Evaluating Clinician Attitudes After Local Implementation of the Veterans Affairs Predictive Analytic Model for Suicide Prevention.

OBJECTIVE: The Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET) program was launched in 2017 to identify Veterans at high risk for suicide and other adverse outcomes using predictive analytics. This quality improvement study evaluated the sustainment of the REACH VET program at a large Veterans Affairs health care system by assessing clinician attitudes. METHODS: A mixed-methods approach was used to collect anonymous survey (N=35) and qualitative interview (n=12) data from Veterans Affairs REACH VET providers. RESULTS: Survey findings demonstrated largely neutral to negative attitudes towards REACH VET, with the most notable responses indicating that REACH VET identified Veterans who were already perceived to be engaged in care. Interview findings reflected a variety of attitudes, including perceived lack of added value and pessimism regarding successful outreach. Clinicians reported that the program was values-consistent and had the potential to improve the quality of care. CONCLUSIONS: Results demonstrate the need for educational interventions and improved communication between local coordinators and clinicians. Clinicians rarely discussed fears about the algorithmic approach, but they highlighted concerns about the value that this approach added to their role. Future evaluations are needed to examine additional sustainment issues.

From everyday life predictions to suicide prevention: Clinical and ethical considerations in suicide predictive analytic tools.

Advances in artificial intelligence and machine learning have fueled growing interest in the application of predictive analytics to identify high-risk suicidal patients. Such application will require the aggregation of large-scale, sensitive patient data to help inform complex and potentially stigmatizing health care decisions. This paper provides a description of how suicide prediction is uniquely difficult by comparing it to nonmedical (weather and traffic forecasting) and medical predictions (cancer and human immunodeficiency virus risk), followed by clinical and ethical challenges presented within a risk-benefit conceptual framework. Because the misidentification of suicide risk may be associated with unintended negative consequences, clinicians and policymakers need to carefully weigh the risks and benefits of using suicide predictive analytics across health care populations. Practical recommendations are provided to strengthen the protection of patient rights and enhance the clinical utility of suicide predictive analytics tools.

Brief Cognitive-Behavioral Therapy for Suicide Prevention (BCBT-SP) via Video Telehealth: A Case Example During the COVID-19 Outbreak.

Although veterans living in remote/rural areas are at elevated risk for suicide, there is very little research specific to treating suicidal veterans who present with barriers to in-person care. The current study aims to examine the delivery of brief cognitive-behavioral therapy for suicide prevention (BCBT-SP) via Clinical Video Telehealth (CVT) to the home of a veteran discharged from the psychiatric inpatient unit after a recent suicide attempt. Preliminary data on acceptability, feasibility, and changes in symptoms were gathered. The veteran received treatment during the 2020 COVID-19 outbreak and additional adaptations were made accordingly. The veteran did not engage in any suicidal behavior during the course of treatment, and suicidal ideation, depression, and anxiety decreased as treatment progressed. The results provide initial support for the feasibility of BCBT-SP via CVT to the home.

Local implementation evaluation of a suicide prevention predictive model at a large VA health care system.

BACKGROUND: The Veterans Health Administration (VHA) implemented REACH VET, which analyzes health records to identify veterans at statistically elevated risk for suicide and other adverse outcomes compared to other veterans in VHA. This project evaluated REACH VET program implementation at a large VA health care system by examining program fidelity and treatment engagement, receipt of suicide prevention interventions, and suicide-related behaviors in the 6 months following identification. METHODS: Over a 12-month period, 218 unique cases were identified by REACH VET within a local VA system. Data were extracted from the VA's electronic medical records. RESULTS: Protocol adherence for required clinical and administrative steps was 94% and above. After identification, 88% received outpatient mental health treatment, 21% had a psychiatric hospitalization, and 83% engaged in Safety Planning around the time of identification or in the following six months. Twenty-six percent of cases were identified by another existing method for identifying high-risk veterans. Five percent had a medically documented suicide attempt, and none were known to die by suicide in the following 6 months. CONCLUSIONS: Local evaluation suggested high protocol fidelity and high engagement in mental health and suicide prevention services following identification among veterans who remained at elevated risk in the 6 months that followed.

What is "safety"?: Lethal means counseling as a cross-cultural communication.

U.S. suicide rates have risen every year over the past two decades with self-directed firearm use as the method accounting for the highest proportion of deaths. This pattern is particularly pronounced among veterans and members of the U.S. Armed Forces. The numerical burden of firearm-related suicide accompanied by characteristics of self-directed firearm injury have motivated the development of lethal means safety initiatives focused on firearms. Simultaneously, research has sought to characterize patterns of firearm ownership and use among veterans as well as optimal strategies for clinicians to deliver suicide prevention messages to firearm owners. Increasingly, findings from research have been understood as cultural factors that warrant greater attention to improve the quality of lethal means counseling. Here, we review and interpret selected research on cultural aspects of firearm ownership and suggest that cultural differences between health care practitioners and firearm owners may result in health care practitioners delivering clinical interventions that are broadly divergent from perspectives within the cultural frameworks of firearm owners. We follow by organizing these cultural factors into existing frameworks of cultural competency training as a basis for developing curriculum for health care practitioners to improve clinical care.

Prediction Models for Suicide Attempts and Deaths: A Systematic Review and Simulation.

Importance: Suicide prediction models have the potential to improve the identification of patients at heightened suicide risk by using predictive algorithms on large-scale data sources. Suicide prediction models are being developed for use across enterprise-level health care systems including the US Department of Defense, US Department of Veterans Affairs, and Kaiser Permanente. Objectives: To evaluate the diagnostic accuracy of suicide prediction models in predicting suicide and suicide attempts and to simulate the effects of implementing suicide prediction models using population-level estimates of suicide rates. Evidence Review: A systematic literature search was conducted in MEDLINE, PsycINFO, Embase, and the Cochrane Library to identify research evaluating the predictive accuracy of suicide prediction models in identifying patients at high risk for a suicide attempt or death by suicide. Each database was searched from inception to August 21, 2018. The search strategy included search terms for suicidal behavior, risk prediction, and predictive modeling. Reference lists of included studies were also screened. Two reviewers independently screened and evaluated eligible studies. Findings: From a total of 7306 abstracts reviewed, 17 cohort studies met the inclusion criteria, representing 64 unique prediction models across 5 countries with more than 14 million participants. The research quality of the included studies was generally high. Global classification accuracy was good (≥0.80 in most models), while the predictive validity associated with a positive result for suicide mortality was extremely low (≤0.01 in most models). Simulations of the results suggest very low positive predictive values across a variety of population assessment characteristics. Conclusions and Relevance: To date, suicide prediction models produce accurate overall classification models, but their accuracy of predicting a future event is near 0. Several critical concerns remain unaddressed, precluding their readiness for clinical applications across health systems.

Suicide in the Military: Understanding Rates and Risk Factors Across the United States' Armed Forces.

This paper presents data from the United States Department of Defense Suicide Event Report System for years 2012-2015 to detail descriptive, longitudinal rate data and risk factor profiles associated with military suicide. The annual findings were aggregated from all U.S. military suicide deaths and suicide attempts. Data elements included the most common method of suicide (firearms), most common behavioral health diagnoses (substance abuse/dependence), common life stressors (failed intimate-partner relationships), and an individual's history of operational deployment. Age- and sex-adjusted rates for the Services were compared with rates for the U.S. adult population. Results showed that the current reporting period (2015) is similar to patterns that have been observed over the preceding years and to patterns reported in the overall U.S. adult population. Suicide rates remain elevated but stable for both the Active and Reserve Components of the Military Services compared to historical levels observed prior to 2003. Finally, we discuss common errors and misinterpretations that can occur when analyzing surveillance data.

Predicting post treatment client satisfaction between behavioural activation for depression delivered either in-person or via home-based telehealth.

INTRODUCTION: Treatment engagement, adherence, cancellations and other patient-centric data are important predictors of treatment outcome. But often these data are only examined retrospectively. In this investigation, we analysed data from a clinical trial focused on innovative delivery of depression treatment to identify which patients are likely to prefer either in-home or in-person treatment based on pre-treatment characteristics. METHODS: Patient satisfaction was assessed in a trial of individuals with depression treated using identical behavioural activation therapy protocols in person or through videoconferencing to the home (N = 87 at post treatment: 42 in-person and 45 in-home participants). The Client Satisfaction Questionnaire was administered at the end of the treatment. A Tobit regression model was used to assess moderation using treatment assignment. Regression lines were generated to model treatment satisfaction as a function of treatment assignment and to identify whether and where the groups intersected. We examined the distributions of the contributing moderators to the subsets of participants above and below the intersection point to identify differences. RESULTS: While no significant differences in patient satisfaction were observed between the two groups, or between patients receiving treatment by different providers, baseline characteristics of the sample could be used to differentiate those with a preference for traditional, in-office care from those preferring in-home care. DISCUSSION: Participants who were more likely to prefer in-home care were characterized by larger proportions of veterans and lower-ranked enlisted service members. They also had more severe symptoms at baseline and less formal education. Understanding client reactions when selecting treatment modality may allow for a more satisfying patient experience.

Financial hardship and risk of suicide among U.S. Army personnel.

Financial stress has been frequently identified as a risk factor for suicidal behavior, both in military and civilian groups. However, it remains unclear to what degree financial stress may be associated independently with suicide behavior when accounting for other risk factors. This study examined data on suicide and suicide attempt cases in the Department of Defense Suicide Event Report compared with service members who did not have recent suicide behavior. The resulting multinomial regression analysis found that financial distress had a weak association with suicide, and its relationship to suicide attempts was not statistically significant. Compared with financial distress, relationship problems and substance abuse history appeared to have much stronger associations with suicidal behavior, as did having a diagnosis of a mood disorder, such as major depressive disorder. The major conclusion from these data are that although financial distress may be a risk factor for suicidal behavior, the relationship is likely indirect and considerably less substantial than previously suspected. In addition, its relative influence is significantly less than other identified risk factors. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Economic evaluation of home-based telebehavioural health care compared to in-person treatment delivery for depression.

Introduction Home-based telebehavioural healthcare improves access to mental health care for patients restricted by travel burden. However, there is limited evidence assessing the economic value of home-based telebehavioural health care compared to in-person care. We sought to compare the economic impact of home-based telebehavioural health care and in-person care for depression among current and former US service members. Methods We performed trial-based cost-minimisation and cost-utility analyses to assess the economic impact of home-based telebehavioural health care versus in-person behavioural care for depression. Our analyses focused on the payer perspective (Department of Defense and Department of Veterans Affairs) at three months. We also performed a scenario analysis where all patients possessed video-conferencing technology that was approved by these agencies. The cost-utility analysis evaluated the impact of different depression categories on the incremental cost-effectiveness ratio. One-way and probabilistic sensitivity analyses were performed to test the robustness of the model assumptions. Results In the base case analysis the total direct cost of home-based telebehavioural health care was higher than in-person care (US$71,974 versus US$20,322). Assuming that patients possessed government-approved video-conferencing technology, home-based telebehavioural health care was less costly compared to in-person care (US$19,177 versus US$20,322). In one-way sensitivity analyses, the proportion of patients possessing personal computers was a major driver of direct costs. In the cost-utility analysis, home-based telebehavioural health care was dominant when patients possessed video-conferencing technology. Results from probabilistic sensitivity analyses did not differ substantially from base case results. Discussion Home-based telebehavioural health care is dependent on the cost of supplying video-conferencing technology to patients but offers the opportunity to increase access to care. Health-care policies centred on implementation of home-based telebehavioural health care should ensure that these technologies are able to be successfully deployed on patients' existing technology.

Unobserved heterogeneity in response to treatment for depression through videoconference.

OBJECTIVE: This study examined treatment response heterogeneity in a recent randomized controlled trial of treatment for depression using videoconferencing technology compared to traditional in-office care. METHOD: Growth mixture modeling was used to identify subgroups of individuals in the trial based on treatment response trajectories. Demographic and baseline characteristics were included to identify correlates of subgroup membership. RESULTS: There were two subgroups based on the trajectories of the Beck Hopelessness Scale. The first subgroup had less symptom severity at baseline, and there was no meaningful difference between the two treatment modalities in change over time. The second subgroup had higher symptom severity at baseline, and individuals who engaged in treatment through the videoconference modality had less symptom improvement than those who underwent the in-office modality. Older participants with higher loneliness and anxiety scores at baseline were more likely to be in the second group. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Treatment of depression using videoconferencing to deliver care to an individual's home offers opportunities for improved access to services, especially among those who are unwilling or unable to seek in-person treatment. However, videoconferencing may not be appropriate for everyone. An individual's symptom level, age, and comorbidities are important clinical considerations when selecting an appropriate treatment modality. (PsycINFO Database Record

Home-based telebehavioral health for U.S. military personnel and veterans with depression: A randomized controlled trial.

OBJECTIVE: Evidence of feasibility, safety, and effectiveness of home-based telebehavioral health (HBTBH) needs to be established before adoption of HBTBH in the military health system can occur. The purpose of this randomized controlled noninferiority trial was to compare the safety, feasibility, and effectiveness of HBTBH to care provided in the traditional in-office setting among military personnel and veterans. METHOD: One hundred and twenty-one U.S. military service members and veterans were recruited at a military treatment facility and a Veterans Health Administration hospital. Participants were randomized to receive 8 sessions of behavioral activation treatment for depression (BATD) either in the home via videoconferencing (VC) or in a traditional in-office (same room) setting. Participants were assessed at baseline, midtreatment (4 weeks), posttreatment (8 weeks), and 3 months posttreatment. RESULTS: Mixed-effects modeling results with Beck Hopelessness Scale and Beck Depression Inventory II scores suggested relatively strong and similar reductions in hopelessness and depressive symptoms for both groups; however, noninferiority analyses failed to reject the null hypothesis that in-home care was no worse than in-office treatment based on these measures. There were not any differences found between treatment groups in regards to treatment satisfaction. Safety procedures were successfully implemented, supporting the feasibility of home-based care. CONCLUSION: BATD can be feasibly delivered to the homes of active duty service members and veterans via VC. Small-group differences suggest a slight benefit of in-person care over in-home telehealth on some clinical outcomes. Reasons for this are discussed. (PsycINFO Database Record

The effects of prolonged exposure and sertraline on emotion regulation in individuals with posttraumatic stress disorder.

The effects of current posttraumatic stress disorder (PTSD) interventions on emotion regulation are relatively unknown. Many conceptualize PTSD as a disorder of emotion dysregulation, and clinicians often fear that emotion regulation impairments will not change with stand-alone PTSD treatments, particularly for individuals with pre-existing emotion regulation difficulties. The present study examined changes in emotion regulation (expressive suppression, cognitive reappraisal, negative mood regulation) with prolonged exposure (PE) therapy or sertraline, specifically examining whether those with higher pre-existing emotion regulation difficulties improved over treatment on these indices. Individuals with chronic PTSD (N = 200) received 10 weeks of PE or sertraline and were followed through 6-month follow-up. Emotion regulation was assessed at pre- and post-treatment and at 3- and 6-month follow-up. Individuals with poorer initial emotion regulation showed greater improvement on all indices of emotion regulation, regardless of which treatment they received. Changes occurred during active treatment and were maintained over follow-up. These findings have both theoretical and clinical implications, arguing that emotion regulation is not impaired across all individuals with PTSD and that PE and sertraline effectively address emotion regulation difficulties.

An Evaluation of the Feasibility and Safety of a Home-Based Telemental Health Treatment for Posttraumatic Stress in the U.S. Military.

BACKGROUND: Although home-based telemental health options have the potential to greatly expand the range of services available to U.S. military service members, there remains a need to demonstrate that home-based care is technically feasible, safe, and effective and meets the military health system's standards of care before widespread implementation can be achieved. The purpose of this preliminary study was to evaluate the feasibility and safety of providing U.S. military service members with a behavioral health treatment delivered directly to the home using videoconferencing. MATERIALS AND METHODS: Ten previously deployed soldiers volunteered to complete eight sessions of a novel behavioral activation treatment for posttraumatic stress disorder. The primary clinical outcomes assessed included symptoms of posttraumatic stress and depression. Patient safety data and attitudes about seeking mental health services, treatment satisfaction, treatment adherence, and treatment compliance were also assessed. RESULTS: Clinically significant reductions in posttraumatic stress symptom severity and depression symptoms were observed. Soldiers indicated high levels of satisfaction with the treatment, and there were no adverse events requiring activation of emergency safety procedures. Technical problems associated with the network were observed but successfully mitigated. CONCLUSIONS: The results provide initial support for the feasibility and safety of telemental health treatments delivered by videoconferencing to the homes of soldiers. The optimal technical infrastructure needs to be determined to support expansion of synchronous videoconferencing capabilities to the home. The findings provide preliminary evidence of the feasibility, safety, and high user satisfaction with home-based telemental health in the military setting.

Patient Perceptions of Telemental Health: Systematic Review of Direct Comparisons to In-Person Psychotherapeutic Treatments.

BACKGROUND: Although there is growing empirical support for the clinical efficacy of telemental health (TMH) treatments, questions remain about how patient perceptions of the TMH treatment process may compare with those of traditional in-person psychotherapy treatments. MATERIALS AND METHODS: Through a systematic review, we specifically examine measures of patient treatment satisfaction and therapeutic alliance in studies that included direct comparisons of video teleconferencing or telephone-based psychotherapeutic TMH treatments with in-person treatment delivery. We performed a comprehensive search of the PsychINFO and MEDLINE databases for articles published in the last 10 years (2004-2014) on TMH treatments that included in-person comparison groups, yielding 552 initial results with 14 studies meeting our full inclusion criteria. RESULTS: The findings generally show comparable treatment satisfaction as well as similar ratings of therapeutic alliance. Some results suggested the potential for decreased patient comfort with aspects of group treatment delivered via TMH. CONCLUSIONS: We discuss implications for providing psychotherapeutic treatments via TMH and review practice recommendations for assuring and enhancing satisfaction with TMH services.

Suicide risk management during clinical telepractice.

The effective assessment and management of suicidal patients is an essential component of telehealth-based care. With this article, we describe how we have implemented procedures for the ongoing assessment and management of suicide risk in a clinical trial that compares in-office treatment to home-based treatment delivered via web-cam to U.S. military service members and veterans with depression. We describe our safety protocol and how it was adapted from current recommended best practices, published guidelines, and local requirements for managing patient safety during home-based telepractice. We conclude with discussion of other key safety issues associated with telepractice. The topics discussed are relevant to all mental health practitioners who are interested in clinical telepractice services.

Changes in emotion regulation in adults with and without a history of childhood abuse following posttraumatic stress disorder treatment.

OBJECTIVE: This study compared changes in emotion regulation and trait affect over the course of PTSD treatment with either prolonged exposure (PE) therapy or sertraline in adults with and without a history of childhood abuse (CA). METHOD: Two hundred adults with PTSD received 10 weeks of PE or sertraline. Emotion regulation and trait affect were assessed pre- and posttreatment and at 6-month follow-up with the Emotion Regulation Questionnaire (Gross & John, 2003), the Negative Mood Regulation Scale (Catanzaro & Mearns, 1990), and the Positive and Negative Affect Schedule (Watson, Clark, & Tellegen, 1988). RESULTS: Individuals with and without a history of CA did not differ from one another at pretreatment on PTSD severity, emotion regulation, or positive/negative affect. In addition, treatment was effective at improving emotion regulation and trait affect in those with and without a history of CA, and no significant differences in emotion regulation or trait affect emerged posttreatment or at 6-month follow-up between adults with and without a history of CA. Furthermore, noninferiority analyses indicated that the emotion regulation and trait affect outcomes of individuals with a history of CA were no worse than those of individuals without a history of CA. CONCLUSION: These findings cast doubt on the assumption that CA is associated with worse emotion regulation following PTSD treatment, arguing against assertions that a history of CA itself is a contraindication for traditional PTSD treatment, and that there is a clear necessity for additional interventions designed to target assumed emotion regulation deficits. [Corrected]