Suicide attemptsHospitalizationSuicidal ideationDepression / moodHopelessnessSuicidal beliefsHope / optimismMeaning in lifeReasons for livingSuicidal ambivalence

MoodReasons for LivingSuicidal ambivalence


Baseline Assessment(n = 103)

Randomized (n = 49)

CRP(n = 17)

TAU(n = 17)

CRP+RFL(n = 15)

54 Declined or Ineligible

26 Ineligible28 Declined


Planned Analyses

1. Between treatment differences– Suicide attempt, hospitalization: survival curve using log-rank and

Wilcoxon statistics– Ambivalence, suicidal ideation, suicide intent: mixed effects

regression with repeated measures

2. Speed of RFL recall – Mixed effects regression with repeated measures and pairwise

comparisons

3. Mediation of RFL recall speed– Sobel test and test of indirect effects using bootstrapping method

4. Fundamental voice frequency analysis– Cross-lagged actor-partner interdependence models (APIMs)


Questions?

Craig J. Bryan, PsyD, ABPP

[email protected]

mailto:[email protected]

mailto:[email protected]

national center for veterans studies brief interventions for short-term suicide risk reduction in...

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