Status of Department of Defense Funded Suicide Research

Status of Department of Defense Funded Suicide Research

Status of Department of Defense Funded Suicide Research Peter M. Gutierrez, Ph.D. (moderator), COL Carl A. Castro, Diana J. Fitek, Ph.D., Dave Jobes, Ph.D., and Marjan Holloway, Ph.D. 20 JUNE 2012 COL Carl A. Castro Chair, Joint Program Committee for Military Operational Medicine (JPC-5) Director, Military Operational Medicine Research Program (MOMRP) UNCLASSIFIED

Scope of the Problem: Suicide in the Military Historically, military suicide rates were below civilian rate Some initial (still unsupported) hypotheses: People at highest risk of death by suicide are not selected for military service? Military service itself is a protective factor? Absence of standardized data collection on suicides prevented testing of these hypotheses Majority of suicide prevention programs and treatments are still not evidence-based As military suicide rate surpassed civilian rate, surveillance data and research needed to develop evidence-based interventions were just beginning CY2010 Suicide Rates (DoDSER) Air Force Army

Marine Corps Navy 15.5 21.7 17.2 11.1 UNCLASSIFIED Possible Military Suicide Risk Factors Recent failure in spousal or intimate relationship, often in month prior to suicide Occupational and/or legal problems History of behavioral health disorder, substance abuse (misuse of prescription medication), prescribed psychotropic medication, accessed outpatient behavioral health services in month prior to suicide

Communicated suicidal ideation to spouse, friend or other family members (DoDSER, 2010) UNCLASSIFIED Rate per 100,000 per year Army Active Duty Suicide Deaths Overall AD Count AD Rate Civilian Rate **

30.0 25.9 25.0 21.9 20.0 Number per year ** 18.2 18.5 17.3

18.9 16.8 19.6 17.7 18.6 23.1 * 150 14.9

15.0 100 12.5 11.5 162 9.6 10.0 5.0

18.7 *21.8 200 80 159 165 140 86 100

115 50 74 67 0.0 0 2003 2004

2005 2006 2007 2008 2009 2010 2011 * = Preliminary Civilian Rate NOT CDC OFFICIAL as of 16 MAR 2011

** = Preliminary Army Rate based on end strength of 715,662 as of 25 MAY 2012 UNCLASSIFIED 2012 Suicide Continuum of Care Determines Research Approach UNCLASSIFIED Research Investment along Continuum of Care $67.5M: Epidemiology/Basic Sciences Army STARRS, risk factors (Hill), role of deployment on suicidality (Reger), epidemiology of medication abuse and overdose (Cooper), Study to Examine Psychological Processes in Suicidal Ideation and Behavior (STEPPS; OConnor)

$5.2M: Prevention, Education & Training behavioral intervention for insomnia (Bernert), understanding resilience during suicide bereavement (Cerel), caring texts (Comtois), training family members to assist servicemembers in help-seeking (Allen), promoting resilience among family members of high-risk servicemembers (Renshaw), reducing anxiety sensitivity (Schmidt) $1.9M: Early Screening & Intervention development and validation of a theory-based screening process for suicide risk (Vannoy), optimizing screening and risk assessment (Joiner) UNCLASSIFIED Research Investment along Continuum of Care $4.2M: Assessment Use of thermal imaging to assess and optimize level of physiologic arousal during treatment (Familoni), toward a gold standard for suicide risk assessment in the military (Gutierrez & Joiner)

$21.9M: Treatment Collaborative Assessment and Management of Suicide (Jobes), Window to Hope (Brenner), brief CBT interventions (Bryan, Holloway, Rudd), Virtual Hope Box (Bush), high-dose left prefrontal TMS (George), DBT (Goodman), blister packaging for medication adherence (Gutierrez), safety planning (Holloway), intranasal delivery of biodegradable neuropeptide nanoparticles (Kubek), risk assessment in group therapy (Johnson & Jobes) $4.5M: Recovery & Postvention caring letters intervention (Luxton), development of guidelines and decision aids for evidencebased response to suicidal behavior during deployment (Stanley) UNCLASSIFIED Largest Investments: How Are they Different? Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) $62.1M ($50M Army, $12.1M NIMH) Co-PIs Robert Ursano, MD (USUHS) and

Murray Stein, MD, MPH (UCSD) 5 major studies Historical Data Study All Army Study New Soldier Study Soldier Health Outcomes Study (A & B) Special Studies Pre/Post-Deployment Study Clinical Calibration Study Studies mostly Soldiers, some Marines Retrospective and prospective epidemiological studies Data informs development of interventions Military Suicide Research Consortium

$17M (funded by Defense Health Program) Co-led by Peter Gutierrez, PhD (Denver VA MIRECC) and Thomas Joiner, PhD (FSU) 7 currently funded studies, 2 additional studies pending Studies may involve any service and/or veterans Focus on interventions (prevention, screening, assessment, treatment, recovery and postvention) UNCLASSIFIED DoD Suicide Research: Challenges and Successes

Omega-3 and Tau proteinhow relevant are they? Importance of establishing and maintaining relationship with command of possible study site Multi-site studies needed, complicates an already lengthy IRB approval process Army STARRS and MSRC UNCLASSIFIED DoD Suicide Research: The Way Ahead Theory-driven, evidence-based treatment studies (in/out patient) Research to examine the effects of brief interventions to reduce suicide behavior, problem drinking, and other outcomes (e.g., accidents, homicide, intimate partner violence, etc.) Basic science to validate underlying psychological and biopsychological theories of suicide

Combined psychotherapy and pharmacotherapy treatment studies Validate suicide prevention training (universal, at-risk populations) Validate objective suicide screening measure(s) for field and clinic use UNCLASSIFIED DoD Research Funding (Search by CFDA number 12.420) licitations.aspx UNCLASSIFIED COL Carl A. Castro Chair, Joint Program Committee for Military Operational Medicine (JPC-5) Director, Military Operational Medicine Research Program 301.619.7301 [email protected] Diana J. Fitek, Ph.D. Portfolio Manager Suicide, Substance Abuse & Violence CITS/MOMRP

301.619.7765 [email protected] MILITARY SUICIDE RESEARCH CONSORTIUM This work was in part supported by the Military Suicide Research Consortium (MSRC; USARMC award W81XWH-10-2-0178), Department of Defense, and VISN 19 Mental Illness Research, Education, and Clinical Center (MIRECC), but does not necessarily represent the views of the Department of Defense, Department of Veterans Affairs, or the United States Government. Peter M. Gutierrez, Ph.D. VISN 19 MIRECC, University of Colorado School of Medicine Thomas Joiner, Ph.D., Florida State University Co-Directors

MSRC Background/Rationale Produce new scientific knowledge about suicidal behavior in the military Use high-quality research methods and analyses to address problems in policy and practice Disseminate knowledge, information, and findings Train future leaders in military suicide research MEAB (Military External

Advisory Board) Core A Executive Management Core Peer Review Program Training & Developmen t Core B Core C

Information Management/ Scientific Communications Core Database/Statistical Management Core Disseminate to Decision Makers Research Program Research Program Areas

Treatment and Case Management Screening and Risk Assessment Basic Research (includes neurobiology and genetics) Prevention Postvention MSRC FUNDED RESEARCH Military Continuity Project Texting a brief intervention to prevent suicidal ideation and behavior

Katherine Anne Comtois, PhD MPH University of Washington Department of Psychiatry A Behavioral Sleep Intervention for Suicidal Behaviors in Military Veterans: A Randomized Controlled Study Rebecca Bernert, Ph.D. Department of Psychiatry and Behavioral Sciences Usability and Utility of a Virtual Hope Box (VHB) for Reducing Suicidal Ideation Nigel Bush, Ph.D. National Center for Telehealth & Technology University of Washington

Brief Intervention for Short- Term Suicide Risk Reduction in Military Populations Craig J. Bryan, PsyD University of Utah National Center for Veterans Studies Development and Evaluation of a Brief, Suicide Prevention Intervention Reducing Anxiety Sensitivity Norman B. Schmidt, Ph.D. Florida State University Window to Hope

Lisa A. Brenner, Ph.D., ABPP VISN 19 MIRECC Suicide Bereavement in Military and their Families Julie Cerel, Ph.D. University of Kentucky COLABORATIVE ASSESSMENT AND MANAGEMENT OF SUICIDALITY SUICIDE STATUS FORM Lori Johnson, Ph.D. Louisville VA Medical Center Toward a Gold Standard Suicide Assessment Peter M. Gutierrez, Ph.D.

VISN 19 MIRECC Thomas Joiner, Ph.D. Florida State University MSRC STUDIES UNDER DEVELOPMENT The Psychophysiology of Suicidal States: Temperamental and Physiologic Suicide Risk Assessment Measures and Their Relation to Self-Reported Ideation and Subsequent Behavior Michael H. Allen, M. D., University of Colorado School of Medicine, VISN 19 MIRECC Theresa D. Hernndez, Ph.D., University of Colorado, VISN 19 MIRECC CONSORTIUM WEBSITE

WWW.MSRC.FSU.EDU The Operation Worth Living (OWL) Project: A Randomized Trial of the Collaborative Assessment and Management of Suicidality vs. Enhanced Care as Usual for Suicidal Soldiers David A. Jobes, Ph.D., ABPP Principal Investigator Professor of Psychology Associate Director of Clinical Training The Catholic University of America STUDY BACKGROUND/RATIONALE: CRITQUE OF THE REDUCTIONISTIC MODEL (Suicide = Symptom of Psychopathology) ??

?? ?? DEPRESSION LACK OF SLEEP POOR APPETITE ANHEDONIA ... ? SUICIDALITY ? THERAPIST PATIENT Traditional treatment = inpatient hospitalization, treating the psychiatric disorder, and using no suicide contracts

CAMS targets Suicide as the primary focus of assessment and problem-focused intervention Suicidality PAIN STRESS AGITATION HOPELESSNESS SELF-HATE REASONS FOR LIVING VS. REASONS FOR DYING THERAPIST & PATIENT

The Suicide Status Form (SSF) is used to guide assessment and treatment Evolving Empirical Support for CAMS Authors Sample/Setting n = Significant Results____ Jobes et al., 1997 College Students 106 Pre/Post Distress Counseling Ctr. Pre/Post Core SSF Jobes et al., 2005 Air Force Personnel 56 Between Group Suicide Outpatient Clinic

Ideation, ED/PC Appts. Arkov et al., 2008 Danish Outpatients 27 Pre/Post Core SSF CMH Clinic Qualitative findings Jobes et al., 2009 College Students 55 Linear reductions Univ. Counseling Ctr. Distress/Ideation Nielsen et al., 2011 Danish Outpatients 42 Pre/Post Core SSF CMH Clinic Ellis et al., 2012

Psychiatric Inpatients 20 Pre/Post Core SSF Ideation, Hopelessness Comtois et al., 2011 Adult Outpatients (RCT) 32 Ideation/Hope/Distress Univ. Research AIMS/Hypotheses Aim 1: To develop a methodology for identifying, screening, referring to treatment, and tracking Soldiers who admit to being suicidal distressed

Aim 2: Evaluate whether the organizing of behavioral health care for suicidal Soldiers by CAMS results in a clinically and statistically significant reduction in suicidal behavior and improvement in mental health (e.g., resiliency, hope, reasons for living) as compared to Enhanced Care as Usual (E-CAU). Hypothesis 1: At post-treatment and at 3, 6, and 12 months follow-up, CAMS will be more effective in reducing suicidal behavior (suicidal ideation and suicide attempts) than E-CAU. Hypothesis 2: At post-treatment and at 3, 6, and 12 months follow-up, CAMS will be more effective in improving mental health (e.g., resiliency, functioning, distress, and psychiatric and health-related symptoms) than E-CAU. Hypothesis 3: CAMS provided adherently will be more effective than CAMS at low adherence in reducing suicidal ideation and behavior and improving Soldiers mental health. Hypothesis 3a (exploratory): At post-treatment and 3, 6, and 12 months follow-up, CAMS will be more effective in reducing hospitalizations to prevent suicide, emergency department, and medical visits than E-CAU. Design and Methodology Consenting Suicidal Soldiers (n=150) Control Group

E-CAU 3 months of outpatient care (n=75) Experimental Group CAMS 3 months of outpatient care (n=75) Dependent Variables: Suicidal Ideation/Attempts, Symptom Distress, Resiliency, Primary Care visits, Emergency Department Visits, and Hospitalizations. Measures: SSI, OQ-45, SHBQ, SASIC, CDRISC, PCL-M, SF-36, NFI, THI (at 1, 3, 6, 12 months) Current and Anticipated Challenges

Delayed start due to IRB process Multisite management issues IRB management and modifications Study transitions and growing pains Demands on clinic and space issues Store and Forward adherence/fidelity Maintaining command support

Clinic moving in September 2012 Staff turn over and additional training Study Progress IRB approval from four different institutions (11 months). New CAMS Manual; revised SSF and CAMS Rating Scale. Hired Project Coordinator; will hire back-fill clinicians. Have consented n=4 CAMS and n=4 E-TAU clinicians.

Experimental arm training conducted 30 April to 2 May. Pilot phase of adherence consultation/training has begun. We estimate that study patients will be recruited and enrolled in late summer/early fall. Dissemination/Transition Plan We hope to obtain definitive data from a well-powered RCT about the effectiveness of CAMS (note: a well-powered Danish study of CAMS is now underway). We will have conducted the study in a real world Army MTF with implications for exportation to other MTFs.

We will obtain new information about the intervention and CAMS training; we are interested in developing an electronic version of the SSF. We ultimately aim to develop a flexible (importable) intervention that will help save Soldiers lives returning them to full duty status with better coping skills and a sense of purpose and meaninga life worth living. DoD Funded Inpatient Psychotherapy Randomized Controlled Trials for the Prevention of Suicide

Marjan G. Holloway, Ph.D. Associate Professor, Clinical & Medical Psychology, Psychiatry Uniformed Services University of the Health Sciences Presentation Outline Psychiatric Diagnoses Leading Cause of Military Hospitalizations Limited Scientific Evidence for Inpatient Care Post Admission Cognitive Therapy (PACT) Brief Summary 4 Psychiatric Diagnoses Leading Cause of Military Hospitalizations

Reasons for Hospitalizations Source: Medical Surveillance Monthly Report, April 2010 4 Source: Medical Surveillance Monthly Report, Nov 2010 MENTAL HEALTHCARE HISTORY & SUICIDE U.S. ARMY MENTAL HEALTHCARE HISTORY & SUICIDE U.S. ARMY

Specifically, the relative risk rate for soldiers with a history of inpatient care for any MH diagnosis was 19.82% higher than for soldiers with no history of MH diagnosis, 2(1, N = 3,754,768) = N N = 3,754,768) = = N = 3,754,768) = 3,754,768) = ) N = 3,754,768) = = N = 3,754,768) = 1933.64, N = 3,754,768) = p N = 3,754,768) = < N = 3,754,768) = .001 (Black et al., 4 Limited Scientific Evidence Inpatient Care Inpatient Psychotherapy RCTs Study 1 (Liberman et al., 1981) 24 Patients Randomized, 2 Yr Follow-up

Behavior Therapy (n = 12); Insight Oriented Therapy (n = 12) 4 Daily Hours of Therapy over 8 Days Outcomes: Depression, Suicide Ideation, & Attempts BT > IOT at 9 Months Study 2 (Patsiokas, 1985) 15 Patients Randomized, No Follow-up Problem Solving (n = 5); Cognitive Restructuring (n = 5); Non-Directive Control (n = 5) 10 Individual Sessions over 3 Weeks Outcomes: Hopelessness, Suicide Ideation, & Intent PS > CR = Control 4

Meta-Analysis of Cognitive-Behavioral Interventions to Reduce Suicide Behavior Terrier, Taylor, & Gooding, 2008 28 Studies CBT (includes DBT) versus Control Used Suicide Behavior as Outcome 5 Adults Significant Adolescents No significant

showed effectswhen when dideffects not significant comparedtoto compared treatment controlactive another effects treatment CBT & DBT showed

significant effects Trial 1 Stage I Trial 2 Stage I Trial 3 Stage II Trial 4 Stage II N = 24

N = 50 N = 218 N = 189 21 18 0 49 Funding

Source National Alliance for Research on Schizophrenia & Depression Congressionally Directed Medical Research Program Amount $60,000

Inclusion Criteria Inpatients Suicide Attempt Total Participants Recruited to Date Intervention United States Department of

Defense United States Department of Defense $6,000,000 $2,893,708 Inpatients Inpatients Inpatients

Suicide Attempt AND Trauma Suicide Attempt Past OR Current Suicide Attempt OR Suicide Ideation $457,609

Post Admission Cognitive Therapy (PACT) Treatment Considerations = Trauma; Traumatic Brain Injury (TBI); Single versus Multiple Attempt Safety Planning Post Admission Cognitive Therapy (PACT) Inpatient Cognitive and Behavioral Treatment for the Prevention of Suicide Cognitive and Behavioral Practice, 2012 Cognitive Therapy for Prevention of Suicide

54 Patients Story On Decision to Attempt Suicide I took all the narcotics out that I could findI laid them all on the bed and I sat there for a couple of minutes and I was thinking, like, it was like a part of me saying, you dont want to do this. And there was a part of me saying, Do it. Just do it. Do it. And a part of me saying oh/no. And it was 3:36 and I was looking at the clock and was just thinking about it back and forth, back and forth. And 3:40I was just to do it. And I just grabbed them all and took em. And I laid there in bed. I started crying and I dont know why I picked up the phone and I called my brother. I didnt tell him what I did or what was going on, I just called him. And we talked for maybe about a minute or two and hung up the phone. Just waiting. Waiting for the effects to

take - for whatever was supposed to happen. 55 PACT 6 Individual Therapy Sessions 90 Min Each Sessions Transcribed Treatment Phase Therapeutic Goals Phase I Sessions 1 and 2 Build Therapeutic Alliance Provide Psychoeducation Collaboratively Plan for Safety Develop Suicide Mode Conceptualization

Assess Readiness for Change Phase II Sessions 3 and 4 Instill Hope Increase Reasons for Living Teach Adaptive Coping Strategies Target Deficits in Problem Solving Address Social Support Concerns Practice Emotion Regulation Skills Phase III Sessions 5 and 6 Promote Linkage to Outpatient Aftercare Teach Relapse Prevention Strategies

Refine Safety Plan before Discharge Study Deliverables 57 Summary Psychiatric hospitalizations provide us with a unique opportunity to provide much needed care for military personnel. We need to develop evidence-informed interventions for military personnel admitted for inpatient care. We need to develop these interventions as soon as possible to address the unique needs of this highly vulnerable group. 58

Contact Information: Marjan G. Holloway, Ph.D. Associate Professor Uniformed Services University of the Health Sciences Department of Medical & Clinical Psychology; Psychiatry 4301 Jones Bridge Road, Room B3050 Bethesda, MD 20814-4799 Phone: (301) 295-3271 [email protected] Collaborators (alphabetical): Canandaigua VA; Columbia University; Denver VA; Duke University; Fort Belvoir Community Hospital; KAI, Inc.; University of Michigan; University of Pennsylvania; University of Rochester; Walter Reed National Military Medical Center


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