NOVEL APPROACHES FOR HIGH-RISK SUICIDAL VETERANS James J. Peters VA Medical Center, Bronx, NY Mental Illness Research, Education and Clinical Center Suicide Prevention and Treatment Research Program SARAH SULLIVAN, M.S., MHC-LP MARIANNE GOODMAN, M.D. ANGELA P. SPEARS, B.S. K. NIDHI KAPIL-PAIR, PH.D. RACHEL E. HARRIS, M.A.
NOVEL INTERVENTIONS To address critical gaps in suicide treatment, our clinical research group has developed three novel interventions: 1. PLF - Project Life Force 2. SAFER - Safe Actions for Families to Encourage Recovery 3. Using TELEHEALTH to improve outcomes in Veterans at risk for suicide .
BACKGROUND: Q & A Question: Of all living US citizens, what percentage are Veterans? ? Map of total US population and distribution
Q & A Answer: Of all living US citizens, 7.3 percent have served in the military at some point in their lives (SAMSHA). % Veterans in the United States Civilians Veterans 7.3% 92.7% Map of total US population and distribution
Q & A Question: How many Veterans live in NY state? ? Map of total US population and distribution
Q & A Answer: 806,827 Veterans are currently living in NY state. # OF VETERANS IN NEW YORK STATE 806,827 20,392,192 NY Veterans Veterans living in other states Map of total US population and distribution
Q & A Question: How many Veterans kill themselves every day?
Q & A Only 6 of the 20 Veterans who die by suicide each day receive services at Answer: 20 the VA 93 Civilians, also die by suicide each day
THE PROBLEM: VETERAN SUICIDE Veterans account for 18% of all suicide deaths in US adults. This is in spite of enhanced suicide prevention resources. Suicide prevention is the #1 clinical priority in the VA.
SUICIDE SAFETY PLAN (SSP) In 2008, the VA mandated that The Suicide Safety Plan (SSP) is a clinicians oversee the construction of written, prioritized list of coping an individualized SSP for every strategies and resources for patient who is identified at “high risk” reducing suicide risk. for suicide. The patient takes the SSP home for It is a prevention tool, developed collaboratively by patient and his/her use at the onset of (or during) clinician (Stanley & Brown, 2008). a suicidal crises.
BREAKDOWN OF SSP 1. Warning signs 2. Internal coping strategies 3. People and social settings that provide distraction 4. People whom I can ask for help 5. Professionals or agencies I can contact during a crisis 6. Making the environment safe (Stanley & Brown, 2008)
VA USE OF THE SSP • There are currently no recommended guidelines or mechanisms for refinement of the SSP beyond its initial development. • There are no recommended guidelines for involving family members or friends in the implementation of, or use of, the SSP. To address these critical gaps, our clinical research group has developed two novel interventions: SAFER - Safe Actions for Families to Encourage Recovery PLF – Project Life Force Please Note: These interventions are adjunctive to standard outpatient mental health care at the James J. Peters VA Medical Center.
PROJECT LIFE FORCE PLF Keeping High-Risk Veterans Alive Through a Group Safety Planning Intervention Funding : VA SPiRE RR&D VA MERIT, CSRD
ORIGINS OF PLF- DBT NEGATIVE RCT RCT: 6-month DBT vs. TAU in 93 high-risk suicidal Veterans: Negative study : Both groups improved in all outcome measures DIALECTICAL BEHAVIOR THERAPY (DBT) TRIAL IN SUICIDAL VETERANS (GOODMAN ET . AL, 2016)
PERSONAL ANECDOTE WITH SUICIDAL VETERAN
QUALITATIVE STUDY OF SUICIDE SAFETY PLAN (SSP) USE (KAYMAN ET AL., 2015) 20 Veterans interviewed after SSP construction and 1 month later Findings notable for: Wide range of use (none to several times daily) Importance of clinician collaboration Barriers/obstacles to use Problems/obstacles: Lack of social network Social withdrawal/depression Avoidant style of coping Burden too great to carry out plan alone Facilitators of use of the plan: Sharing of plan with significant others Mobile formats of the plan Individualized plans
QUALITATIVE STUDY OF SUICIDE SAFETY PLAN (SSP) USE (KAYMAN ET AL., 2015) 20 Veterans interviewed after SSP construction and 1 month later Findings notable for: PLF incorporates: Wide range of use (none to several times daily) 1) Teaching of distress Importance of clinician collaboration tolerance and emotion regulation skills applied to Barriers/obstacles to use individual steps of the SSP, PLF aims to address these concerns 2) Introduces use of a mobile Problems/obstacles: SSP Application, Lack of social network 3) Helps Veterans identify Social withdrawal/depression individuals they can call for Avoidant style of coping help, and practice asking for help, Burden too great to carry out plan alone 4) Aims to develop detailed, personalized and meaningful Facilitators of use of the plan: SSPs, Sharing of plan with significant others 5) Delivered in a group Mobile formats of the plan context offering support. Individualized plans
THE SOLUTION: PROJECT LIFE FORCE PROJECT LIFE FORCE (PLF) is a manualized, 90-minute group therapy for 10 sessions, lasting 3 months. • Combines psychoeducation and emotion regulation skills with suicide safety planning development and implementation. Psychoeducation Emotion Suicide Safety Regulation Skills Planning Group Technologic Psychotherapy integration
GROUP SUICIDE SAFETY PLANNING & SKILLS INTERVENTION PLF Session 2: Emotion Recognition Skills PLF Session 3: Distress Tolerance Skills PLF Session 4-5: Interpersonal Communication Skills with Family PLF Session 6: Interpersonal Communication Skills with Clinical PLF Session 1: Team Crisis Prevention Services PLF Session 7: Means Restriction
PLF SKILLS AND SAFETY PLANNING IN A GROUP Project Life Force Session Outline 1) PLF=manualized, weekly 90-minute Session Focus Skill Covered group treatment lasting 10 weeks. Introduction, psychoeducation about Crisis Management Skills 2) Each session of PLF corresponds to 1 suicide, SSP step #5 - crisis Urge Restriction numbers, meet local SPC a step of the safety plan and teaches skills to maximize the use of that SSP step #1 - Identification Emotion, Thought or Behavior 2 of Warning Signs Recognition skills particular step of the plan. SSP step #2 - Internal 3 Distraction Skills 3) PLF is augmented with education Coping Strategies pertaining to suicide risk, means SSP step #3 - Identifying 4 Making Friends Skills people to help distract restriction and suicide prevention mobile SSP step #4 - Sharing SSP with Interpersonal Skills/Practicing applications. 5 Family Asking for Help 4) A manual with 84 pages of session SSP step #5 - Skills to Maximize Treatment 6 Professional Contacts Efficacy & Adherence handouts has been developed & tested. SSP step #6 - Making Means Restriction, 5) Designed to meet VA mandated 6 the Environment Safe Psychoeducation About Methods monitoring and permit immediate access. Use of Safety Planning Mobile 7 Improving Access to the SSP Apps and Virtual Hope Box 6) Capitalizes on group support & is Decreasing Vulnerability to 8 Physical Health Management cost effective. Negative Emotion Building Meaning and Reasons 9 Building a Meaningful Life **PLF is one of the only manualized outpatient for Living 10 group treatments for suicidal individuals. Recap/Review
PLF = SAFETY PLANNING IN A GROUP FORMAT PLF is one of the only manualized outpatient group treatments for individuals at high risk for suicide. This is surprising given that groups: 1. Diminish social isolation and increasing social support/social connectedness, a protective factor against suicide; 2. It’s cost effectiveness and maximizing staff time; 3. The peer movement among those who have experienced suicidal crises is strong and growing; and 4. Veterans and military service members are familiar with working as a unit, with team approach to problems.
OPEN LABEL PILOT Initial effectiveness in Test feasibility and tolerability of depression, suicidal symptoms, intervention on 50 Veterans. hopelessness. Plus post-intervention Feedback on each session from feedback from treating patient and PLF therapist. clinician(s).
PROJECT LIFE FORCE - OUTCOMES After 10 weeks of PLF, Veterans had: >40% suicide symptom severity/ideation >30% depression , >20% hopelessness CSSRS = Columbia Suicide Severity Rating Scale; BDI = Beck Depression Inventory; BHS = Beck Hopelessness Scale; BSS = Beck Suicide Ideation Scale
PROJECT LIFE FORCE - OUTCOMES Feasibility/Acceptability Pilot Data (N=45) • <2.0 total hours/week per clinician • Veteran satisfaction 4.7 out of 5 point likert scale • 5.0 of 5 rating on recommending the treatment to others • <17% attrition • 100% of participants developed updated safety plans and increased use patterns.
QUALITATIVE FEEDBACK ON PLF More Effective Use of Safety Plan “Going through each step in depth makes it a living document, instead of just filling it out on the fly and never using it.”
QUALITATIVE FEEDBACK ON PLF Hope/Improved Depressive and Suicidal Feelings “I wake up wanting to live now.” More Effective Use of Safety Plan “Going through each step in depth makes it a living document, instead of just filling it out on the fly and never using it.”
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