Veteran Preferences for the Caring Contacts Suicide Prevention Intervention

Text2whaiora after a suicide attempt: Text message design alongside people with lived experience

BACKGROUND

People with lived experience have had limited opportunities to meaningfully contribute to the design of caring contacts interventions. The objective of this study was to co-design text messages with peer support specialist staff to determine optimal language and delivery, within a cultural context.

METHODS

In this qualitative study, participants were professional peer support specialist staff with lived experience employed by specialist mental health services. They were asked to evaluate the initial series of text messages by taking part in a focus group using a semi-structured interview. This was audiotaped, transcribed and analysed using reflexive thematic analysis with specific coding of cultural themes.

RESULTS

Three main themes were identified: upholding a person's autonomy; establishing connection as a bridge to safety; and, words as healing rongoā (remedy). The last theme contained a cultural subtheme: Māori language providing entry to the Māori world.

CONCLUSION

People with lived experience breathe empowerment and hope into caring contacts interventions and should be considered vital partners in developing any suicide prevention initiative. Feeling genuinely cared for promotes connection and may enable an internal sense of safety. Tailoring of texts can be enhanced by culturally nuanced language.

Baseline Sociodemographic Characteristics and Mental Health Status of Primary Caregivers and Children Attending Schools on the Navajo Nation During COVID-19

BACKGROUND

Despite historical and contemporary trauma, American Indian and Alaska Native (AIAN; Indigenous) communities responded with resilience to the COVID-19 pandemic. However, AIANs experienced disproportionate rates of infection, hospitalization, death, and reduced life expectancy. School closures exacerbated disparities, leading to learning loss, economic instability, and mental health challenges among AIAN youth.

METHODS

The Project SafeSchools cohort study employed a comprehensive longitudinal convergent mixed-methods approach, integrating community-based participatory research principles. The study enrolled Navajo Nation caregivers whose children were eligible to attend local reservation-based schools. We conducted an analysis of caregiver self-report baseline data collected between August 2021 and May 2022.

RESULTS

A total of 242 caregivers completed at least part of the baseline assessment and were included in data analysis. Caregivers were primarily female (88.7%), non-Hispanic (97%), and Indigenous (97%). Most caregivers were in their late 30s (mean age 38), with varying educational backgrounds and employment statuses. Children were evenly split between males and females and distributed across different age groups. Most children attended school at baseline in various formats, including in-person, hybrid, and online-only settings. Caregivers reported a range of psychosocial and behavioral risks, including general mental distress, depressive symptoms, and anxiety for themselves and their children. Furthermore, caregivers and children exhibited various protective factors, such as strong cultural identity, resilience, and academic self-efficacy.

CONCLUSIONS

This study highlights the higher rates of mental health distress among participating caregivers and children compared to national averages. Despite these challenges, cultural protective factors remained strong and should guide future crisis response efforts.

Evaluating the Prevalence of Four Recommended Practices for Suicide Prevention Following Hospital Discharge

BACKGROUND

The Joint Commission's National Patient Safety Goal (NPSG) for suicide prevention (NPSG.15.01.01) requires that accredited hospitals maintain policies/procedures for follow-up care at discharge for patients identified as at risk for suicide. The proportion of hospitals meeting these requirements through use of recommended discharge practices is unknown.

METHODS

This cross-sectional observational study explored the prevalence of suicide prevention activities among Joint Commission-accredited hospitals. A questionnaire was sent to 1,148 accredited hospitals. The authors calculated the percentage of hospitals reporting implementation of four recommended discharge practices for suicide prevention.

RESULTS

Of 1,148 hospitals, 346 (30.1%) responded. The majority (n = 212 [61.3%]) of hospitals had implemented formal safety planning, but few of those (n = 41 [19.3%]) included all key components of safety planning. Approximately a third of hospitals provided a warm handoff to outpatient care (n = 128 [37.0%)] or made follow-up contact with patients (n = 105 [30.3%]), and approximately a quarter (n = 97 [28.0%]) developed a plan for lethal means safety. Very few (n = 14 [4.0%]) hospitals met full criteria for implementing recommended suicide prevention activities at time of discharge.

CONCLUSION

The study revealed a significant gap in implementation of recommended practices related to prevention of suicide postdischarge. Additional research is needed to identify factors contributing to this implementation gap.

Withdrawal: Baseline Sociodemographic Characteristics and Mental Health Status of Primary Caregivers and Children Attending Schools on the Navajo Nation and White Mountain Apache Tribe During COVID-19

Withdrawal: 'Baseline Sociodemographic Characteristics and Mental Health Status of Primary Caregivers and Children Attending Schools on the Navajo Nation and White Mountain Apache Tribe During COVID-19' by Shannon Archuleta MPH, Joshuaa D. Allison-Burbank PhD, Allison Ingalls MPH, Renae Begay MPH, Ryan Grass BS, Francene Larzelere PhD, Vanessa Begaye BS, Lacey Howe BS, Alicia Tsosie BS, Angelina Phoebe Keryte BA, Emily E. Haroz PhD, J Sch Health 2024, 10.1111/josh.13419. The above article, published online on 15 January 2024 in Wiley Online Library (https://onlinelibrary.wiley.com/doi/full/10.1111/josh.13419) has been withdrawn by agreement between the authors, the journal's Editor in Chief, Michael W. Long, the American School Health Association and Wiley Periodicals LLC. The withdrawal has been agreed because consent for publication from one of the tribes participating in the study was pending at the time of publication.

Lessons Learned From Implementing a Caring Contacts Clinical Practice Guideline Recommendation

The U.S. Department of Veterans Affairs (VA) and Department of Defense clinical practice guideline on the treatment of veterans at risk for suicide recommends considering caring contacts interventions after a psychiatric hospitalization for suicidal ideation or suicide attempt. This quality improvement project examined the implementation of the recommendation at a large VA health care system. The project enrolled 29% of hospitalized veterans (N=135 of 462). Enrollment barriers included lack of staff availability and veteran ineligibility due to homelessness or housing instability. Opportunities to improve the reach of the intervention in future quality improvement processes are discussed, especially because acceptability of the intervention was high among veterans.

Qualitative Evaluation of a Caring Letters Suicide Prevention Intervention for the Veterans Crisis Line

OBJECTIVE

Suicide is a leading cause of death in the United States. This has prompted the U.S. surgeon general to issue a report describing actionable items to reduce suicide rates, including a recommendation to increase the use of the caring letters intervention. This intervention involves mailing brief, nondemanding messages of care. As part of the Department of Veterans Affairs' (VA's) efforts to reduce suicide rates among veterans, a caring letters project was developed for veterans who contact the Veterans Crisis Line (VCL). This article describes the results of qualitative interviews conducted to better understand the experiences of veterans who received caring letters.

METHODS

Beginning in 2020, all identifiable veterans who used Veterans Health Administration services and contacted the VCL received nine letters over 1 year, along with a list of mental health resources. Semistructured interviews (N=23) were conducted, and content analysis was used to identify veterans' perspectives and suggestions for improving the intervention.

RESULTS

Sixteen men and seven women participated (mean age=53 years). Feedback varied, with most participants reporting that receiving caring letters had a positive impact and others noting aspects that could be improved to enhance the intervention's caring intent. Some also reported that the letters helped them engage with community resources and made them more likely to seek VA care.

CONCLUSIONS

The caring letters intervention, received after contact with the VCL, was well received by participants. They described feeling appreciated, cared for, encouraged, and connected. The results of this study will inform future evaluation examining veteran outcomes.

Encouraging the use of the Veterans Crisis Line among high-risk Veterans: A randomized trial of a Crisis Line Facilitation intervention

The Veterans Crisis Line (VCL) is a core component of VA's suicide prevention strategy. Despite the availability and utility of the VCL, many Veterans do not utilize this resource during times of crisis. A brief, psychoeducational behavioral intervention (termed Crisis Line Facilitation [CLF]) was developed to increase utilization of the VCL and reduce suicidal behaviors in high-risk Veterans. The therapist-led session includes educational information regarding the VCL, as well as a chance to discuss the participant's perceptions of contacting the VCL during periods of crisis. The final component of the session is a practice call placed to the VCL by both the therapist and the participant. The CLF intervention was compared to Enhanced Usual Care (EUC) during a multi-site randomized clinical trial for 307 Veteran participants recently hospitalized for a suicidal crisis who reported no contact with the VCL in the prior 12 months. Initial analyses indicated that participants randomized to the CLF intervention were less likely to report suicidal behaviors, including suicide attempts compared to participants randomized to receive EUC over 12-months of follow-up (χ² = 18.48/p < 0.0001), however this effect was not sustained when analyses were conducted on an individual level. No significant differences were found between conditions on VCL utilization. Initial evidence suggests a brief CLF intervention has an impact on preventing suicidal behaviors in Veterans treated in inpatient mental health programs; however, it may not change use of the VCL. This brief intervention could be easily adapted into clinical settings to be delivered by standard clinical staff.

Leveraging behavioral economics and implementation science to engage patients at risk for suicide in mental health treatment: a pilot study protocol

BACKGROUND

Primary care is an ideal setting to connect individuals at risk for suicide to follow-up care; however, only half of the patients referred from the primary care attend an initial mental health visit. We aim to develop acceptable, feasible, low-cost, and effective new strategies to increase treatment initiation among at-risk individuals identified in primary care.

METHODS

We will conduct a multi-phase, mixed-methods study. First, we will conduct a chart review study by using administrative data, including medical records, to identify characteristics of primary care patients at risk for suicide who do or do not attend an initial mental health visit following a referral. Second, we will conduct a mixed methods study by using direct observations and qualitative interviews with key stakeholders (N = 65) to understand barriers and facilitators to mental health service initiation among at-risk individuals. Stakeholders will include patients with suicidal ideation referred from primary care who do and do not attend a first mental health visit, primary care and behavioral health providers, and individuals involved in the referral process. We also will collect preliminary self-report and behavioral data regarding potential mechanisms of behavior change (i.e., self-regulation and social support) from patients. Third, we will leverage these findings, relevant frameworks, and the extant literature to conduct a multi-arm, non-randomized feasibility trial. During this trial, we will rapidly prototype and test strategies to support attendance at initial mental health visits. Strategies will be developed with subject matter experts (N = 10) and iteratively pilot tested (~5 patients per strategy) and refined. Research will be completed in the Penn Integrated Care Program (PIC), which includes fourteen primary care clinics in Philadelphia that provide infrastructure for electronic referrals, patient communication, and data access.

DISCUSSION

We will leverage frameworks and methods from behavioral economics and implementation science to develop strategies to increase mental health treatment initiation among individuals at risk for suicide identified in primary care. This project will lead to an evaluation of these strategies in a fully powered randomized trial and contribute to improvements in access to and engagement in mental health services for individuals at risk for suicide.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05021224.

Substance use-related suicide after release from correctional, behavioral health, and healthcare facilities using national violent death reporting system data

INTRODUCTION

Suicide and substance use are prevalent problems among persons discharged from facilities. This study (1) articulated rates of substance-related suicide deaths among those discharged correctional, behavioral health, and healthcare facilities, and (2) identified factors associated with substance-related suicide deaths unique to, or generalizing across, facility discharge.

METHODS

We used data from the National Violent Death Reporting System. Suicide deaths (N = 105,968) were aggregated from 2003 to 2017. Chi-square and independent samples t-tests were used to examine associations between drug/alcohol-related deaths and each correlate. Logistic regression was employed to identify the most robust substance-related suicide death-related factors.

RESULTS

Suicide deaths were commonly marked as being substance-related: 69% from correctional institutions, 54% from behavioral health facilities, 45% from those not released from a facility, and 39% from healthcare facilities. Regression models indicated housing interruptions and interpersonal stressors increased odds of the suicide death being marked as substance-related across discharge categories. Each discharge category also had unique predictors, underscoring the need for tailored prevention.

CONCLUSIONS

Substance-related suicide deaths are particularly common among adults discharged from correctional and behavioral health facilities. Findings are discussed with respect to community-focused, discharge planning, and clinical care suicide prevention strategies.

Adapting Caring Contacts for Veterans in a Department of Veterans Affairs Emergency Department: Results From a Type 2 Hybrid Effectiveness-Implementation Pilot Study

Transitions in care, such as discharge from an emergency department (ED), are periods of increased risk for suicide and effective interventions that target these periods are needed. Caring Contacts is an evidence-based suicide prevention intervention that targets transitions, yet it has not been widely implemented. This pilot study adapted Caring Contacts for a Department of Veterans Affairs (VA) ED setting and population, created an implementation toolkit, and piloted implementation and evaluation of effectiveness. To inform adaptation, qualitative interviews were conducted with stakeholders. Data were used by an advisory board comprised of stakeholders, experts, and veterans to make adaptations and develop an implementation planning guide to delineate steps needed to implement. Key decisions about how to adapt Caring Contacts included recipients, author, content, and the schedule for sending. Pilot implementation occurred at one VA ED. Caring Contacts involved sending patients at risk of suicide brief, non-demanding expressions of care. Program evaluation of the pilot used a type 2 hybrid effectiveness-implementation design to both pilot an implementation strategy and evaluate effectiveness of Caring Contacts. Evaluation included qualitative interviews with veteran patients during implementation. VA electronic health records were used to evaluate VA service utilization in the 6-month periods immediately before and after veterans were delivered their first Caring Contact. Hundred and seventy-five veterans were mailed Caring Contacts and the facility continued adoption after the pilot. Participants were positive about the intervention and reported feeling cared about and connected to VA as a result of receiving Caring Contacts. This project developed an implementation planning process that successfully implemented Caring Contacts at one site. This can be used to further implement Caring Contacts at additional VA or community EDs.

Differential Preferences for the Caring Contacts Suicide Prevention Intervention Based on Patient Characteristics

The Caring Contacts suicide prevention intervention has been promoted by the Joint Commission, given its effectiveness, high reach, and cost effectiveness. Despite its increased application, no study has examined whether patient characteristics influence perceptions of the intervention, which may inform implementation efforts and ultimately impact effectiveness. One hundred fifty-four veterans were recruited from a Veterans Affairs psychiatric inpatient unit. Participants completed a survey to provide feedback on preferences, including the message correspondent, format (e.g., postcard, email), the importance of handwriting (vs. typed), visual presentation, and schedule for mailings. Results demonstrated that Caring Contacts preferences did not differ by most variables, including military rank, combat deployment history, or most personal technology use characteristics. Some demographic differences were identified, especially by age. More older veterans preferred messages to be sent in a physical letter compared to younger veterans, but if messages were sent via postal mail, younger veterans had a stronger preference for messages to be handwritten and sent using real stamps and colorful envelopes. Overall, findings suggest that few Caring Contacts adaptations are needed based on patient characteristics. Programs targeting older cohorts should consider postal mail formats for Caring Contacts.

Adapting and implementing Caring Contacts in a Department of Veterans Affairs emergency department: a pilot study protocol

Background

Suicide among veterans is a problem nationally, and suicide prevention remains a high priority for the Department of Veterans Affairs (VA). Focusing suicide prevention initiatives in the emergency department setting provides reach to veterans who may not be seen in mental health and targets a critical risk period, transitions in care following discharge. Caring Contacts is a simple and efficacious suicide prevention approach that could be used to target this risk period. The purpose of this study is to (1) adapt Caring Contacts for use in a VA emergency department, (2) conduct a pilot program at a single VA emergency department, and (3) create an implementation toolkit to facilitate spread of Caring Contacts to other VA facilities.

Methods

This project includes planning activities and a pilot at a VA emergency department. Planning activities will include determining available data sources, determining logistics for identifying and sending Caring Contacts, and creating an implementation toolkit. We will conduct qualitative interviews with emergency department staff and other key stakeholders to gather data on what is needed to adapt and implement Caring Contacts in a VA emergency department setting and possible barriers to and facilitators of implementation. An advisory board of key stakeholders in the facility will be created. Qualitative findings from interviews will be presented to the advisory board for discussion, and the board will use these data to inform decision making regarding implementation of the pilot. Once the pilot is underway, the advisory board will convene again to discuss ongoing progress and determine if any changes are needed to the implementation of the Caring Contacts intervention.

Discussion

Findings from the current project will inform future scale-up and spread of this innovation to other VA medical center emergency departments across the network and other networks. The current pilot will adapt Caring Contacts, create an implementation toolkit and implementation guide, evaluate the feasibility of gathering outcome measures, and provide information about what is needed to implement this evidence-based suicide prevention intervention in a VA emergency department.