Suicide-Focused Group Therapy for Veterans

Group brief cognitive behavioral therapy for suicide prevention compared to dialectal behavior therapy skills group for military service members: a study protocol of a randomized controlled trial

BACKGROUND

Suicide is a pressing matter for the military. Not only does it pose a health risk, but suicide also compromises operational readiness. Despite provision of suicide prevention clinical best practices, the Department of Defense suffers several challenges (e.g., clinician shortages) limiting the agency's ability to effectively respond to service member suicide. Implementation of evidence-based suicide-specific group therapy is a possible solution to service member well-being needs and system challenges. Service members can also gain coping skills useful beyond managing suicidal thoughts and behaviors.

METHODS

This 2-arm non-inferiority randomized controlled trial compares a group therapy format of Brief Cognitive Behavioral Therapy (i.e., G-BCBT) with Dialectical Behavior Therapy (DBT) Skills Group. Both therapies are delivered in-person at a United States Naval Medical Center. Participants (N = 136) are active-duty service members with recent suicidal thoughts or suicidal behavior. Evaluation features electronically delivered questionnaires at baseline, after each treatment session, and at 3- and 6-month follow-up.

DISCUSSION

The primary outcome concerns G-BCBT impacts on suicidal ideation. Secondary outcomes of interest are suicide attempt, psychological distress (e.g., symptoms of depression, anxiety), and self-regulatory skills (e.g., emotion regulation). We also examine self-regulatory skills as treatment moderators. Clinical trial strengths and limitations are reviewed.

TRIAL REGISTRATION

This study was registered at Clinicaltrials.gov (protocol NCT05401838).

Cost comparison of in-person and telehealth modalities for a suicide safety planning group intervention: interim results from the "Project Life Force" randomized clinical trial

Suicide prevention is a clinical priority for the US Veterans Health Administration. Evidence-based interventions, including developing a suicide safety plan, are recommended practices and are becoming more widespread. Adaptations to further augment safety planning include a manualized group intervention (Project Life Force, PLF) that combines safety planning with the teaching of skills to maximize use of the plan. A multi-year randomized controlled trial to test efficacy of PLF compared to treatment as usual is currently in progress. However, approximately a year into the study, in-person groups were converted to telehealth groups due to the COVID-19 pandemic. This study compares the per-veteran cost of PLF when delivered in-person versus by telehealth using preliminary trial data from the first 2.5 years of the trial. Cost to deliver PLF was obtained from the Veterans Health Administration's Managerial Cost Accounting data, which relies on activity-based costing. We found no significant differences in the average number of sessions or average group size between in-person and telehealth. However, the cost per group session was lower for the telehealth modality and this led to significant overall per-veteran savings. While efficacy data comparing from the two arms is still underway and we await the ongoing RCT results, our interim cost analysis highlights potential savings with the telehealth modality.

Suicide-Focused Group Therapy

Background: Although there are several studies focusing on group models for therapy specific to suicidal thoughts and behaviors, scoping reviews providing an overview of these studies' findings are limited. Aims: The aim of this paper was to conduct a scoping review of group therapies that explicitly target suicidal thoughts and behaviors (i.e., suicide-focused) for adults and their suicide-related outcomes. Methods: Following the PRISMA-ScR guidelines, a literature search using PubMed, Cochrane Library, and PsycINFO to identify relevant records published between 2000 and 2021 as well as a review of reference lists from relevant records was conducted. Results: There were 14 records identified with 12 unique suicide-focused group therapies. Even with variable methodological designs, sample sizes (M = 136, SD = 98), and population targeted, all records showed reductions in suicide-related outcomes by the end of the therapy; although most were not powered to determine effectiveness. Limitations: This review only included records written in English and excluded support groups that were led by peers as the focus was on therapy groups and gray literature. Conclusions: There are few evaluated therapy groups that explicitly address suicidal thoughts and behaviors. Available data indicate suicide-focused group therapy are generally feasible, acceptable, and may reduce suicidal-related outcomes. This is encouraging for future research; recommendations to include randomized controlled trials of the efficacy of suicide-focused group therapy are discussed.

Pilot study of the Collaborative Assessment and Management of Suicidality-Group

INTRODUCTION

Few evidence-based options exist for outpatient treatment of patients at risk of suicide, and to-date almost all research has focused on individually delivered psychotherapy. Group therapy for veterans at risk of suicide is a promising alternative.

METHODS

Thirty veterans receiving care at an urban Veterans Affairs Medical Center in the southern United States were randomized to either care as usual (CAU) or to CAU plus the Collaborative Assessment and Management of Suicide-Group (CAMS-G). Veterans were assessed prior to randomization to condition and at 1, 3, and 6 months post-randomization on a range of suicide-specific measures, burdensomeness, belonging, treatment satisfaction, and group cohesion.

RESULTS

Across measures and follow-up assessments, veterans in CAMS-G reported good satisfaction with the intervention, a sense of cohesion with other members of the group, and reduced symptom distress. Veterans in both conditions reported decreases in suicidal ideation and behavior, with CAMS-G participants potentially improving slightly faster.

CONCLUSION

This description of CAMS-G for veterans adds to the growing literature on suicide-specific interventions and supports the need for additional research to determine if wide-spread rollout is justifiable.

Costs, benefits, and cost-benefit of Collaborative Assessment and Management of Suicidality versus enhanced treatment as usual

Suicide rates have been steadily increasing in both the U.S. general population and military, with significant psychological and economic consequences. The purpose of the current study was to examine the economic costs and cost-benefit of the suicide-focused Collaborative Assessment and Management of Suicidality (CAMS) intervention versus enhanced treatment as usual (ETAU) in an active duty military sample using data from a recent randomized controlled trial of CAMS versus ETAU. The full intent-to-treat sample included 148 participants (mean age 26.8 years ± 5.9 SD years, 80% male, 53% White). Using a micro-costing approach, the cost of each condition was calculated at the individual level from a healthcare system perspective. Benefits were estimated at the individual level as cost savings in past-year healthcare expenditures based on direct care reimbursement rates. Cost-benefit was examined in the form of cost-benefit ratios and net benefit. Total costs, benefits, cost-benefit ratios, and net benefit were calculated and analyzed using general linear mixed modeling on multiply imputed datasets. Results indicated that treatment costs did not differ significantly between conditions; however, CAMS was found to produce significantly greater benefit in the form of decreased healthcare expenditures at 6-month follow-up. CAMS also demonstrated significantly greater cost-benefit ratios (i.e., benefit per dollar spent on treatment) and net-benefit (i.e., total benefit less the cost of treatment) at 12-month follow-up. The current study suggests that beyond its clinical effectiveness, CAMS may also convey potential economic advantages over usual care for the treatment of suicidal active duty service members. Our findings demonstrate cost savings in the form of reduced healthcare expenditures, which theoretically represent resources that can be reallocated toward other healthcare system needs, and thus lend support toward the overall value of CAMS.

Group treatments for individuals at risk for suicide: A PRISMA scoping review (ScR)

BACKGROUND

This PRISMA scoping review explored worldwide research of interventions for suicide prevention delivered within a group setting. Research on group treatments underscores the importance of peer connection in diminishing social isolation and increasing social support. Additional benefits of group treatment include cost efficiency and maximization of staff time. However, the clinical outcomes of group treatments with individuals at risk for suicide are less understood and under researched.

AIM

This scoping review had two objectives: 1) To identify existing group treatments where suicidal thoughts and behaviors are openly discussed; 2) To examine the outcomes of these identified treatments, with special attention to treatment integrity.

METHOD

To address these aims the authors searched Medline (Ovid), Embase (Ovid), and PsycINFO (Ovid), on November 25, 2020. At the Full Text stage, articles were included that were peer reviewed, described a suicide specific group intervention and reported suicide specific outcomes. An additional requirement was open dialogue of suicide in the group intervention.

RESULTS

Only ten research reports of suicide-specific group treatments were identified in our PRISMA-ScR. In spite of many differences in setting, population, length, and frequency of sessions, all ten groups reported improvements in varying aspects of suicide symptoms. The only adverse impacts were reported by two studies wherein two (of 92) participants attempted suicide and a small number (7%) of adolescents reported feeling triggered with suicidal thinking during a session. Despite our focus on empirical data in this review, the methodological rigor of the studies evaluated was limited.

CONCLUSION

Despite the paucity of group treatment research in which suicidal thoughts and behaviors are openly discussed, the outcomes of these treatments were promising in decreasing suicide risk. These results may be due to unfounded fears of contagion. Further implications of these findings are considered along with limitations that may have excluded clinical work from meeting inclusion criteria for this review. Nonetheless, this evidence suggests that, suicide-focused groups have great potential for prevention of suicidal symptoms and should be further expanded in the future.

An Open Trial of a Suicide Safety Planning Group Treatment: "Project Life Force"

In 2008, the Department of Veterans Affairs mandated that clinicians oversee the construction of a Suicide Safety Plan for every patient who is identified as "high risk" for suicide. While the Suicide Safety Plan is a mandated "best practice," there are currently no recommended guidelines for its augmentation in a group setting. To address this gap, a novel group intervention, "Project Life Force," (PLF; a 10-session manualized psychotherapy), was developed and piloted. Results indicate high feasibility and acceptability. Exploratory analysis revealed statistically significant decreases in suicidal thoughts/behaviors, depression, and hopelessness. Feedback from Veterans and PLF therapists is also discussed. Despite some limitations (e.g. small sample size) exploratory results suggest that PLF may be a promising treatment for Veterans with suicidal symptomology.

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.

Veteran Suicide Risk Factors: A National Sample of Nonveteran and Veteran Men Who Died by Suicide

Veteran suicide is a serious public health problem. Some data suggest that veteran suicide risk profiles differ from those of nonveterans. Records for veteran (n = 21,692) and nonveteran (n = 83,430) men who died by suicide were examined from 17 U.S. states using the National Violent Death Reporting System data. Seventeen precipitating factors were examined and combined through meta-analysis of proportions. Many precipitating factors were found to be less frequent for veterans. A smaller number of factors were found to be higher in the veteran population, including physical health problems. A sizable cumulative effect size (1.02) was observed, suggesting that veteran and nonveteran men show meaningful and substantive differences in their risk profiles-differences that should be considered when planning and implementing suicide prevention and intervention efforts. The conspicuous role of physical health problems among veterans who die by suicide is discussed. The article concludes with specific practice recommendations for social workers.

Evaluation of Structured Assessment and Mediating Factors of Suicide-Focused Group Therapy for Veterans Recently Discharged from Inpatient Psychiatry

The current study investigated the impact of adding the Suicide Status Form (SSF) to a suicide-focused group therapy for veterans recently discharged from an inpatient psychiatry setting. A sample of 141 veterans was enrolled and randomized into a Usual Assessment Group Therapy or SSF-Assessment Group Therapy. Participants completed interviews at baseline, 1, and 3 months. No significant differences were observed between groups regarding group attendance (IRR = 1.01, Std. Err = 0.08, 95% CI = 0.87, 1.18) or client satisfaction (β = 0.23, Std. Err = 0.66, p = 0.73, d = -.25). No main effects were observed across the study on secondary outcomes of interest for suicidal ideation and overall symptom distress, although participants in both treatment conditions reported significant improvements on these outcomes over the course of the study. Patients in the Usual Assessment Group Therapy demonstrated greater reductions in overall symptom distress across the 3-month follow-up window (β = 6.08, Std. Err = 2.04, p = 0.003; f² = 0.05). Follow-up path analyses revealed that more frequent session attendance was significantly related to less suicidal ideation at 1-month, higher working alliance between individual members and group facilitators was associated with greater suicidal ideation at 1-month, and higher group cohesion among group members at 1-month was significantly associated with less thwarted belongingness at 1-month. Although the SSF did not improve the impact of an existing suicide-focused group therapy, the study findings support future research on group treatments for suicidal veterans.

Older Military Veteran Care: Many Still Believe They Are Forgotten

BACKGROUND

Almost 44% of our nation's 23 million men and women veterans are 65 years of age or older. Most are proud of their service, yet many believe their services for our country were forgotten, especially those in combat between 1950 and 1975.

PURPOSE

Further information to ultimately assist their holistic well-being will be important for nursing practice as countless older veterans are beginning to obtain more care within civilian facilities. Using the Korean War (1950-1953) as a backdrop to illustrate the interconnectiveness of older veteran physical, emotional, and spiritual concerns that can occur from a military deployment, the major purposes of this article are to provide a brief historical snapshot of that war and discuss prior-era military environmental situations that now are producing the lingering effects from their combat exposure.

DESIGN

Relevant literature about the Korean War and Veterans was compiled.

FINDINGS

Some of these health risks for both the Korean men and women veterans are cold exposure, neurologic, and posttraumatic stress disorder concerns, as well as the need for hepatitis C and suicide assessments.

CONCLUSIONS

To ultimately improve their bio-psycho-socio-spiritual well-being, prompt identification of the older military veteran, their lingering combat effects, and reminiscing will be important.

Suicide Attempt Characteristics Among Veterans and Active-Duty Service Members Receiving Mental Health Services: A Pooled Data Analysis

Past suicidal behaviors are among the strongest and most consistent predictors of eventual suicide and may be particularly salient in military suicide. The current study compared characteristics of suicide attempts in veterans (N = 746) and active-duty service members (N = 1,013) receiving treatment for acute suicide risk. Baseline data from six randomized controlled trials were pooled and analyzed using robust regression. Service members had greater odds of having attempted suicide relative to veterans, though there were no differences in number of attempts made. Service members also had higher rates of premilitary suicide attempts and nonsuicidal self-injury (NSSI). Veterans disproportionately attempted suicide by means of overdose. In veterans, combat deployment was associated with lower odds of lifetime suicide attempt, while history of NSSI was associated with greater attempt odds. Neither was significantly associated with lifetime suicide attempt in service members. Implications for suicide assessment and treatment are discussed.