So in terms of intervention, there are a lot of different approaches
that we could take and I think just how we approach this has evolved
quite a bit over the last ten years or so. But I think generally speaking
we want to treat sort of the underlying disorder.
If you think back to those contributing factors, things like depression,
psychiatric illness, chronic pain, that can contribute to someone's
suicide risk, in addition to some of the specific suicide indicators,
it's really important to be treating and managing those.
So our case again, one of the things that took her low acute risk down
is because her depression was being treated; it was stable.
So treating those underlying factors is really important,
but we can't solely focus on that. There's a lot of evidence showing
that we actually need to be treating suicide specifically, and a lot of
our evidence-based treatments that we have for suicide actually target
and suicide-related behaviors, cognition specifically.
So some combination of both of those is really kind of the ideal.
In terms of actual evidence-based treatments or practices,
most of them really focus on preventing reattempts.
So they're targeting really high-risk populations or indicated populations
who have already engaged in some form of suicidal behavior
and the goal is to prevent reattempts. We don't really have evidence-based
interventions, true prevention interventions that prevent the onset of behavior.
I think that's an area of problem solving. Problem-solving skills
in general have been long recognized as a protective factor and
there are some interesting studies done with school-aged children...
the good behavior game - I don't know if anyone has heard of that -
but basically it's promoting problem solving and pro-social behavior and
they actually found that that does prevent suicidal behavior in the long term.
Children that got that intervention in grade school actually had a lower risk
of suicidal behavior than those who did not.
It's a great line of research that they've done.
But problem solving and cognitive behavioral therapy for suicide or
cognitive therapy for suicide, as well as dialectical behavior therapy
are the three evidence-based interventions that we have for preventing
reattempts or suicidal behavior. These things I know are being implemented
just in varying degrees and the VA... in terms of DBT ... this is...
I'm talking to everyone here... this is Washington, so I really don't need
to say much about it here, but I'm obviously not going to go into a whole lot
of detail about these interventions other than to basically say
these are sort of what we know as the evidence-based.
There are other ways and other types of interventions that really target aspects
of suicide risk that are integral that we're finding really matter,
so things like treatment engagement - again, if you think about that
really high-risk period after hospitalization, the thing that
really seems to differentiate those who do die by suicide and
those who don't is treatment engagement.
It's a very, very difficult time to engage patients in treatment as well.
So there are a lot of challenges and I think some of the strategies and
interventions for how we're doing that have changed and evolved and
we're getting more creative with it.
So how can we do things like send caring letters and sort of more frequent,
but short contact with patients to keep them engaged
and to potentially keep them connected? Home-based care is
a really big area that's being looked at with relation to suicide risk too.
And I know Lisa alluded to this before, but a program that we have that started
as a pilot and is really growing into a larger clinical demonstration research project,
multi-site, is basically looking at meeting with patients while they're on the unit,
so they're setting a safety plan with them, following up with them via telephone
within a day or two after their discharge, and then doing a home visit,
again reevaluating where they're at, looking over their safety plan,
and seeing if that increases treatment engagement.
The preliminary data look really good and we're hoping to look at that even more
and look at how we can model this across the VA with implementation
and feasibility in general.
So, I kind of touched on this, but most of the data out there as far as
interventions that target suicide and have the greatest reduction in the
first three months, again, these are specifically targeting suicidal behavior
or different aspects related to suicide, treatment engagement is huge.
It's really hard to factor an impact if you can't get the goal to come to treatment
or engage in treatment. These interventions are only effective in the sense that
people are coming and they're actually getting exposure to it.
I think DBT does a really nice job of addressing that and some of
these other interventions do as well.
Does anybody here have training in DBT, cognitive therapy... that are problem-solving?
Great.
I think just generally speaking problem solving is an area that has a lot
of different potential options and I think safety planning is one way of
targeting problem solving in a very brief and focused way, and Sarra will be talking
more about that and the elements that feed into that.
But I think that is a particular intervention that has been looked at
in different populations that are at risk for suicide.
We are doing a trial where we're focusing on aspects of that cognitive therapy
as well as problem solving for individuals with moderate to severe TBI.
TBI is a risk factor for suicide in veterans as well, and looking at ways
that we can address that in pretty high-risk populations.
Given that these are evidence-based psychotherapies and more time intensive,
we need to be thinking about when we have a patient and we do a risk assessment
and we conceptualize that they're at high, acute risk or intermediate, acute risk,
what are some things that we could be doing right then and there
to help increase their safety? And safety planning is something that really gives us
that tool and gives us the ability to do that in collaboration with the patient.
And how many people here do safety planning often with their patients?
Great, that's wonderful. I think there are ways to enhance safety planning,
or what we call kind of super charge safety planning,
and we're going to be going over that with you step by step.
There are a lot of wonderful applications, mobile applications and clinical tools
that we can integrate to make safety planning more interactive and useful to patients,
and Sarra will be coming up to talk about that now.
Any questions about the evidence-based psychotherapies specifically?
Questions about implementation at the VA, or training?
I know each facility differs in terms of opportunities for training in these
different areas, but I think generally speaking there is a smaller percentage
of clinicians who are trained to deliver these therapies.
And while they are really important, again, I want to stress that you don't
have to be doing these therapies or know these therapies to help manage
suicide risk in your patients. Transition safety planning?
Yes?
Woman: ...formulating it exactly, but I'm thinking about we're talking about
evidence-based therapies, that they evaluate risk...over time.
Are you recommending these are interventions for acute threats, but ...
Well, these three interventions basically prevent reattempt, the time period
of usually six months to a year, and it is for a very high-risk population
because these individuals have already engaged in suicidal behavior.
But what about all the people who haven't engaged in suicidal behavior
and you identified them as being at high risk?
What do we have in terms of interventions for those?
It might not be that everybody needs this particular type of intervention
or this intense of intervention, but something where we can enhance,
something like safety planning where we can actually debrief, it's really
targeted on suicide behaviors, and it really hits at some of these active
ingredients like problem solving; they might be some alternatives to be thinking about.
(Dr. Brenner) There's one exception to that; it's the window to hope intervention
which was developed by Graham Simpson in Australia for folks
with moderate to severe TBI. We are closing in on that trial.
It is a cognitive behavioral intervention with some problem-solving therapy aspects.
And who we're recruiting in that study is not folks necessarily with
a previous history, but folks who are very hopeless, and the idea is that
we know that hopelessness is a predictor of suicidal behavior, particularly for
people with TBI, and so trying to target hopelessness to prevent future suicidal behavior.
Similarly right now we're doing an interesting treatment development grant;
we just got a treatment development grant not long ago; where we're combining
problem-solving therapy with safety planning, and actually I heard that
Barbara Stanley at Columbia is doing a DBT safety planning intervention.
So again, combining these evidence-based treatments with safety planning
and using the skills that you learn in the therapy: problem-solving therapy,
DBT to enhance the safety plan and to engage people in using their safety plan.
So in the problem-solving therapy plus safety planning intervention we're developing,
it's again for moderate to severe TBI.
Barbara Stanley's work... I think it's Marianne Williamson who's the PI on it...
theirs is more for people with borderline personality disorder.
But the idea is that we may need to do things to engage people both in treatment
and in safety planning activities.
And this idea that this is for trans-diagnostic too, that we need to be looking
at this across disorders, across people, and not just psychiatric disorders,
but other medical conditions that increase people's risk for suicide.
I feel like problem solving... different aspects... another tool moving forward;
I don't know if people have heard about that at all.
If you've been to the website, tried it at all... Moving forward,
yeah.
It was really more for reintegration, like more stress management and problem solving...
integration following deployment, but actually we've been looking at it in more of a
behavioral... setting and how it can be used to teach people about problem solving
and the impact it has on functioning and coping.
It has a lot of really nice modules and veterans, patients, you guys, anyone can go
and try some of the modules and it teaches some basic coping skills.
But I think, again, targeting it from a lot of different angles.
There's nothing specific to suicide; it's more general problem solving.
(Dr. Brenner) I just want to make sure people know what it is. It's a website
that's free and it was built by the VA and DOD. You can access it anywhere;
any computer, VA or non-VA. Have people heard of this?
It's called "Moving Forward." Do people have the thing with the VA resources on it?
I think it's right there. I think Moving Forward is on there. Can I just see?
So I don't see it, but I've been told that it's on here.
Oh, right here.
So right here, Moving Forward - it's a free online educational and life coaching
program that helps veterans to better handle life's challenges.
It's OEF focused. It's really, really good and it looks super fancy;
it looks like super fancy people developed it. It's really nice.
So I've used this with veterans in my office; we do it together in my office;
then they can do it at home.
There are videos, there are modules, there's all kinds of stuff on it; so just
another resource that you can use that's available to you as a VA provider.
...games that you can play to teach you the concepts that's really neat.
It actually does a really nice job of teaching you how stress impacts your
decision making and problem solving.