Comparison of the Safety Planning Intervention With Follow-up vs Usual Care of Suicidal Patients Treated in the Emergency Department.

Importance: Suicidal behavior is a major public health problem in the United States. The suicide rate has steadily increased over the past 2 decades; middle-aged men and military veterans are at particularly high risk. There is a dearth of empirically supported brief intervention strategies to address this problem in health care settings generally and particularly in emergency departments (EDs), where many suicidal patients present for care. Objective: To determine whether the Safety Planning Intervention (SPI), administered in EDs with follow-up contact for suicidal patients, was associated with reduced suicidal behavior and improved outpatient treatment engagement in the 6 months following discharge, an established high-risk period. Design, Setting, and Participants: Cohort comparison design with 6-month follow-up at 9 EDs (5 intervention sites and 4 control sites) in Veterans Health Administration hospital EDs. Patients were eligible for the study if they were 18 years or older, had an ED visit for a suicide-related concern, had inpatient hospitalization not clinically indicated, and were able to read English. Data were collected between 2010 and 2015; data were analyzed between 2016 and 2018. Interventions: The intervention combines SPI and telephone follow-up. The SPI was defined as a brief clinical intervention that combined evidence-based strategies to reduce suicidal behavior through a prioritized list of coping skills and strategies. In telephone follow-up, patients were contacted at least 2 times to monitor suicide risk, review and revise the SPI, and support treatment engagement. Main Outcomes and Measures: Suicidal behavior and behavioral health outpatient services extracted from medical records for 6 months following ED discharge. Results: Of the 1640 total patients, 1186 were in the intervention group and 454 were in the comparison group. Patients in the intervention group had a mean (SD) age of 47.15 (14.89) years and 88.5% were men (n = 1050); patients in the comparison group had a mean (SD) age of 49.38 (14.47) years and 88.1% were men (n = 400). Patients in the SPI+ condition were less likely to engage in suicidal behavior (n = 36 of 1186; 3.03%) than those receiving usual care (n = 24 of 454; 5.29%) during the 6-month follow-up period. The SPI+ was associated with 45% fewer suicidal behaviors, approximately halving the odds of suicidal behavior over 6 months (odds ratio, 0.56; 95% CI, 0.33-0.95, P = .03). Intervention patients had more than double the odds of attending at least 1 outpatient mental health visit (odds ratio, 2.06; 95% CI, 1.57-2.71; P < .001). Conclusions and Relevance: This large-scale cohort comparison study found that SPI+ was associated with a reduction in suicidal behavior and increased treatment engagement among suicidal patients following ED discharge and may be a valuable clinical tool in health care settings.

Staff Views of an Emergency Department Intervention Using Safety Planning and Structured Follow-Up with Suicidal Veterans.

The objective of this study is to summarize staff perceptions of the acceptability and utility of the safety planning and structured post-discharge follow-up contact intervention (SPI-SFU), a suicide prevention intervention that was implemented and tested in five Veterans Affairs Medical Center emergency departments (EDs). A purposive sampling approach was used to identify 50 staff member key informants. Interviews were transcribed and coded using thematic analysis. Almost all staff perceived the intervention as helpful in connecting SPI-SFU participants to follow-up services. A slight majority of staff believed SPI-SFU increased Veteran safety. Staff members also benefited from the implementation of SPI-SFU. Their comfort discharging Veterans at some suicide risk increased. SPI-SFU provides an appealing option for improving suicide prevention services in acute care settings.

Concerns of Older Veteran Callers to the Veterans Crisis Line.

When the Veterans Crisis Line (VCL) was implemented, it was uncertain if veterans, and particularly older male veterans, would utilize the service. We examined VCL use by a growing group of veterans at increased risk for suicide: those aged 60 and older. Real-time clinical data were gathered from a weekly random sampling of calls. Approximately 25% of calls were from veterans aged 60 or older; over 80% reported benefit from the call. Several significant differences in presenting concerns between older and younger callers were found. Targeted outreach to encourage older veterans to use the VCL is suggested.

Cognitive Behavioral Therapy for Insomnia and Imagery Rehearsal in Combat Veterans with Comorbid Posttraumatic Stress: A Case Series.

Disrupted sleep is common among combat veterans and can negatively impact response to mental health treatments. A trial of cognitive behavioral therapy for insomnia (CBT-I) and imagery rehearsal therapy (IRT) for nightmares was conducted with 14 combat veterans diagnosed with insomnia, and who were experiencing posttraumatic stress and/or depression. In the case-series that follows veterans experienced clinically significant changes in sleep, and statistically significant reductions in insomnia, nightmare, depression and posttraumatic stress severity following treatment. Combined CBT-I and IRT is a promising treatment for patients with combat-related trauma and psychiatric morbidity.

An Emergency Department Intervention and Follow-Up to Reduce Suicide Risk in the VA: Acceptability and Effectiveness.

OBJECTIVE: Emergency departments (EDs) are often the primary contact point for suicidal individuals. The post-ED visit period is a high suicide risk time. To address the need for support during this time, a novel intervention was implemented in five Department of Veterans Affairs medical center EDs. The intervention combined the Safety Planning Intervention (SPI) with structured follow-up and monitoring (SFU) by telephone for suicidal individuals who did not require hospitalization. This study assessed the intervention's acceptability and perceived usefulness. METHODS: A selected sample of 100 intervention participants completed a semistructured interview consisting of open-ended questions about the intervention's acceptability, usefulness, and helpfulness. Satisfaction with the SPI and SFU was separately evaluated. RESULTS: Nearly all participants found the SAFE VET intervention to be acceptable, reporting that it was helpful in preventing further suicidal behavior and fostering treatment engagement. CONCLUSIONS: The SAFE VET intervention showed promise as an ED intervention for suicidal patients.

Brief Intervention and Follow-Up for Suicidal Patients With Repeat Emergency Department Visits Enhances Treatment Engagement.

We implemented an innovative, brief, easy-to-administer 2-part intervention to enhance coping and treatment engagement. The intervention consisted of safety planning and structured telephone follow-up postdischarge with 95 veterans who had 2 or more emergency department (ED) visits within 6 months for suicide-related concerns (i.e., suicide ideation or behavior). The intervention significantly increased behavioral health treatment attendance 3 months after intervention, compared with treatment attendance in the 3 months after a previous ED visit without intervention. The trend was for a decreasing hospitalization rate.

Rationale and study protocol for a two-part intervention: Safety planning and structured follow-up among veterans at risk for suicide and discharged from the emergency department.

There are no evidence-based, brief interventions to reduce suicide risk in Veterans. Death by suicide is a major public health problem. This article describes a protocol, Suicide Assessment and Follow-up Engagement: Veteran Emergency Treatment [SAFE VET], developed for testing the effectiveness of a brief intervention combining a Safety Planning Intervention with structured follow-up (SPI-SFU) to reduce near-term suicide risk and increase outpatient behavioral health treatment engagement among Veterans seeking treatment at Veteran Affairs Medical Center (VAMC) emergency departments (EDs) who are at risk for suicide. In addition to describing study procedures, outcome measures, primary and secondary hypotheses, and human subjects' protection issues, the rationale for the selection of SPI-SFU as the intervention is detailed, as are safety considerations for the unique study setting and sample.

Safety Planning for Military (SAFE MIL): rationale, design, and safety considerations of a randomized controlled trial to reduce suicide risk among psychiatric inpatients.

Mental health related hospitalizations and suicide are both significant public health problems within the United States Department of Defense (DoD). To date, few evidence-based suicide prevention programs have been developed for delivery to military personnel and family members admitted for psychiatric inpatient care due to suicidal self-directed violence. This paper describes the rationale and detailed methodology for a study called Safety Planning for Military (SAFE MIL) which involves a randomized controlled trial (RCT) at the largest military treatment facility in the United States. The purpose of this study is to test the efficacy of a brief, readily accessible, and personalized treatment called the Safety Planning Intervention (Stanley and Brown, 2012). Primary outcomes, measured by blinded assessors at one and six months following psychiatric discharge, include suicide ideation, suicide-related coping, and attitudes toward help seeking. Additionally, given the study's focus on a highly vulnerable patient population, a description of safety considerations for human subjects' participation is provided. Based on this research team's experience, the implementation of an infrastructure in support of RCT research within DoD settings and the processing of regulatory approvals for a clinical trial with high risk suicidal patients are expected to take up to 18-24 months. Recommendations for expediting the advancement of clinical trials research within the DoD are provided in order to maximize cost efficacy and minimize the research to practice gap.

Mood, anxiety, and substance-use disorders and suicide risk in a military population cohort.

There are meager prospective data from nonclinical samples on the link between anxiety disorders and suicide or the extent to which the association varies over time. We examined these issues in a cohort of 309,861 U.S. Air Force service members, with 227 suicides over follow-up. Mental disorder diagnoses including anxiety, mood, and substance-use disorders (SUD) were based on treatment encounters. Risk for suicide associated with anxiety disorders were lower compared with mood disorders and similar to SUD. Moreover, the associations between mood and anxiety disorders with suicide were greatest within a year of treatment presentation.

Exposure to prescription drugs labeled for risk of adverse effects of suicidal behavior or ideation among 100 Air Force personnel who died by suicide, 2006-2009.

Prescription drugs for many indications are labeled with warnings for potential risk of suicidal ideation or behavior. Exposures to prescription drugs labeled for adverse effects of suicidal behavior or ideation among 100 Air Force personnel who died by suicide between 2006 and 2009 are described. Air Force registry data were linked to administrative prescription data. Descriptive statistics illustrate utilization: 89 personnel had a prescription history, 35 filled at least one prescription labeled with a warning, 26 had antidepressants on hand at death, and 2 died by drug overdose. Most airmen were not exposed to any prescriptions labeled for risk of suicidal ideation or behavior prior to death by suicide.

Implementation and early utilization of a Suicide Hotline for veterans.

Suicide crisis lines have a respected history as a strategy for reducing deaths from suicide and suicidal behaviors. Until recently, however, evidence of the effectiveness of these crisis lines has been sparse. Studies published during the past decade suggest that crisis lines offer an alternative to populations who may not be willing to engage in treatment through traditional mental health settings. Given this promising evidence, in 2007, the Department of Veterans Affairs in collaboration with the Department of Health and Human Services' Substance Abuse and Mental Health Administration implemented a National Suicide Hotline that is staffed 24 hours a day, 7 days a week, by Veterans Affairs clinical staff. We report here on the implementation of this suicide hotline and our early observations of its utilization in a largely male population.

An emergency department-based brief intervention for veterans at risk for suicide (SAFE VET).

Reducing deaths from veteran suicide is a public health priority for veterans who receive their care from the Department of Veterans Affairs (VA) and those who receive services in community settings. Emergency departments frequently function as the primary or sole point of contact with the health care system for suicidal individuals; therefore, they represent an important venue in which to identify and treat veterans who are at risk for suicide. We describe the design, implementation and initial evaluation of a brief behavioral intervention for suicidal veterans seeking care at VA emergency departments. Initial findings of the feasibility and acceptability of the intervention suggest it may be transferable to diverse VA and non-VA settings, including community emergency departments and urgent care centers.

Prevalence and characteristics of suicide ideation and attempts among active military and veteran participants in a national health survey.

The relationships between military service and suicide are not clear, and comparatively little is known about the characteristics and correlates of suicide ideation and attempts among those with history of military service. We used data from a national health survey to estimate the prevalence and correlates of suicidal behaviors among veterans and service members in 2 states. The prevalence of suicidal behaviors among Veterans was similar to previous estimates of ideation and attempts among adults in the US general population.

Use of the Air Force Post-Deployment Health Reassessment for the identification of depression and posttraumatic stress disorder: public health implications for suicide prevention.

OBJECTIVES: Military members are required to complete the Post-Deployment Health Assessment on return from deployment and the Post-Deployment Health Reassessment (PHDRA) 90 to 180 days later, and we assessed the PDHRA's sensitivity and specificity in identifying posttraumatic stress disorder (PTSD) and depression after a military deployment among US Air Force personnel. METHODS: We computed the PDHRA's sensitivity and specificity for depression and PTSD and developed a structural model to suggest possible improvements to it. RESULTS: For depression, sensitivity and specificity were 0.704 and 0.651, respectively; for PTSD, they were 0.774 and 0.650, respectively. Several variables produced significant direct effects on depression and trauma, suggesting that modifications could increase its sensitivity and specificity. CONCLUSIONS: The PDHRA was moderately effective in identifying airmen with depression and PTSD. It identified behavioral health concerns in many airmen who did not develop a diagnostic mental health condition. Its low level of specificity may result in reduced barriers to care and increased support services, key components of a public health approach to suicide prevention, for airmen experiencing subacute levels of distress after deployment, which may, in part, account for lower suicide rates among airmen after deployment.

Suicide mortality among patients treated by the Veterans Health Administration from 2000 to 2007.

OBJECTIVES: We sought to examine rates of suicide among individuals receiving health care services in Veterans Health Administration (VHA) facilities over an 8-year period. METHODS: We included annual cohorts of all individuals who received VHA health care services from fiscal year (FY) 2000 through FY 2007 (October 1, 1999-September 30, 2007; N = 8,855,655). Vital status and cause of death were obtained from the National Death Index. RESULTS: Suicide was more common among VHA patients than members of the general US population. The overall rates of suicide among VHA patients decreased slightly but significantly from 2000 to 2007 (P < .001). Male veterans between the ages of 30 and 64 years were at the highest risk of suicide. CONCLUSIONS: VHA health care system patients are at elevated risk for suicide and are appropriate for suicide reduction services, although the rate of suicide has decreased in recent years for this group. Comprehensive approaches to suicide prevention in the VHA focus not only on recent returnees from Iraq and Afghanistan but also on middle-aged and older Veterans.

Prevalence, correlates, and symptom profiles of depression among men with a history of military service.

PURPOSE: The purpose of this study was to examine the prevalence, correlates, and symptom profiles of depressive disorders in men with a history of military service. METHODS: Data were obtained from the 2006 Behavioral Risk Factor Surveillance System survey. Multivariable logistic regressions were used to identify correlates of lifetime and current depression. Regularly occurring symptom profiles were identified via cluster analysis. RESULTS: Prevalence of lifetime and current depression was similar in men with and without a history of military service. Younger age was positively, and black minority status, being in a relationship and self-reported good health were negatively associated with a lifetime diagnosis of depression. Other minority status (non-Hispanic, non-black) was positively, and older age, some college, being in a relationship, and self-reported good health were negatively associated with current depression. A cluster of younger men who experience significant depressive symptoms but may not report depressed mood or anhedonia was identified. CONCLUSIONS: Depression is as prevalent in men with a history of military service as it is in men without a history. Research should focus on subpopulations of men with a history of military service in which depression may be more prevalent or burdensome. Younger men with significant depressive symptoms may be missed by standard depression screens and still be at elevated risk for negative outcomes associated with depression.

Does a brief suicide prevention gatekeeper training program enhance observed skills?

BACKGROUND: Suicide is a significant public health problem worldwide that requires evidence-based prevention efforts. One approach to prevention is gatekeeper training. Gatekeeper training programs for community members have demonstrated positive changes in knowledge and attitudes about suicide. Changes in gatekeeper skills have not been well established. AIMS: To assess and to predict the impact of a brief, gatekeeper training on community members' observed skills. METHODS: Participants in a community gatekeeper training were employees at US universities. 50 participants were randomly selected for skills assessment and videotaped interacting with a standardized actor prior to and following training. Tapes were reliably rated for general and suicide-specific skills. RESULTS: Gatekeeper skills increased from pre- to posttest: 10% of participants met criteria for acceptable gatekeeper skills before training, while 54% met criteria after training. Pretraining variables did not predict increased skills. LIMITATIONS: Results do not provide conclusions about the relationship between observed gatekeeper skills and actual use of those skills in the future. CONCLUSIONS: Gatekeeper training enhances suicide-specific skills for the majority of participants. Other strategies, such as behavioral rehearsal, may be necessary to enhance skills in the remaining participants.

The US Air Force suicide prevention program: implications for public health policy.

OBJECTIVES: We evaluated the effectiveness of the US Air Force Suicide Prevention Program (AFSPP) in reducing suicide, and we measured the extent to which air force installations implemented the program. METHODS: We determined the AFSPP's impact on suicide rates in the air force by applying an intervention regression model to data from 1981 through 2008, providing 16 years of data before the program's 1997 launch and 11 years of data after launch. Also, we measured implementation of program components at 2 points in time: during a 2004 increase in suicide rates, and 2 years afterward. RESULTS: Suicide rates in the air force were significantly lower after the AFSPP was launched than before, except during 2004. We also determined that the program was being implemented less rigorously in 2004. CONCLUSIONS: The AFSPP effectively prevented suicides in the US Air Force. The long-term effectiveness of this program depends upon extensive implementation and effective monitoring of implementation. Suicides can be reduced through a multilayered, overlapping approach that encompasses key prevention domains and tracks implementation of program activities.