Evaluating the Effectiveness of Safety Plans for Military Veterans: Do Safety Plans Tailored to Veteran Characteristics Decrease Suicide Risk?

Supported decision-making interventions in mental healthcare: A systematic review of current evidence and implementation barriers

BACKGROUND

There is a growing momentum around the world to foster greater opportunities for the involvement of mental health service users in their care and treatment planning. In-principle support for this aim is widespread across mental healthcare professionals. Yet, progress in mental health services towards this objective has lagged in practice.

OBJECTIVES

We conducted a systematic review of quantitative, qualitative and mixed-method research on interventions to improve opportunities for the involvement of mental healthcare service users in treatment planning, to understand the current research evidence and the barriers to implementation.

METHODS

Seven databases were searched and 5137 articles were screened. Articles were included if they reported on an intervention for adult service users, were published between 2008 and October 2023 and were in English. Evidence in the 140 included articles was synthesised according to the JBI guidance on Mixed Methods Systematic Reviews.

RESULTS

Research in this field remains exploratory in nature, with a wide range of interventions investigated to date but little experimental replication. Overarching barriers to shared and supported decision-making in mental health treatment planning were (1) Organisational (resource limitations, culture barriers, risk management priorities and structure); (2) Process (lack of knowledge, time constraints, health-related concerns, problems completing and using plans); and (3) Relationship barriers (fear and distrust for both service users and clinicians).

CONCLUSIONS

On the basis of the barriers identified, recommendations are made to enable the implementation of new policies and programs, the designing of new tools and for clinicians seeking to practice shared and supported decision-making in the healthcare they offer.

PATIENT OR PUBLIC CONTRIBUTION

This systematic review has been guided at all stages by a researcher with experience of mental health service use, who does not wish to be identified at this point in time. The findings may inform organisations, researchers and practitioners on implementing supported decision-making, for the greater involvement of people with mental ill health in their healthcare.

Recognizing and coping with suicidal thoughts: A mixed-methods investigation of digital safety plan content

OBJECTIVES

Suicide safety plans are a personalized means of documenting how a person at risk of suicide recognizes and intends to cope with emerging suicidal thoughts. This study aimed to understand how users of digital suicide safety plans describe their warning signs, methods of coping and any relationships between these that may emerge.

METHODS

A sample comprising 150 users of the Australian suicide safety planning smartphone app Beyond Now consented to share the content of their safety plans. Reflexive thematic analysis was used to identify themes in overall plan content. Most participants identified as women (61%), had a history of at least one suicide attempt (61%) and completed their plans by themselves (84%).

RESULTS

Three major themes emerged: (1) interpersonal challenges and complexity; (2) matching coping strategies to warning signs; and (3) helpful and harmful digital technology use. Most plans appeared to demonstrate high self-awareness of warning signs and available supports.

CONCLUSIONS

Safety plan content provides a window into the thought process underlying the recognition of suicidal thoughts and the attempts to manage them. An opportunity exists for practitioners and support persons to use this content when collaboratively supporting a safety plan user to improve their coping strategies and support networks.

Digital safety plan effectiveness and use: Findings from a three-month longitudinal study

Few studies have examined the effectiveness of self-guided smartphone apps for suicide safety planning, despite their increasing use. Participants (n = 610) were self-selected users of the Beyond Now suicide prevention safety planning app with a history of suicidal thoughts and behaviours. Surveys were completed (baseline, one and three months), safety plan content and app usage data was shared. Repeated-measures ANOVAs examined changes in suicidal ideation and suicide-related coping over three months. Multiple regression models were used to predict suicidal ideation and suicide-related coping at one- and three-month follow-ups with plan-related variables: perceived usefulness, personalised content, app use time and co-authoring of the plan with a third party. Significant reductions in suicidal ideation and increases in suicide-related coping were found over three months. Higher suicide-related coping at three months predicted lower suicidal ideation. Higher perceived usefulness and personalised content at three months were associated with higher suicide-related coping, but not suicidal ideation. App use time and co-authoring were not significantly related to suicidal ideation or suicide-related coping. Practitioners should empower clients to create safety plans with personalised (not generic) strategies that a client perceives to be useful. Such plans may strengthen beliefs about coping with suicidal ideation, which in turn reduces suicidal ideation over time.

Perceived Usefulness of Self-Guided Versus Collaborative Suicide Safety Plans in Online Help-Seekers

Background: Suicide safety plans were originally devised to be paper-based and clinician-guided, but digital self-guided plans are now common. Aim: This study explored whether plan format (paper vs. digital), assistance (self-authored vs. collaboration), and suicide attempt history were associated with differences in suicidal ideation, suicide-related coping, and perceived usefulness. Method: An online sample of safety plan users (N = 131) completed a survey assessing suicidal ideation, suicide-related coping, and perceived usefulness of their plan. t tests compared outcomes by plan format, collaboration, and suicide attempt history. Pearson correlations explored associations between reasons for plan use, suicidal ideation, and suicide-related coping. Results: Suicidal ideation was significantly higher, and perceived usefulness significantly lower in participants with a past suicide attempt (vs. none) and in those who had collaborated to make their safety plan (vs. self-authored). Collaborators were largely health professionals. No significant differences were found between plan formats. Suicide-related coping was associated with higher perceived usefulness overall. Limitations: Our study design was cross-sectional, utilizing a largely young, female, English-speaking, online help-seeking sample. Conclusions: For clients with prior suicide attempts and higher levels of suicidal ideation, meaningful collaboration may be needed to find safety plan coping strategies that are perceived as useful.

Prototyping the implementation of a suicide prevention protocol in primary care settings using PDSA cycles: a mixed method study

Introduction

In Canada, approximately 4,500 individuals die by suicide annually. Approximately 45% of suicide decedents had contact with their primary care provider within the month prior to their death. Current versus never smokers have an 81% increased risk of death by suicide. Those who smoke have additional risks for suicide such as depression, chronic pain, alcohol, and other substance use. They are more likely to experience adverse social determinants of health. Taken together, this suggests that smoking cessation programs in primary care could be facilitators of suicide prevention, but this has not been studied.

Study objectives

The objectives of the study are to understand barriers/facilitators to implementing a suicide prevention protocol within a smoking cessation program (STOP program), which is deployed by an academic mental health and addiction treatment hospital in primary care clinics and to develop and test implementation strategies to facilitate the uptake of suicide screening and assessment in primary care clinics across Ontario.

Methods

The study employed a three-phase sequential mixed-method design. Phase 1: Conducted interviews guided by the Consolidated Framework for Implementation Research exploring barriers to implementing a suicide prevention protocol. Phase 2: Performed consensus discussions to map barriers to implementation strategies using the Expert Recommendations for Implementing Change tool and rank barriers by relevance. Phase 3: Evaluated the feasibility and acceptability of implementation strategies using Plan Do Study Act cycles.

Results

Eleven healthcare providers and four research assistants identified lack of training and the need of better educational materials as implementation barriers. Participants endorsed and tested the top three ranked implementation strategies, namely, a webinar, adding a preamble before depression survey questions, and an infographic. After participating in the webinar and reviewing the educational materials, all participants endorsed the three strategies as acceptable/very acceptable and feasible/very feasible.

Conclusion

Although there are barriers to implementing a suicide prevention protocol within primary care, it is possible to overcome them with strategies deemed both acceptable and feasible. These results offer promising practice solutions to implement a suicide prevention protocol in smoking cessation programs delivered in primary care settings. Future efforts should track implementation of these strategies and measure outcomes, including provider confidence, self-efficacy, and knowledge, and patient outcomes.

Veteran Experiences With Suicide Ideation, Suicide Attempt, and Social Support in Safety Planning Within the Department of Veterans Affairs

INTRODUCTION

This evaluation examined the role of safety plans, one of a host of clinical suicide prevention interventions available for veterans through the United States Department of Veterans Affairs' national network of health care facilities managed by the Veterans Health Administration (VHA).

MATERIALS AND METHODS

Interviews were conducted with veterans who had experienced suicidal ideation or a suicide attempt since enrolling in the Department of Veterans Affairs health care system (N = 29). Topics included negative life experiences, triggers for suicidal ideation or a suicide attempt, ability to recall and utilize safety plans in crisis, safety plan elements found most and least useful, and improvements to safety planning.

RESULTS

Eighteen (62.07%) of the veterans in the sample had attempted suicide. Drug use was by far the most triggering and overdose was the most negative life event to subsequent ideation or attempt. Although all at-risk veterans should have a safety plan, only 13 (44.38%) created a safety plan, whereas 15 (51.72%) could not recall ever creating a safety plan with their provider. Among those who did recall making a safety plan, identifying warning signs was the most remembered portion. The most useful safety plan elements were: recognizing warning signs, supportive people and distracting social settings, names and numbers of professionals, giving the veteran personal coping strategies, options for using the plan, and keeping their environment safe. For some veterans, safety plans were seen as insufficient, undesirable, not necessary, or lacking a guarantee. The suggested improvements included involving concerned significant others, specific actions to take in a crisis, and potential barriers and alternatives.

CONCLUSIONS

Safety planning is a critical component in suicide prevention within VHA. However, future research is needed to ensure safety plans are accessible, implemented, and useful to veterans when in crisis.

A national examination of suicidal ideation, planning, and attempts among United States adults: Differences by military veteran status, 2008-2019

There is a widening disparity in suicide deaths between United States (U.S.) military veterans and nonveterans. However, it is unclear if there are similar differences in suicidal ideation, planning, and attempts that often precipitate these deaths. A better understanding of trends in suicidal thoughts and behaviors could illuminate opportunities for prevention. We examined pooled cross-sectional data (N = 479,801 adults) from the 2008 to 2019 National Survey on Drug Use and Health. We examined differences in past-year suicidal ideation, suicide planning, and suicide attempts between U.S. veterans (n = 26,508) and nonveterans (n = 453,293). We conducted post hoc analyses to examine for differences in these relationships by race/ethnicity and sex. Lastly, we examined trends in these outcomes over time and tested for differences in trends by veteran status. Overall, veterans had significantly greater odds of past-year suicidal ideation (aOR = 1.33, 95% CI 1.20 to 1.47) and suicide planning (aOR = 1.52, 95% CI 1.30 to 1.78) compared to nonveterans. However, the association between veteran status and past-year suicide attempt was not statistically significant (aOR = 1.29, 95% CI 1.00 to 1.68). These relationships did not differ by race/ethnicity or sex (ps > 0.05). Among all adults, there were significant linear increases in past-year suicidal ideation, planning, and attempts (ps < 0.001). However, these trends did not differ between veterans and nonveterans (ps > 0.05). Veterans may be more likely to experience suicidal thoughts and behaviors than nonveteran adults. Upward trends in suicidal thoughts and behaviors among both veterans and nonveterans from 2008 to 2019 highlight opportunities for intervention.

Systems Approach to Suicide Prevention: Strengthening Culture, Practice, and Education

Contemporary approaches to suicide prevention extend beyond an individual's interactions with care providers to seek opportunities for improvement in the wider care system. A systems-based analysis can yield opportunities to improve prevention and recovery across the care continuum. This article uses an example of an individual seeking care in an emergency department to show how a traditional clinical case formulation can be framed in terms of the outer and inner contexts of the EPIS (Exploration, Preparation, Implementation, Sustainment) framework to illuminate the impact of systemic factors on outcomes and to identify opportunities for improvement. Three mutually reinforcing domains (a culture of safety and prevention; best practices, policies, and pathways; and workforce education and development) of a systems approach to suicide prevention are outlined, along with their defining characteristics. A culture of safety and prevention requires engaged, informed leaders who prioritize prevention; lived experience integrated into leadership teams; and adverse events review in a Restorative Just Culture focused on healing and improvement. Best practices, policies, and pathways that promote safety, recovery, and health require codesign of processes and services and evolve through continuous measurement and improvement. To support a culture of safety and prevention, and caring, competent application of policy, organizations benefit from a longitudinal approach to workforce education. This includes a common framework and language; models clinical and lived experience collaboration; and supports continuous learning, as well as onboarding of new staff, rather than following a "one-and-done" approach, so that suicide prevention training remains top of mind across the workforce.

Predictive Importance of Social Contacts on U.S. Veteran Suicide Safety Plans

OBJECTIVE

Safety planning is a suicide prevention intervention that relies partly on an individual's social relationships as distractions during or help in a suicidal crisis. The primary objectives of this study were to estimate rates of missingness on social aspects of safety plans to determine whether rates differ by demographic characteristics and diagnoses and to examine whether missing social contacts on safety plans may affect clinical outcomes.

METHODS

Data were drawn from the U.S. Department of Veterans Affairs San Diego Healthcare System's electronic medical record (N=1,602 individuals) from 2018 to 2021. Safety plans were coded according to the absence of listed distraction or help contacts, and clinical records of suicide attempts, suicide deaths, and use of crisis services were recorded for 1 year after completion of the safety plan.

RESULTS

In total, 30% of plans lacked a contact for distraction or help. Male veterans were less likely to have a distraction contact listed, and veterans identifying as Hispanic or Latino were more likely to have a help contact listed. The lack of a help contact (odds ratio [OR]=2.11) and having neither distraction nor help contacts (OR=2.45) were associated with a markedly higher risk for next-year suicide attempt or death. The lack of a help contact was associated with increased odds of a next-year psychiatric inpatient hospitalization (OR=1.90) and an emergency department visit (OR=1.88).

CONCLUSIONS

A lack of social contacts on safety plans may be a potential indicator for increased suicide risk among veterans.

Adapted suicide safety plans to address self-harm, suicidal ideation, and suicide behaviours in autistic adults: protocol for a pilot randomised controlled trial

BACKGROUND

Suicide prevention is a national priority for the UK government. Autistic people are at greater risk of experiencing self-harm and suicidal thoughts and behaviours than the general population. Safety plans are widely used in suicide prevention but have not yet been designed with and for autistic people. We developed the first safety plan specifically targeting suicidality in autistic adults: the Autism Adapted Safety Plan (AASP). It consists of a prioritised list of hierarchical steps that can be used prior to or during a crisis to mitigate risk of self-harm and suicidal behaviour. This is a pilot study that aims to assess the feasibility and acceptability of the AASPs and the research processes, including the response rates, potential barriers and reach of AASPs, methods of recruitment, what comprises usual care, and economic evaluation methods/tools.

METHODS

This is an external pilot randomised controlled trial of a suicide prevention tool aimed at mitigating the risk of self-harm and suicidal behaviour in autistic adults: AASPs. Participants will be assessed at baseline and followed up 1 month and 6 months later. Assessments include questions about self-harm, suicidality, service use, and their experience of the AASP/taking part in the study. Autistic adults who have a clinical autism diagnosis and self-reported history of self-harm, suicidal thoughts, or suicidal behaviours within the last 6 months will be invited to take part in the study. Informed consent will be obtained. Participants will be recruited via community and third sector services (including community settings, autism charities, and mental health charities). They may also "self-refer" into the study through social media recruitment and word of mouth. Ninety participants will be randomised to either develop an AASP or receive their usual care in a 1:1 ratio.

DISCUSSION

The present study will provide an evaluation of the suitability of the processes that would be undertaken in a larger definitive study, including recruitment, randomisation, methods, questionnaires, outcome measures, treatment, and follow-up assessments.

TRIAL REGISTRATION

ISRCTN70594445, Protocol v4: 8/2/22.

Effectiveness of Suicide Safety Planning Interventions: A Systematic Review Informing Occupational Therapy

Background. Suicide safety planning (SSP) is a suicide prevention approach that involves developing a collaborative plan between a service provider such as an occupational therapist and a person who is at risk of suicide. Purpose. To synthesize effectiveness studies on SSP. Method. Using the Joanna Briggs Institute methodology, we conducted a systematic review of effectiveness studies including a: (1) title and abstract screening; (2) full-text review; (3) critical appraisal; and (4) narrative synthesis. Findings. We included 22 studies. Critical appraisal scores ranged from 38.5 to 92.3 (m = 63.7). The types of interventions included were: standard and enhanced SSP (n = 11); electronically delivered SSP (n = 5); and SSP integrated with other approaches (n = 6). Only three studies identified meaningful activity as a component of SSP. Evidence across a range of studies indicates that SSP is effective for reducing suicide behavior (SB) and ideation (SI). While some studies have demonstrated effectiveness for reducing symptoms of mental illness, promoting resilience and service use, the number of studies exploring these outcomes is currently limited. Implications. Occupational therapists support individuals expressing SI, and SSP is a necessary skill for practice.

Utilizing digital predictive biomarkers to identify Veteran suicide risk

Veteran suicide is one of the most complex and pressing health issues in the United States. According to the 2020 National Veteran Suicide Prevention Annual Report, since 2018 an average of 17.2 Veterans died by suicide each day. Veteran suicide risk screening is currently limited to suicide hotlines, patient reporting, patient visits, and family or friend reporting. As a result of these limitations, innovative approaches in suicide screening are increasingly garnering attention. An essential feature of these innovative methods includes better incorporation of risk factors that might indicate higher risk for tracking suicidal ideation based on personal behavior. Digital technologies create a means through which measuring these risk factors more reliably, with higher fidelity, and more frequently throughout daily life is possible, with the capacity to identify potentially telling behavior patterns. In this review, digital predictive biomarkers are discussed as they pertain to suicide risk, such as sleep vital signs, sleep disturbance, sleep quality, and speech pattern recognition. Various digital predictive biomarkers are reviewed and evaluated as well as their potential utility in predicting and diagnosing Veteran suicidal ideation in real time. In the future, these digital biomarkers could be combined to generate further suicide screening for diagnosis and severity assessments, allowing healthcare providers and healthcare teams to intervene more optimally.

Crisis service utilization following completion of a suicide safety plan for Veterans with and without affective and nonaffective psychosis

OBJECTIVE

Psychosis is associated with increased suicide risk. Safety planning is a suicide prevention practice that is associated with decreased suicidal behavior and psychiatric hospitalizations. A common feature of safety planning is listing of crisis line numbers. The primary purpose of this study was to compare Veterans with and without psychosis who completed a safety plan in terms of their next year crisis service use, including Veterans Crisis Line (VCL) calls, and suicidal behavior.

METHODS

Data were drawn from the VA San Diego's electronic medical record system for (N = 1602) safety plans from 2018 to 2021. Clinical records of crisis services and suicide attempt/death were recorded for one year after the safety plan.

RESULTS

Following completion of a safety plan, Veterans with psychosis were more likely to have a next year psychiatric hospitalization (OR = 4.1), emergency department visit (OR = 2.3), and psychiatric emergency clinic visit (OR = 2.2) than those without psychosis. In contrast, there were no group differences in likelihood of calling the VCL.

CONCLUSIONS

Veterans with psychosis who recently completed a safety plan do not show elevated rates of VCL use that are commensurate with increases in crisis service use. Interventions for this high-risk group may focus on understanding the motivation and ability to call the VCL as ways to enhance safety planning.

Feasibility of Peer-Delivered Suicide Safety Planning in the Emergency Department: Results From a Pilot Trial

OBJECTIVE

The emergency department (ED) is an important site for suicide prevention efforts, and safety planning has been identified as a best practice for suicide prevention among ED patients at increased suicide risk. However, few ED clinicians are prepared to assess suicide risk or guide patients in the creation of safety plans. This study was a pilot randomized controlled trial of the feasibility, acceptability, and preliminary effects of safety planning by individuals with lived experience of suicide attempt or of severe suicidal ideation but without medical training (i.e., peers) in the ED.

METHODS

Patients at risk for suicide in a general ED were randomly assigned to receive peer-delivered or mental health provider–delivered safety planning. Intervention feasibility measures included ED length of stay, safety plan completeness, and safety plan quality. Acceptability measures included patient satisfaction. Preliminary effects were assessed as number of ED returns within the 3 months after the ED visit.

RESULTS

Data from 31 participants were available for analysis. Compared with participants with provider-delivered safety planning, participants with peer-delivered safety planning had similar ED lengths of stay, higher safety plan completeness, and higher safety plan quality. Acceptability of the safety planning process was similar for the two groups. Compared with participants receiving provider-delivered safety planning, participants receiving peer-delivered planning had significantly fewer ED visits during the subsequent 3 months than during the 3 months preceding the ED visit.

CONCLUSIONS

Peer-delivered safety planning is feasible and acceptable and may result in fewer return ED visits. These findings provide preliminary support for peer-delivered safety planning in the ED.

The Effectiveness of the Safety Planning Intervention for Adults Experiencing Suicide-Related Distress: A Systematic Review

The safety planning intervention (SPI) is gaining momentum in suicide prevention practice and research. This systematic review sought to determine the effectiveness of the SPI for adults experiencing suicide-related distress. Systematic searches of international, peer-reviewed literature were conducted in six databases (Cochrane Trials, Embase, Emcare, Medline, PsycINFO and Web of Science), including terms for safety planning, suicide, and suicide-related outcomes. A total of 565 results were included for screening. Result screening (title/abstract and full-text), data extraction and critical appraisal were conducted in duplicate. Twenty-six studies met the inclusion criteria. Studies were primarily quantitative (n = 20), largely with general adult or veteran samples; a small number of studies explored the perspectives of staff and significant others. Half of the studies included the SPI as a standalone intervention, while the other half examined the SPI in combination with other interventions. Most interventions were delivered in-person, with a hard-copy safety plan created, while a smaller number explored internet-based interventions. Primary measures included: suicidality (ideation, behavior, deaths; 10 studies), suicide-related outcomes (depression, hopelessness; 5 studies) and treatment outcomes (hospitalizations, treatment engagement; 7 studies). The evidence supports improvements in each of these domains, with complementary findings from the remaining quantitative and qualitative studies suggesting that the SPI is a feasible and acceptable intervention. While positive, these findings are limited by the heterogeneity of interventions and study designs, making the specific impact of the SPI difficult to both determine and generalize. Conversely, this also points to the flexibility of the SPI.HighlightsThe Safety Planning Intervention (SPI) is a valuable indicated intervention for general adult and veteran populations experiencing suicide-related distress, primarily in face-to-face, clinical settings.Quantitative findings indicate associations between the SPI and improvements in suicidal ideation and behavior, decreases in depression and hopelessness, along with reductions in hospitalizations and improvements in treatment attendance.Qualitative studies suggest the SPI is acceptable and feasible, with areas for development.SPIs have been shown to be adaptable to the clinical area in its modality (digital or paper-based), delivery (face-to-face or online), facilitation (clinician or self-administered) and multiplicity (as stand-alone or combined intervention).

Local implementation evaluation of a suicide prevention predictive model at a large VA health care system

BACKGROUND

The Veterans Health Administration (VHA) implemented REACH VET, which analyzes health records to identify veterans at statistically elevated risk for suicide and other adverse outcomes compared to other veterans in VHA. This project evaluated REACH VET program implementation at a large VA health care system by examining program fidelity and treatment engagement, receipt of suicide prevention interventions, and suicide-related behaviors in the 6 months following identification.

METHODS

Over a 12-month period, 218 unique cases were identified by REACH VET within a local VA system. Data were extracted from the VA's electronic medical records.

RESULTS

Protocol adherence for required clinical and administrative steps was 94% and above. After identification, 88% received outpatient mental health treatment, 21% had a psychiatric hospitalization, and 83% engaged in Safety Planning around the time of identification or in the following six months. Twenty-six percent of cases were identified by another existing method for identifying high-risk veterans. Five percent had a medically documented suicide attempt, and none were known to die by suicide in the following 6 months.

CONCLUSIONS

Local evaluation suggested high protocol fidelity and high engagement in mental health and suicide prevention services following identification among veterans who remained at elevated risk in the 6 months that followed.

Self-reported Access to Firearms Among Patients Receiving Care for Mental Health and Substance Use

Question

Did patients respond to a standard question about firearm access on a mental health questionnaire, and, if so, how did they respond?

Findings

In this cross-sectional study of 128 802 patients receiving care for mental health and substance use, 83% of primary care patients answered a standard question about firearm access and 21% reported access. In mental health clinics, 92% of patients answered the question and 15% reported access.

Meaning

In this study, most patients reported firearm access on standard questionnaires; this screening practice may improve efforts to identify and engage patients at risk of suicide in discussions about securing firearms.

Importance

Firearms are the most common method of suicide, one of the “diseases of despair” driving increased mortality in the US over the past decade. However, routine standardized questions about firearm access are uncommon, particularly among adult populations, who are more often asked at the discretion of health care clinicians. Because standard questions are rare, patterns of patient-reported access are unknown.

Objective

To evaluate whether and how patients self-report firearm access information on a routine mental health monitoring questionnaire and additionally to examine sociodemographic and clinical associations of reported access.

Design, Setting, and Participants

Cross-sectional study of patients receiving care for mental health and/or substance use in primary care or outpatient mental health specialty clinics of Kaiser Permanente Washington, an integrated health insurance provider and care delivery system.

Main Outcomes and Measures

Electronic health records were used to identify patients who completed a standardized self-reported mental health monitoring questionnaire after a single question about firearm access was added from January 1, 2016, through December 31, 2019. Primary analyses evaluated response (answered vs not answered) and reported access (yes vs no) among those who answered, separately for patients seen in primary care and mental health. These analyses also evaluated associations between patient characteristics and reported firearm access. Data analysis took place from February 2020 through May 2021.

Results

Among patients (n = 128 802) who completed a mental health monitoring questionnaire during the study period, 74.4% (n = 95 875) saw a primary care clinician and 39.3% (n = 50 631) saw a mental health specialty clinician. The primary care and mental health samples were predominantly female (63.1% and 64.9%, respectively) and White (75.7% and 77.0%), with a mean age of 42.8 and 51.1 years. In primary care, 83.4% of patients answered the question about firearm access, and 20.9% of patients who responded to the firearm question reported having access. In mental health, 91.8% of patients answered the question, and 15.3% reported having access.

Conclusions and Relevance

In this cross-sectional study of adult patients receiving care for mental health and substance use, most patients answered a question about firearm access on a standardized mental health questionnaire. These findings provide a critical foundation to help advance understanding of the utility of standardized firearm access assessment and to inform development of practice guidelines and recommendations. Responses to standard firearm access questions used in combination with dialogue and decision-making resources about firearm access and storage may improve suicide prevention practices and outcomes.

"What Will Happen If I Say Yes?" Perspectives on a Standardized Firearm Access Question Among Adults With Depressive Symptoms

OBJECTIVE

Addressing firearm access is recommended when patients are identified as being at risk of suicide. However, the practice of assessing firearm access is controversial, and no national guidelines exist to inform practice. This study qualitatively explored patient perspectives on a routine question about firearm access to optimize the patient centeredness of this practice in the context of suicide risk.

METHODS

Electronic health record data were used to identify primary care patients reporting depressive symptoms, including suicidal thoughts, within 2 weeks of sampling. Participants completed a semistructured telephone interview (recorded and transcribed), which focused broadly on the experience of being screened for suicidality and included specific questions to elicit beliefs and opinions about being asked a standard firearm access question. Directive (deductive) and conventional (inductive) content analysis was used to analyze responses to the portion of the interview focused on firearm assessment and disclosure.

RESULTS

Thirty-seven patients in Washington State ages 20-95 completed the qualitative interview by phone. Organizing themes included apprehensions about disclosing access to firearms related to privacy, autonomy, and firearm ownership rights; perceptions regarding relevance of the firearm question, informed by experiences with suicidality and common beliefs and misconceptions about the inevitability of suicide; and suggestions for connecting questions about firearms and other lethal means to suicide risk.

CONCLUSIONS

Clarifying the purpose and use of routine firearm access assessment, contextualizing firearm questions within injury prevention broadly, and addressing misconceptions about suicide prevention may help encourage disclosure of firearm access and increase the patient centeredness of this practice.

Staff Perspectives of Safety Planning as a Suicide Prevention Intervention for People of Refugee and Asylum-Seeker Background

Background: Safety planning involves the co-development of a personalized list of coping strategies to prevent a suicide crisis. Aims: We explored the perspectives of workers regarding safety planning as a suicide prevention strategy for people of refugee background and those seeking asylum in Australia. Method: Participants attended suicide prevention training, specific to refugees and asylum seekers, at which safety planning was a key component. Semistructured, posttraining interviews (n = 12) were analyzed thematically. Results: Four key themes were identified: safety planning as a co-created, personalized activity for the client; therapeutic benefits of developing a safety plan; barriers to engaging in safety planning; strategies to enhance safety planning engagement. Limitations: First-hand refugee and asylum-seeker experiences were not included. Conclusion: As a relatively low-cost, flexible intervention, safety planning may be valuable and effective for these groups.

Suicide safer care in behavioral health settings: A comparative analysis of perceptions, training completion, and practice between mental health and substance use disorder treatment providers

BACKGROUND

Despite prevention and treatment efforts, opioid overdose deaths continue to rise in the United States and totaled 46,802 in 2018. This public health crisis is closely linked with suicide, with those who misuse opioids at six times the risk of death by suicide. Suicide prevention in substance use disorder (SUD) treatment may be a critical step in saving lives and promoting recovery among those at risk for opioid overdose.

METHODS

We distributed an electronic survey to clinicians in mental health and SUD treatment in nine health systems across New York State from November 2018 to January 2019. The goal of the survey was to assess attitudes, perceptions, practice, and training needs among SUD treatment providers and how they differ from those of mental health providers.

RESULTS

A total of 633 clinicians responded to the survey (62.4% response rate). Seventy-one percent of SUD providers reported working with a client who attempted suicide. Even so, less than half of SUD providers reported routinely screening new (48.9%) or existing patients (25.6%) for suicidal thoughts/behaviors; overall, 28.4% of SUD providers reported low levels of action to address suicide risk, compared to 9.0% of mental health providers (p < 0.001). Perceived self-efficacy and effectiveness at reducing a patient's risk of suicide and training completion were strongly associated with routine delivery of suicide safer care in adjusted logistic regression models.

CONCLUSIONS

The results of this study identify key areas for targeted training and technical assistance to increase the provision of quality suicide safer care in SUD treatment.

Areas of Improvement in Suicide Risk Identification, Assessment, and Risk Mitigation Documentation by Mental Health Prescribers at a Veterans Affairs Health Care System

PURPOSE

Veterans have a suicide rate 1.5 times higher than the non-veteran population. The Department of Veterans Affairs (VA) implemented suicide risk screening recommendations in 2018. This project assessed the impact of mental health (MH) prescribers on these recommendations and identified areas of improvement.

METHODS

Seventy MH Clinical Pharmacy Specialists (CPS) and 52 other MH prescribers were included. Patients with a positive question nine (from the Patient Health Questionnaire-9) and a same-day Columbia Suicide Severity Rating Scale (C-SSRS) between 11/01/18 and 11/01/19 at a VA system were reviewed. Completion of same-day Comprehensive Suicide Risk Evaluation (CSRE), same-day Suicide Prevention Safety Plan (SPSP), number of patients who were not offered naloxone despite access to opioids, and number of patients who were not offered a gunlock despite access to firearms were compared between groups. Time from C-SSRS to suicidal behavior was compared between those who did and did not receive a same-day CSRE.

RESULTS

MH CPS were significantly more likely to complete a same-day CSRE (p = 0.0201) and SPSP (p < 0.001) when recommended. Naloxone outcomes were not assessed due to availability of only one data point. Rates of gunlock offers did not differ significantly between groups (Fisher's exact test, p = 0.3189) however there was no documentation stating why they were not offered when appropriate 40% of the time. Time to suicidal behavior did not vary across patients based on CSRE completion (p = 0.16).

CONCLUSION

MH CPS play an important role in suicide risk screening for veterans. There is a need for improvement regarding the offering and documentation of firearm risk mitigation strategies.

Metacognitive Training for Depression: Feasibility, safety and acceptability of two new treatment modules to reduce suicidality

Recent evidence favours psychological interventions explicitly targeting suicidality; however, group treatments on suicidality are rare and are assumed to have unfavourable effects. We developed two modules specifically addressing suicidality that replace two existing modules in the Metacognitive Training for Depression (D-MCT). The aim of the current study was to examine the feasibility, safety, and acceptability of this intervention (D-MCT/S). Forty-eight inpatients with depression received eight sessions of D-MCT/S over 4 weeks in addition to standard treatment. Patients were assessed before the training, 4 and 8 weeks later regarding suicidality (primary outcome: Beck Suicide Scale [BSS]), hopelessness, depression (e.g. Hamilton Depression Rating Scale [HDRS]), dysfunctional attitudes, and self-esteem. Negative effects of the modules and subjective appraisal were assessed. Suicidality, hopelessness, and depression decreased over time. Whereas the effects on the BSS only reached trend level, a large effect was observed when the suicide item of the HDRS was used. Two of the 46 patients (4%) reported a deterioration in their symptoms, but this was not associated with the D-MCT/S. Negative effects of the general training were rather low, and acceptability was high. In general, patients evaluated the two new modules on suicidality similarly to the established modules. However, both modules were assessed as distressing by 39% of the patients. When we addressed suicidality in the D-MCT/S, we did not observe any contagious effects. In fact, the pilot versions of the two modules on suicidality are promising in terms of feasibility, safety, and acceptability. The results will be used to improve current shortcomings. The trial was registered with the German Clinical Trials Register (#DRKS-ID: DRKS00010543) on 23 August 2016.

Implementing nudges for suicide prevention in real-world environments: project INSPIRE study protocol

Background

Suicide is a global health issue. There are a number of evidence-based practices for suicide screening, assessment, and intervention that are not routinely deployed in usual care settings. The goal of this study is to develop and test implementation strategies to facilitate evidence-based suicide screening, assessment, and intervention in two settings where individuals at risk for suicide are especially likely to present: primary care and specialty mental health care. We will leverage methods from behavioral economics, which involves understanding the many factors that influence human decision making, to inform strategy development.

Methods

We will identify key mechanisms that limit implementation of evidence-based suicide screening, assessment, and intervention practices in primary care and specialty mental health through contextual inquiry involving behavioral health and primary care clinicians. Second, we will use contextual inquiry results to systematically design a menu of behavioral economics-informed implementation strategies that cut across settings, in collaboration with an advisory board composed of key stakeholders (i.e., behavioral economists, clinicians, implementation scientists, and suicide prevention experts). Finally, we will conduct rapid-cycle trials to test and refine the menu of implementation strategies. Primary outcomes include clinician-reported feasibility and acceptability of the implementation strategies.

Discussion

Findings will elucidate ways to address common and unique barriers to evidence-based suicide screening, assessment, and intervention practices in primary care and specialty mental health care. Results will yield refined, pragmatically tested strategies that can inform larger confirmatory trials to combat the growing public health crisis of suicide.

Usual Care for Emergency Department Patients Who Present with Suicide Risk: A Survey of Hospital Procedures in Washington State

Hospital emergency departments (EDs) are important settings for the implementation of effective suicide-specific care. Usual care for suicidal patients who present to EDs remains understudied. This study surveyed EDs in Washington State to assess the adoption of written procedures for recommended standards of care for treating suicidality. Most (N = 79, 84.9%) of the 93 EDs in Washington State participated. Most (n = 58, 73.4%) hospitals had a written protocol for suicide risk assessment, but half (n = 42, 53.2%) did not include documentation of access to lethal means. There was evidence of an association between patient volume and the adoption of suicide-specific protocols and procedures. Our findings suggest the need to enhance the adoption and implementation of recommended standard care in this setting.

DSM-5 PTSD symptom clusters and suicidal ideation in veterans

Posttraumatic stress disorder (PTSD) is associated with significantly greater risk for suicidal ideation (SI). In civilians, the negative alterations in cognitions and mood (NACM) and alterations in arousal and reactivity (AAR) clusters are most strongly associated with SI. This study sought to examine the association between PTSD symptom clusters and SI in a large sample of veterans. Veterans (n = 1,789) completed the PTSD Checklist for DSM-5 and the Patient Health Questionnaire (PHQ) during primary care visits. Wald chi-square tests of parameter constraints were computed to test hypothesized relations between PTSD factors and the PHQ-9 suicidal ideation item. Each of the PTSD symptom clusters were significantly associated with SI. The NACM cluster was more strongly associated with SI than AAR and marginally more strongly associated with SI than the avoidance symptom clusters. In a restricted sample of only veterans with PTSD, NACM remained more strongly associated with SI than avoidance. Each of the NACM symptoms were significantly associated with SI. Changes in cognitions and mood were most strongly associated with SI in this large sample of veterans. These findings suggest that directly targeting the NACM symptom cluster may be an important goal for suicide prevention efforts among veterans with PTSD.

Integrating crisis response planning for suicide prevention into trauma-focused treatments: A military case example

OBJECTIVE

Posttraumatic stress disorder (PTSD) and suicidal thoughts and behaviors are common in military members and veterans and produce anxiety for many clinicians. Although there are separate interventions for PTSD and elevated suicide risk, there is not much guidance on how to integrate these approaches. Crisis response planning (CRP) is an evidence-based tool used to prevent suicide attempts that can easily be integrated into trauma-focused therapies for patients with PTSD.

METHOD

Given the high frequency of suicidal thoughts among patients with PTSD, the current paper discusses how CRP can be integrated into trauma-focused therapy. A clinical case example is provided to demonstrate how the CRP can be integrated into cognitive processing therapy for a suicidal veteran diagnosed with PTSD.

RESULTS

Using CRP within a cognitive processing therapy treatment program reduced both PTSD and suicidal ideation.

CONCLUSIONS

Suicide specific treatments can be integrated effectively into trauma-focused treatments.

Are the "Right" People Selected for First Disclosures About Suicidal Thoughts? Exploring What We Know About Advance Care Planning in the Context of Safety Planning

Nominating primary confidants (i.e., safety plan nominees) is central to safety planning for suicide but there is a dearth of research about such confidants-a serious oversight given their high-leverage position to affect pathways into clinical care. Informed by advance care planning (ACP) work, this study examined differences between social network members who were and were not identified as primary confidants on attributes that could impact their effectiveness in a helping role. Using social network methodology, information was collected from 41 individuals with affective disorders about the 332 people and relationships in their networks. Logistic regression analysis revealed that being perceived as capable of managing stress and prioritizing the participant's best interests over one's own increased the odds of being a primary confidant. Clinicians working with suicidal individuals may benefit from integrating ACP principles-which recognize the thoughtful selection of nominees based on specific attributes-into their safety planning procedures.

Cognitive behavioral therapy for suicide prevention (CBT-SP): Implications for meeting standard of care expectations with suicidal patients

Accumulating evidence supports the efficacy of cognitive behavioral therapy for suicide prevention (CBT-SP) as an empirically supported treatment approach for suicidal patients. In light of these findings, several procedures pulled from CBT-SP have been recommended for standard care with suicidal patients. The present article provides an overview of the procedures used in CBT-SP and discusses how these procedures meet, or even exceed, standard of care expectations for outpatient mental healthcare clinicians. Finally, the relevance of clinician fidelity to the CBT-SP model when evaluating standard of care expectations is discussed.

Documenting suicide risk assessments and proportionate clinical actions to improve patient safety and mitigate legal risk

Few clinical practices are as important for simultaneously augmenting patient safety and mitigating legal risk as the judicious evaluation and stratification of a patient's risk for suicide, proportionate clinical actions based thereon taken by the healthcare provider, and contemporaneous documentation of the foregoing. In this article, we draw from our combined decades of multidisciplinary experience as a clinical psychologist, forensic psychiatrist, medical malpractice attorney, and clinical psychology trainee to discuss the documentation of suicide risk assessment and management as a conduit to patient safety and legal risk mitigation. We additionally highlight documentation as a core clinical competency across disciplines and note areas of improvement, such as increased training, to bolster documentation practices.