Facilitating treatment engagement during high-risk transition periods: a potential suicide prevention strategy

Associations of active-duty mental health trajectories with post-military adjustment: Results from the STARRS Longitudinal Study

BACKGROUND

Many servicemembers experience difficulties transitioning from military to civilian life. We examined whether changes in mental health observed during active duty were associated with indices of post-military adjustment.

METHODS

Survey data from the multi-wave Army STARRS Pre/Post Deployment Study (PPDS; conducted 2012-2014) were linked to follow-up data from wave 1 of the STARRS Longitudinal Study (STARRS-LS1; conducted 2016-2018). Empirical Bayes estimates of intercepts and slopes of posttraumatic stress, problematic anger, and depressive symptoms during the PPDS were extracted from mixed-effects growth models and evaluated as predictors of life stress among 1080 participants who had separated or retired from the Army at STARRS-LS1; and of job satisfaction among 586 veterans who were employed at STARRS-LS1.

RESULTS

Higher average levels and larger increases in posttraumatic stress, anger, and depression over the deployment period were each associated with increased stress and (in the case of anger and depression) reduced job satisfaction. Posttraumatic stress and anger slopes were associated with overall stress (b = 5.60, p < 0.01 and b = 15.64, p = 0.04, respectively) and relationship stress (b = 5.50, p = 0.01 and b = 22.86, p = 0.01, respectively) beyond the average levels of those symptoms.

LIMITATIONS

Some transition-related difficulties may have resolved before outcome assessment; some measures were not previously validated.

CONCLUSIONS

Larger increases in posttraumatic stress and anger over a deployment period were associated with increased stress after leaving the Army, even after controlling for average symptom levels during the same period. Monitoring changes in mental health during active duty may help identify personnel who need additional support to facilitate the military-to-civilian transition.

Health, Suicidal Thoughts, and the Life Course: How Worsening Health Emerges as a Determinant of Suicide Ideation in Early Adulthood

Poor physical health places adults at greater risk for suicide ideation. However, the linkage between health and suicidal thoughts may emerge and become established during early adulthood, concomitant with other social processes underlying suicidality. Using nationally representative survey data from Waves III through V of the National Longitudinal Study of Adolescent to Adult Health (n = 8,331), we examine the emergence of health as a predictor of suicide ideation across the early adult life course (ages 18-43). We find that worsening health does not significantly predict suicide ideation until young adults approach the transition into midlife. Our findings suggest this may be due to the increasing severity of health problems, reduced social network engagement, and disruption of social responsibilities later in early adulthood. Our findings underscore the need for social science research to examine the relationship between mental and physical health from a life course perspective.

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.

The First Year After Military Service: Predictors of U.S. Veterans' Suicidal Ideation

INTRODUCTION

Little is known about predictors of military veterans' suicidal ideation as they transition from service to civilian life, a potentially high-risk period that represents a critical time for intervention. This study examined factors associated with veterans' suicidal ideation in the first year after military separation.

METHODS

A national sample of U.S. veterans (N=7,383) from The Veterans Metrics Initiative Study reported on their mental health, psychosocial well-being, and demographic/military characteristics in an online survey at 3 and 9 months after separation. Cross-validated random forest models and mean decrease in accuracy values were used to identify key predictors of suicidal ideation. Bivariate ORs were calculated to examine the magnitude and direction of main effects associations between predictors and suicidal ideation. Data were collected in 2016/2017 and analyzed in 2021.

RESULTS

In the first year after separation, 15.1% of veterans reported suicidal ideation. Endorsing depression symptoms and, to a lesser extent, identifying oneself as experiencing depression, were most predictive of suicidal ideation. Other psychopathology predictors included higher anxiety and posttraumatic stress disorder symptoms. Psychosocial well-being predictors included higher health satisfaction and functioning, community satisfaction and functioning, and psychological resilience. Logistic models performed similarly to random forest models, suggesting that relationships between predictors and suicidal ideation were better represented as main effects than interactions.

CONCLUSIONS

Results highlight the potential value of bolstering key aspects of military veterans' mental health and psychosocial well-being to reduce their risk for suicidal ideation in the first year after separation. Findings can inform interventions aimed at helping veterans acclimate to civilian life.

Trajectories of suicidal ideation following separation from military service: Overall trends and group differences

BACKGROUND

Although the transition out of military service is a high-risk time for suicidal ideation (SI), a paucity of research examines the development of SI during this transition process and veteran subgroups at risk for SI as they readjust to civilian life.

METHODS

A population-based, longitudinal post-9/11 veteran cohort reported SI frequency at 3, 9, 15, 21, and 27 months post-separation using the Patient Health Questionnaire-9. We identified distinct trajectories of SI over time (i.e., classes) using latent class growth analysis and examined demographic and military service predictors of class membership overall and by gender using multinomial logistic regression.

RESULTS

Four SI trajectories that were similar across genders were identified: resilient (90.1%), delayed onset (5.0%), remitting (2.7%), and chronic (2.2%). Younger age, minority race/ethnicity, medical and other (vs. honorable) separation types, and Veterans Health Administration service utilization were associated with increased odds of assignment to a higher-risk trajectory (delayed onset, remitting, and/or chronic vs. resilient), whereas continued service in the National Guard/Reserves and officer rank was associated with lower odds of assignment to a higher-risk trajectory.

CONCLUSIONS

Findings regarding veterans at greatest risk for SI following military separation can inform targeted assessment and early intervention efforts.

A virtual, pilot randomized trial of a brief intervention to prevent suicide in an integrated healthcare setting

OBJECTIVE

Patients who die by suicide are often seen in primary care settings in the weeks leading to their death. There has been little study of brief interventions to prevent suicide in these settings.

METHOD

We conducted a virtual, pilot, randomized controlled trial of a brief suicide prevention strategy called Veterans Affairs Brief Intervention and Contact Program (VA BIC) in patients who presented to a primary care mental health walk-in clinic for a new mental health intake appointment and were at risk for suicide. Our primary aim was to assess feasibility. We measured our ability to recruit 20 patients. We measured the proportion of enrolled patients who completed all study assessments. We assessed adherence among patients assigned to VA BIC.

RESULTS

Twenty patients were enrolled and 95% (N = 19) completed all study assessments. Among the 10 patients assigned to VA BIC, 90% (N = 9) of patients completed all required intervention visits, and 100% (N = 10) completed ≥70% of the required interventions visits.

CONCLUSION

It is feasible to conduct a virtual trial of VA BIC in an integrated care setting. Future research should clarify the role of VA BIC as a suicide prevention strategy in integrated care settings using an adequately powered design.

CLINICAL TRIAL REGISTRATION

NCT04054947.

A Pilot Randomized Trial of a Brief Intervention to Prevent Suicide After Inpatient Psychiatric Discharge

OBJECTIVE

Risk for suicide is high after psychiatric hospitalization. The World Health Organization's Brief Intervention and Contact (BIC) program has shown efficacy in preventing suicide. A version adapted for the U.S. Department of Veterans Affairs (VA) was studied to determine preliminary effects.

METHODS

Patients receiving psychiatric hospitalization because of acute risk for self-harm were randomly assigned to the VA BIC or standard care alone. Effect sizes (Hedges' g) for suicidal ideation (primary outcome), social connectedness (measured as thwarted belongingness and perceived burdensomeness), hopelessness, and engagement were calculated at 1 and 3 months.

RESULTS

Patients were randomly assigned to the VA BIC (N=10) or standard care (N=9). The VA BIC had a medium or large effect on most measures at 1 month (suicidal ideation, g=0.45). Effects diminished at 3 months, except for thwarted belongingness (g=0.81).

CONCLUSIONS

The VA BIC had meaningful effects on suicide-related outcomes. The largest effect was seen in the first month.

Cost-effectiveness of a Contact Intervention and a Psychotherapeutic Program for Post-discharge Suicide Prevention

OBJECTIVE

To determine the cost-effectiveness of 2 strategies for post-discharge suicide prevention, an Enhanced Contact intervention based on repeated in-person and telephone contacts, and an individual 2-month long problem-solving Psychotherapy program, in comparison to facilitated access to outpatient care following a suicide attempt.

METHODS

We conducted a cost-effectiveness analysis based on a decision tree between January and December 2019. Comparative effectiveness estimates were obtained from an observational study conducted between 2013 and 2017 in Madrid, Spain. Electronic health care records documented resource use (including extra-hospital emergency care, mortality, inpatient admission, and disability leave). Direct cost data were derived from Madrid's official list of public health care prices. Indirect cost data were derived from Spain's National Institute of Statistics.

RESULTS

Both augmentation strategies were more cost-effective than a single priority outpatient appointment considering reasonable thresholds of willingness to pay. Under the base-case scenario, Enhanced Contact and Psychotherapy incurred, respectively, €2,340 and 6,260 per averted attempt, compared to a single priority appointment. Deterministic and probabilistic sensitivity analyses showed both augmentation strategies to remain cost-effective under several scenarios. Enhanced Contact was slightly cost minimizing in comparison to Psychotherapy (base-case scenario: €-196 per averted attempt).

CONCLUSIONS

Two post-discharge suicide prevention strategies based on Enhanced Contact and Psychotherapy were cost-effective in comparison to a single priority appointment. Increasing contacts between suicide attempters and mental health-care providers was slightly cost minimizing compared to psychotherapy.

Associations between veteran encounters with suicide prevention team and suicide-related outcomes

OBJECTIVE

Suicide rates have been of increasing concern across the United States, particularly among military veterans. The Veterans Health Administration has initiated multiple suicide prevention initiatives, but little research has examined the impact of these programs. The purpose of this study was to test the hypothesis that more frequent contact with suicide prevention clinicians would predict lower odds of suicidal behavior.

METHOD

Retrospective medical record review was performed for 1364 veterans identified as high risk for suicide during 2012-2018. Logistic regression was used to test whether the number of suicide prevention contacts predicted the odds of suicide attempt, any self-directed violence, or reactivation of high-risk status in the next year, accounting for age, sex, length of high-risk episode, and other mental health contacts.

RESULTS

Each additional suicide prevention coordinator contact was associated with 4%-5% lower odds of suicide attempt, suicidal behavior, and reactivation of high-risk status in the next year (ps < 0.05). For suicide attempt and self-directed violence, associations were stronger when considering only initial high-risk episodes (8%-10% lower odds, ps < 0.05).

CONCLUSIONS

Findings suggest ongoing support from suicide prevention clinicians can have a significant protective effect. Additional research is needed to identify mechanisms by which this support reduces risk.

A Qualitative Investigation of Barriers to Seeking Treatment for Suicidal Thoughts and Behaviors Among Army Soldiers with a Deployment History

This study aimed to identify barriers to treatment seeking and service utilization among previously deployed Army soldiers who recently experienced a suicidal crisis. Confidential interviews were conducted on a psychiatric inpatient unit with 12 Army soldiers with a deployment history following a suicidal crisis. Qualitative analysis focused on statements coded as "barriers to seeking help" and "explicit recommendations." Suicidal Army soldiers with a deployment history experienced different barriers to seeking help, including stigma and logistical challenges (e.g., long wait times for appointments). Negative and positive perceptions of support were reported for various resources - for example, family, crisis hotlines, chaplains, and command. Suicidal Army soldiers, interviewed in this study, experienced a number of challenges and frustrations associated with various helping resources. This study highlights the need for greater attention toward understanding these challenges and subsequently addressing them through appropriate resource allocation and additional training for those working directly with Army soldiers at risk for suicide.

Fatal and Non-fatal Self-Injury in the USA: Critical Review of Current Trends and Innovations in Prevention

PURPOSE OF REVIEW

To examine current trends in suicide and self-injury in the USA, as well as potential contributors to their change over time, and to reflect on innovations in prevention and intervention that can guide policies and programs to reduce the burden of suicide and self-injury in the USA.

RECENT FINDINGS

Suicide and non-fatal self-injury are on the rise in the USA. Reasons for such trends over time remain speculative, although they seem linked to coincident increases in mood disorders and drug use and overdose. Promising innovative prevention and intervention programs that engage new technologies, such as machine learning-derived prediction tools and computerized ecologic momentary assessments, are currently in development and require additional evidence. Recent increases in fatal and non-fatal self-harm in the USA raise questions about the causes, interventions, and preventive measures that should be taken. Most innovative prevention efforts target individuals seeking to improve risk prediction and access to evidence-based care. However, as Durkheim pointed out over 100 years ago, suicide rates vary enormously between societal groups, suggesting that certain causal factors of suicide act and, hence, should be targeted at an ecological level. In the next generation of suicide research, it is critical to examine factors beyond the proximal and clinical to allow for a reimagining of prevention that is life course and socially focused.

Relations Between Thwarted Belongingness, Perceived Burdensomeness, and History of Suicide Attempts and Readiness for Mental Health Treatment in High-Risk Veterans, Reserves, and Active Duty Service Members

Suicide rates for service members and veterans are growing rapidly in the United States. Despite availability of evidence-based approaches, a large number of high-risk individuals are reluctant to seek out treatment. The present study used the interpersonal theory of suicide, involving 3 primary predictors of death by suicide to investigate treatment readiness in high-risk U. S. veterans, reserves, and active duty service members. Four hundred and two service members were recruited. Inclusion criteria involved (a) reporting active suicidal ideation and (b) denying active behavioral health treatment. All participants completed a self-report battery that assessed burdensomeness, thwarted belongingness, lifetime suicide attempts, and perceptions about treatment. Regression analyses revealed that thwarted belongingness was significantly predictive of treatment perceptions and readiness, in that higher or more severe scores on the thwarted belongingness scale were significantly related to lower or less likely treatment perceptions and readiness scores. The findings suggested that, in high-risk service members, thwarted belongingness is predictive of lower treatment readiness, and contributes to the growing literature on perceived stigmas, treatment barriers and readiness, and suicidal behaviors and risk factors.

Connecting Veterans at Risk for Suicide to Care Through the HOME Program

The Home-Based Mental Health Evaluation (HOME) program, which engages veterans in care following psychiatric hospitalization, was evaluated. Thirty-four veterans who participated in the HOME program were compared to 34 veterans from a matched archival control group on treatment engagement and implementation outcomes. Veterans who participated in the HOME program were significantly more likely to engage in care, engaged in care more quickly, and attended significantly more individual mental health appointments. Veterans reported high levels of satisfaction. Results suggest that the HOME program is effective at engaging veterans in care during the high-risk period of time following psychiatric hospitalization.

Assessing civilian perceptions of combat veterans: An IAT study

OBJECTIVE

Evidence suggests that civilians may have considerable ambivalence to returning veterans. While civilians are frequently grateful for the service of military personnel, they can often be wary of the mental health and stability of returning veterans. If civilians do hold such negative biases toward veterans, whether implicit or explicit, this may have a significant impact on the ability of military personnel to integrate back into society. The goal of the study was to test whether participants held an implicit bias of mental instability toward veterans.

METHOD

In this study, 48 participants took an adapted version of the Implicit Association Test (IAT; Greenwald, McGhee, & Schwartz, 1998). Pictures of veterans and civilians were paired with words that either reflected mental stability (safe, sane, reliable, responsible) or instability (crazy, dangerous, unstable, unpredictable).

RESULTS

The results demonstrated a finding of moderate effect size for an association between veterans and instability. Participants had significantly shorter response times (RTs) for IAT blocks in which veteran pictures and negative words were paired.

CONCLUSIONS

This is the first study in the literature to demonstrate implicit biases of veterans as unstable. If implicit biases do in fact exist, the reintegration issues that veterans face may be due, at least in part, to a negative bias they face upon their return. (PsycINFO Database Record

Insomnia brings soldiers into mental health treatment, predicts treatment engagement, and outperforms other suicide-related symptoms as a predictor of major depressive episodes

Given the high rates of suicide among military personnel and the need to characterize suicide risk factors associated with mental health service use, this study aimed to identify suicide-relevant factors that predict: (1) treatment engagement and treatment adherence, and (2) suicide attempts, suicidal ideation, and major depressive episodes in a military sample. Army recruiters (N = 2596) completed a battery of self-report measures upon study enrollment. Eighteen months later, information regarding suicide attempts, suicidal ideation, major depressive episodes, and mental health visits were obtained from participants' military medical records. Suicide attempts and suicidal ideation were very rare in this sample; negative binomial regression analyses with robust estimation were used to assess correlates and predictors of mental health treatment visits and major depressive episodes. More severe insomnia and agitation were significantly associated with mental health visits at baseline and over the 18-month study period. In contrast, suicide-specific hopelessness was significantly associated with fewer mental health visits. Insomnia severity was the only significant predictor of major depressive episodes. Findings suggest that assessment of sleep problems might be useful in identifying at-risk military service members who may engage in mental health treatment. Additional research is warranted to examine the predictive validity of these suicide-related symptom measures in a more representative, higher suicide risk military sample.

Deployment, Mental Health Problems, Suicidality, and Use of Mental Health Services Among Military Personnel

Following deployment, soldiers may struggle to cope with the after-effects of combat service and experience increased suicidality. Therefore, connection to mental health services is vital. Research regarding the relationship between deployment, suicidality, and mental health connections has been equivocal, with some studies finding a link between deployment history and mental health outcomes, and others not. The purpose of this study was to examine the effects of military deployment on mental health and service utilization outcomes using a longitudinal design. Deployment history, mental health visits, symptoms of suicidality, and various mental health outcomes were assessed in a sample of 1,566 Army recruiters at study entry and 18-months follow-up. Deployment history was positively associated with mental health visits, number of major depressive episodes, and acquired capability for suicide at baseline; however, no significant relationship between deployment, mental health visits, and any other suicide or mental health-related outcomes emerged at baseline or follow-up. Findings suggest a disconnection from mental health services among military personnel. Implications for treatment and suicide prevention efforts among military personnel are discussed.