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

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

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

3. Study Background/Rationale Active duty hospitalizations for suicidal ideation, 2005-20101 1. Medical Surveillance Monthly Report, Vol. 18 (4), April 2011.

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

5. Study Background/Rationale • Suicidal individuals experience cognitive rigidity & failed problem solving • Overestimate likelihood of negative/undesirable outcomes2 • Anticipate fewer positive events will occur in future3 • Impaired ability to consider reasons for why undesirable events will not occur • Suicidal & nonsuicidalindiv. 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).

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

7. Study Background/Rationale • Most suicidal individuals experience both desire for life and desire for death simultaneously • Reasons for living associated with lower suicidal intent and perception of suicide as 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)

8. Research Question(s)/Hypotheses • 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). • 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. • Greater ambivalence about suicide and faster recall of reasons for living will mediate the relationship between intervention and reduced risk for suicide attempt during follow-up.

9. Design and Methodology

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

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

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

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

14. Planned Analyses • 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 • Speed of RFL recall • Mixed effects regression with repeated measures and pairwise comparisons • Mediation of RFL recall speed • Sobel test and test of indirect effects using bootstrapping method • Fundamental voice frequency analysis • Cross-lagged actor-partner interdependence models (APIMs)

15. Questions? Craig J. Bryan, PsyD, ABPP craig.bryan@utah.edu