Skill Use Mediates the Within-Person Effect of the Alliance on Session-to-Session Changes in Anxiety and Depression in the Unified Protocol.

Objective: Both the therapeutic alliance and the specific skills taught in treatment are thought to contribute to change in cognitive-behavior therapy (CBT), but it is unclear if or how these processes influence each other and outcomes in treatment. We tested the hypothesis that the degree to which patients used CBT skills would mediate the relation between the alliance and session-to-session changes in anxiety and depression. Method: Adult participants (N = 70; Mage = 33.74, 67% female, 70% White) with emotional disorders were randomized to receive 6 or 12 sessions of the Unified Protocol. Before each session, participants reported anxiety and depression severity and past-week skillfulness. After each session, participants rated the strength of the alliance. We tested whether greater within-person skillfulness mediated the relation between within-person alliance strength and session-to-session changes in anxiety and depression. Results: Skillfulness significantly mediated the effect of the alliance on session-to-session changes in anxiety, ab = -.02, p = .04, and depression, ab = -.02, p = .02, such that a stronger alliance predicted greater next-session skillfulness, which predicted session-to-session decreases in anxiety and depression. When alliance subscales were examined separately, the strongest effect was observed for agreement on therapy tasks. Conclusions: Improvements in the alliance may facilitate skill use and indirectly predict reductions in anxiety and depression through skill use in CBT. We encourage research on how to enhance both the alliance and skillfulness in CBT.

Within-person changes in aversive reactivity predict session-to-session reductions in anxiety and depression in the unified protocol.

ABSTRACTThe Unified Protocol (UP) theoretically leads to reductions in emotional disorder symptoms by reducing aversive reactions to emotions. However, aversive reactions can take many forms (e.g., non-acceptance, behavioral avoidance). We examined if (1) multiple aspects of aversive reactivity predicted session-to-session changes in anxiety and depression in the UP, (2) these aspects reflected a single latent construct, and (3) changes in this latent construct predicted changes in anxiety and depression. Participants (N = 70, Mage = 33.74, 67.1% female, 74.3% white) completed six sessions of UP modules and measures of aversive reactivity, anxiety, and depression before each session. We used hierarchical linear modeling and random-intercept cross-lagged panel models to test aspects of aversive reactivity and a latent factor of aversive reactivity, respectively, as predictors of session-to-session changes in anxiety and depression. Within-person improvements in four of five aspects of aversive reactivity predicted decreases in anxiety, and improvements in two aspects predicted decreases in depression. However, within-person improvements in latent aversive reactivity predicted decreases in anxiety at five sessions and in depression across all sessions. These results add to the growing literature highlighting the role of aversive reactivity as a potential transdiagnostic process involved in improvements in emotional disorder symptoms during treatment.

Comparative effectiveness of safety planning intervention with instrumental support calls (ISC) versus safety planning intervention with two-way text message caring contacts (CC) in adolescents and adults screening positive for suicide risk in emergency departments and primary care clinics: Protocol for a pragmatic randomized controlled trial.

BACKGROUND: Suicide is a leading cause of death in adolescents and adults in the US. Follow-up support delivered when patients return home after an emergency department (ED) or primary care encounter can significantly reduce suicidal ideation and attempts. Two follow-up models to augment usual care including the Safety Planning Intervention have high efficacy: Instrumental Support Calls (ISC) and Caring Contacts (CC) two-way text messages, but they have never been compared to assess which works best. This protocol for the Suicide Prevention Among Recipients of Care (SPARC) Trial aims to determine which model is most effective for adolescents and adults with suicide risk. METHODS: The SPARC Trial is a pragmatic randomized controlled trial comparing the effectiveness of ISC versus CC. The sample includes 720 adolescents (12-17 years) and 790 adults (18+ years) who screen positive for suicide risk during an ED or primary care encounter. All participants receive usual care and are randomized 1:1 to ISC or CC. The state suicide hotline delivers both follow-up interventions. The trial is single-masked, with participants unaware of the alternative treatment, and is stratified by adolescents/adults. The primary outcome is suicidal ideation and behavior, measured using the Columbia Suicide Severity Rating Scale (C-SSRS) screener at 6 months. Secondary outcomes include C-SSRS at 12 months, and loneliness, return to crisis care for suicidality, and utilization of outpatient mental health services at 6 and 12 months. DISCUSSION: Directly comparing ISC and CC will determine which follow-up intervention is most effective for suicide prevention in adolescents and adults.

Comparative effectiveness of two versions of a caring contacts intervention in healthcare providers, staff, and patients for reducing loneliness and mental distress: A randomized controlled trial.

BACKGROUND: Caring Contacts can effectively reduce suicide ideation, attempts, and death. In published clinical trials, Caring Contacts were sent by someone who knew the recipient. At scale, Caring Contacts programs rarely introduce the recipient and sender. It is not known whether receiving Caring Contacts from someone unknown is as effective as messages from someone the recipient has met. METHODS: Pragmatic randomized controlled trial comparing Caring Contacts with (CC+) versus without an introductory phone call (CC). Recruitment occurred January-July 2021, with outcomes assessed at 6 months. Participants were primary care patients or healthcare providers/staff reporting adverse mental health outcomes on a qualifying survey. Participants were sent 11 standardized caring text messages over 6 months; when participants replied, they received personalized unscripted responses. CC+ calls were semi-structured. The primary outcome was loneliness (NIH Toolkit). RESULTS: Participants included 331 patients (mean [SD] age: 45.5 [16.4], 78.9 % female) and 335 healthcare providers/staff (mean [SD] age: 40.9 [11.8], 86.6 % female). There were no significant differences in loneliness at 6 months by treatment arm in either stratum. In patients, mean (SD) loneliness was 61.9 (10.7) in CC, and 60.8 (10.3) in CC+, adjusted mean difference of -1.0 (95 % CI: -3.0, 1.0); p-value = 0.31. In providers/staff, mean (SD) loneliness was 61.2 (11) in CC, and 61.3 (11.1) in CC+, adjusted mean difference of 0.2 (95 % CI: -1.8, 2.2); p-value = 0.83. LIMITATIONS: Study population was 93 % white which may limit generalizability. CONCLUSIONS: Including an initial phone call added operational complexity without significantly improving the effectiveness of a Caring Contacts program.

BPD compass: A randomized controlled trial of a short-term, personality-based treatment for borderline personality disorder.

Borderline personality disorder (BPD) is a heterogeneous condition that is particularly associated with three broad personality dimensions: neuroticism (i.e., high negative affectivity), agreeableness (i.e., low antagonism), and conscientiousness (i.e., low disinhibition). The purpose of the present study was to explore whether treatment with BPD Compass, a novel personality-based intervention for BPD, results in greater reductions in BPD symptoms, neuroticism, agreeableness, and conscientiousness compared to a waitlist control (WLC) condition. We also aimed to characterize within-treatment effects for participants assigned to the BPD Compass condition and evaluate patients' satisfaction with treatment. Participants (N = 51; Mage = 28.38; 83.3% female; 93.8% White; 54.2% sexual minority) meeting DSM-5 criteria for BPD were enrolled in a randomized controlled trial to evaluate the efficacy of BPD Compass. Patients were randomly assigned to receive 18 sessions of BPD Compass or complete an 18-week waiting period. BPD Compass led to larger reductions in BPD symptoms (assessor-rated [ß = -0.47] and self-reported [ß = -0.62]) and neuroticism (ß = -0.37), but not agreeableness (ß = 0.08) or conscientiousness (ß = 0.10), compared to the WLC condition. Within the BPD Compass condition, pre- to posttreatment improvements in BPD symptoms, neuroticism, and conscientiousness were significant and large in magnitude (Hedges' gs: -1.38 to -1.08). Patients were highly satisfied with BPD Compass and generally perceived it to be an appropriate length. Thus, BPD Compass may be an accessible and useful complement to more specialty or intensive treatments for BPD. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Suicide Notes, Attempts, and Attempt Lethality During Episodes of Ideation Among Suicidal Soldiers and Marines.

OBJECTIVE: Suicide remains a significant public health problem among military personnel despite expanded suicide prevention efforts over the last two decades. It is important to understand the behavioral antecedents of suicide, including the writing of a suicide note, to inform efforts to identify imminent risk. However, the completion of a suicide note increasing the likelihood of making a suicide attempt (SA) and predicting a higher lethality SA during episodes of suicidality have not been evaluated. METHOD: To determine whether or not the completion of a suicide note increased the likelihood of making a SA during a given episode of suicidal ideation (current or worst) and predicted a higher lethality SA, we conducted secondary data analysis with a sample of 657 help-seeking, active-duty U.S. Soldiers and Marines. We hypothesized that service members who completed a suicide note would be more likely to make a SA during that given episode of suicidality and make a higher lethality SA. RESULTS: Completion of a suicide note increased the likelihood of making a SA in both current and worst episodes of suicidal ideation. Additionally, writing a suicide note predicted making a higher lethality SA during a service member's current episode of ideation but not their worst episode. CONCLUSIONS: This is the first study to examine note-writing behavior during episodes of suicidal ideation rather than following a suicide death or attempt, demonstrating a non-trivial number (17%) had written a suicide note and this increased the likelihood of making a SA and a higher lethality SA.HIGHLIGHTSThe first study of suicide notes during periods of ideation regardless of attempt.A suicide note written during an episode of ideation predicted making an attempt.A suicide note predicted making a more lethal suicide attempt.

Conceptual development and case data for a modular, personality-based treatment for borderline personality disorder.

Borderline personality disorder (BPD) is a heterogenous condition, and variations in its presentation may be accounted for by individual differences in personality dimensions. Extant treatments for BPD are long term and intensive; it is possible that prioritizing the personality-based difficulties that underlie an individual's symptoms may improve the efficiency of care. This article describes the conceptual background for the development of a novel, personality-based intervention for BPD (BPD Compass), which was informed by recent research on personality mechanisms maintainin this condition, and was designed to address gaps left by existing treatments and to be maximally efficient and disseminable. BPD Compass is a comprehensive, short-term package with a fully modular design that allows for personalization (e.g., all skills can be presented in isolation or in any order based on pretreatment assessment). We discuss the theoretical background for its development, an overview of the skills included in the treatment, as well as preliminary efficacy data. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Caring Texts, a strength-based, suicide prevention trial in 5 native communities: Research design and methods.

BACKGROUND: Despite their intrinsic strengths and resilience, some American Indian and Alaska Native (AI/AN) communities experience among the highest rates of suicide of any racial and ethnic group. Caring Contacts is one of the only interventions shown to reduce suicide in clinical trials, but it has not been tested in AI/AN settings. OBJECTIVE: To compare the effectiveness of Enhanced Usual Care (control) to Enhanced Usual Care augmented with a culturally adapted version of Caring Contacts (intervention) for reducing suicidal ideation, suicide attempts, and suicide-related hospitalizations. METHODS: We are implementing a single blind randomized controlled trial of Caring Contacts in five AI/AN communities across the country (South Dakota, Montana, Oklahoma, and Alaska). Eligible participants have to be (1) actively suicidal or have made a suicide attempt within the past year; (2) at least 18 years of age; (3) AI/AN; (4) able to speak and read English; (5) able to participate voluntarily; (6) willing to be contacted by text, email or postal mail; and (7) able to provide consent. Following consent and baseline assessment, participants are randomized to receive either Enhanced Usual Care alone, or Enhanced Usual Care with 12 months (25 messages) of culturally adapted Caring Contacts. Follow-up assessments are conducted at 12 and 18 months. CONCLUSIONS: If effective, this study of Caring Contacts will inform programs to reduce suicide in the study communities as well as inform future research on Caring Contacts in other tribal settings. Modifications to continue the trial during the COVID-19 pandemic are discussed. CLINICAL TRIALS REGISTRATION: NCT02825771.

Effectiveness of a Suicide Prevention Module for Adults in Substance Use Disorder Treatment: A Stepped-Wedge Cluster-Randomized Clinical Trial.

Importance: Individuals with substance use disorders (SUDs) are at high risk for suicide. The Preventing Addiction Related Suicide (PARS) module is the first suicide prevention module developed in and for community substance use intensive outpatient programs (IOPs). Objective: To evaluate the effectiveness of PARS on suicide-related outcomes (ie, knowledge, attitudes, and help-seeking behavior) compared with usual care. Design, Setting, and Participants: This stepped-wedge cluster-randomized clinical trial was conducted from 2017 to 2020, with follow-up assessments conducted after treatment and at 1, 3, and 6 months. Participants included adult outpatients in SUD treatment at community IOPs across western Washington state. Data were analyzed from July 1, 2020, to January 20, 2022. Interventions: The intervention, PARS, was a 1-session secondary prevention module administered by trained SUD counselors consisting of didactic presentations and group discussions about suicide risk factors, warning signs, and actions to take if suicide risk is observed in self or others. The control group received usual care. Main Outcomes and Measures: Primary outcomes were suicide knowledge, attitudes about suicide, and help-seeking behavior among patients enrolled in an IOP. Results: A total of 906 participants (mean [SD] age, 37.5 [12.0] years; 540 [59.6%] men) were included, with 478 participants receiving usual care and 428 participants receiving PARS. In intent-to-treat analysis from baseline to after treatment, there was a greater improvement in suicide knowledge (d = 0.15; 95% CI, 0.08 to 0.23; P < .001) and a greater reduction in maladaptive attitudes (d = 0.18; 95% CI, 0.14 to 0.25; P < .001) for PARS participants compared with those receiving usual care. Improvements were maintained at follow-up for suicide knowledge (1 month: d = 0.16; 95% CI, 0.07 to 0.22; P < .001; 3 months: d = 0.12; 95% CI, 0.05 to 0.19; P = .001; 6 months: d = 0.13; 95% CI, 0.06 to 0.20; P < .001) and reductions in maladaptive attitudes (1 month: d = 0.20; 95% CI, 0.12 to 0.23; P < .001; 3 months: d = 0.10; 95% CI, 0.05 to 0.16; P < .001; 6 months: d = 0.14; 95% CI, 0.09 to 0.19; P < .001), with 788 participants (87.0%) of the sample responding across time points. From baseline to 6 months, there was a greater improvement in help-seeking in the PARS group vs usual care (d = 0.16; 95% CI, 0.01 to 0.32; P = .04). Conclusions and Relevance: This stepped-wedge cluster-randomized clinical trial found that PARS was superior to usual care in improving suicide knowledge, maladaptive attitudes, and help-seeking in adults undergoing community addiction treatment. As a 1-session IOP module developed in partnership with community addiction agencies, PARS has the potential for wide impact in the national suicide prevention strategy. Trial Registration: ClinicalTrials.gov Identifier: NCT03166709.

Exploring the Psychometric Properties of the Stigma of Suicide Scale Using a Sample of Adults Bereaved by Suicide and Suicide Attempt Survivors.

The Stigma of Suicide Scale (SOSS) is a measure of public attitudes toward suicide decedents, which makes it unique from other scales that measure more general attitudes toward suicide. The aim of this study was to further replicate and extend the reliability and factor structure of the SOSS (both long- and short form) in a sample of individuals directly impacted by suicide. This study also sought to identify factors that impact suicide attitudes unique to this sample. The sample included 312 participants who had personal experience with suicide. Results provided support for the oblique three-factor structure of the SOSS (stigma, isolation/depression, and glorification/normalization), with a superior model fit for the 16-item short form version. Correlates of suicide attitudes among individuals exposed to suicide included perceived relationship closeness to a suicide decedent, experience with both loss and attempt, and the sex of the suicide decedent.

Borderline personality disorder and self-directed violence in a sample of suicidal army soldiers.

There has been a sharp increase in the military suicide rates in 2004. While, borderline personality disorder (BPD) has a stronger association with suicide attempts than any other mental health disorder, there is limited evidence concerning the prevalence and scope of BPD symptoms among military personnel. This secondary data analysis compared active duty suicidal soldiers to characterize the presence-absence of BPD diagnostic criteria and lifetime history of self-directed violence in a suicidal military sample. The current study examined data of 137 active Service Members with significant suicidal ideation. Approximately one-quarter of the soldiers in this sample met full diagnostic criteria for BPD. The presence of BPD criteria was generally consistent among participants with BPD who reported past self-directed violence relative to those who did not. The number of BPD criteria was a significant predictor of the odds of reporting any nonsuicidal self-injury (NSSI) as well as the amount of NSSI, but was not associated with suicide attempt. This study demonstrated that a nontrivial proportion of suicidal soldiers meet criteria for this condition, which is strongly associated with self-directed violence. It is important to rigorously assess for the presence-absence of BPD criteria among suicidal military personnel and cultivate prevention strategies and treatment options for BPD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Addiction counselors and suicide: Education and experience do not improve suicide knowledge, beliefs, or confidence in treating suicidal clients.

Substance use disorders (SUDs) are strongly associated with suicide deaths. However, SUD treatment is associated with lower suicide risk. To this date, we know little about whether SUD counselors are sufficiently knowledgeable about suicide and feel prepared and comfortable with treating and assessing their suicidal clients. This study was designed to characterize SUD counselors' general knowledge and confidence in treating suicidal clients, which was measured by their self-report of general knowledge of suicide prevention and belief in common myths about suicide as well as their self-reported confidence in treating suicidal clients. We hypothesized that confidence would be greater for counselors with more years of education and experience, that degree of education would predict greater knowledge and fewer beliefs in suicide myths, and finally that those counselors with greater knowledge and fewer beliefs in myths would have more confidence when treating suicidal clients. A total of 118 SUD counselors from 15 sites in Western Washington State agreed to participate in the study and completed baseline assessments. They were consented in group setting, usually during a staff meeting, and they were administered surveys on tablet computers. On average, the SUD counselors answered more than half the knowledge questions correctly and disagreed or strongly disagreed with common suicide myths. Their confidence in treating suicidal clients scored across the entire range. Our hypotheses were not supported: Confidence was not greater for those with more education or with more years of experience; degree of education and experience did not predict fewer beliefs in suicide myths; degree of education and experience did not predict greater knowledge; and greater knowledge and fewer beliefs in myths did not predict more confidence. The surprising finding that neither general suicide knowledge nor confidence were associated with the years of their work experience as a SUD counselor nor the level of their education and neither was associated with the other suggests that SUD treatment leadership should not depend on experience, education, general suicide knowledge to assure counselors are confidently able to treat suicidal clients. New or more precise training methods should be considered and evaluated.

Perceived burdensomeness, bullying, and suicidal ideation in suicidal military personnel.

OBJECTIVE: Suicide is a major public health concern among military servicemembers and previous research has demonstrated an association between bullying and suicide. This study evaluated the association between workplace bullying and suicidal ideation via perceived burdensomeness and thwarted belongingness which were hypothesized to mediate this association. METHOD: Four hundred and seventy-one suicidal Army Soldiers and U.S. Marines completed self-report measures of suicidal ideation, thwarted belongingness, perceived burdensomeness, and bullying. A series of regressions were used to test the hypothesized mediation model using the baseline data from a larger clinical trial. RESULTS: Perceived burdensomeness was a significant mediator of the association between bullying and the level of suicidal ideation, but thwarted belongingness was not a significant mediator. CONCLUSIONS: Perceived burdensomeness may represent a malleable target for intervention to prevent suicide among military service members, and should be evaluated further as an intervening variable with regard to suicidality in the setting of bullying victimization.