Evidence-Based Synthesis Program - 26 -Department of Veteran Affairs

Suicide Prevention Interventions and Suicide Risk Factors and Risk Assessment Tools

**Transcript of Cyberseminar**

**Department of Veterans Affairs**

**Evidence Based Synthesis Program (ESP)**

**Suicide Prevention Interventions and Suicide Risk Factors and Risk Assessment Tools**

**Maya O’Neill, PhD, MS**

**Elizabeth Haney, MD**

**June 11, 2012**

Moderator:  Okay.  I’d like to introduce our presenters for today.  We do have Dr. Maya O’Neill.  She is a core investigator for the Evidence Based Synthesis Program located at the Portland VA Medical Center.  And she is also affiliated with Oregon Health Science—Oregon Health and Science University.  Joining her today as a co-presenter is Dr. Elizabeth Haney.  She is also an Assistant Professor in the Department of Medicine, Medical informatics and clinical epidemiology also at Oregon Health and Science University.

Joining us today generously offering their time is some panelists that will be available for the question and answer portion at the end of today’s presentation.  Those are Dr. Lisa Brenner.  She is the director of MIRECC and also the director of the Advanced Fellowship program in mental illness located in VISN 19 and she works for Central office.  Also joining her is Marcia Valenstein.  Dr. Marcia Valenstein.  I apologize.  She is a research scientist on serious mental illness treatment evaluation center located in Ann Arbor Michigan.  And finally we have Dr. John Bradley joining us who’s the Deputy Director of Mental Health Services, VA Boston Healthcare System.  We are very grateful to all of our presenters and panelists for sharing their expertise with us.  With that I would like to introduce our first speaker which is Dr. O’Neil.  Maya are you prepared to share your screen now?

Maya O’Neil:  Yes.  I’m all set.

Moderator:  Turn it over to you.  You’ll see a pop up and I’ll let you know when we can see your slides.  Great.  Thank you.

Maya O'Neil:  Excellent.  Thank you so much again for all the help with the preparing of the Cyberseminar and the introduction and organizing all this.  So thank you.  I’m here in Portland with Dr. Betsy Haney and we’re going to be doing about a thirty to forty minute presentation on the results of the two systematic reviews that we conducted for the evidence synthesis program that we conducted here in Portland.  And then a large portion of the presentation today is going to be focused on the discussion with our panelists.  Thank you very much for participating with us.  We really appreciate that you all are here and joining us today.

It looks like we still have some people starting but I’m going to go ahead and get started.  You all will have access to the slides afterwards and I’ll list in the presentation where you can get those.  I know we have a couple of questions about people wanting access to the slides over e-mail and we’ll address all of your questions after the cyber seminar.

We’ve just got to get these slides going here now.  All right.  So one of the very important things about these reports is that they take a lot of time and energy to complete and we absolutely could not do them without our outstanding team of research assistants and research associates and co investigators.  So a huge thank you to all of the coauthors on these reports.  This is really, truly an outstanding team.  These people just worked their tails off on these reports and they deserve a huge amount of credit for them.  Thank you.  Also thank you to our presenters and discussants because they’re here today—Drs. Brenner, Bradley and Valenstein and we also have a quite a large and involved team of peer reviewers and a technical expert panel.

I’ll tell you a little bit more about what those roles involve as we tell you a bit about the report.  We have a disclosure slide which I’m not going to read through, but feel free to read through that slide at your convenience.  But I do want to tell you a bit about the Evidence-based Synthesis Program.  And who were sponsored by, what kind of things we do.  I know a lot of people aren’t familiar with us.  They’re more familiar with the clinical or research topics that we’re talking about that have less familiarity with systematic reviews and what the other evidence based program does for the VA.

Importantly we’re sponsored by the VA QUERI program which is all about implementation in the VA and what we’re tasked to do is provide timely and accurate synthesis and reports on healthcare topics that are identified by all types of VA clinicians and managers and policy makers.  Anything that is really could be of benefit to our Veterans.  So these—our evidence based synthesis programs we’ve built on the back of expertise already in place.  At the evidence based practice centers but are designated by four of the evidence based practice centers.  There are about thirteen to fifteen nationwide in general but four of them are mixed with evidence synthesis programs in Durham; in Los Angeles; Portland and Minneapolis.  That’s the sites that we had.  Portland was assigned these two reports on suicide prevention.

A little bit more about the evidence synthesis program.  We developed clinical policies that are informed by evidence.  We design reports to develop clinical policies on evidence.  We focus on the reports such as healthy implementation of effective services to improve patient outcomes and support via clinical process guidelines.  That’s what these reports were designed to do to work with a clinical process group and I’m going to tell you a bit more about that and the process of discussing these reports.  It’s a very broad topic nomination process and this is important for all of you to know.  If you have any ideas about what kinds of reports could be really useful to our Veterans.  The broad topic nomination process is supported by our website which you can see there listed on the slide.  We have topic nomination forms.  And pretty much anyone can nominate a topic.  So do take a look at that.  If you are a clinician, a researcher, a policymaker.  Take a look at out topic nomination forms and this is how we get the ideas for the stakeholders.  The folks that are really invested in the reports that we do for the evidence based synthesis program.  This is a very important part of the process.  For each of the reports we also—I wanted to highlight we have a technical advisory panel or a technical expert panel known as a TAP or TEP for each of the reports.  These are the experts on each of the clinical topics that we are focusing on.  We also have a very large external peer review process.  So we work with policy partners, other clinical experts, researchers in the area.  And we make sure that we get plenty of reviews and comments on the draft reports before they’re finally submitted.  And they’re posted on our website and widely disseminated through the VA.  So as you can see the links to the report is right there on the next slide, slide number six so that you can access those reports at any time from any computer.  We really appreciate all the dissemination that folks do with these reports so please feel free to send out the reports and read through them later.  They’re very long reports and you can’t get to all of the details in the presentation today.  If you have questions, please feel free to use your question function.  Thank you.  Also take a look at the reports published online because they have all the citations and information that we won’t be able to get to today in the presentation.

So the two current reports as Maya mentioned.  The first one is Suicide Risk Factors and Risk Assessment Tools:  A systematic review.  This one was led by Dr. Haney and she is going to be presenting all of the risk factors on that cyber seminar today.  So I’ll turn it over to her in a few seconds here.  The second report we’re going to cover is on Suicide Prevention Interventions and Referrals/Follow-up Services.  Again, the reports are available on the website.  A brief overview of the presentation, we’re going to talk a bit about the background and give you the scope of these reviews so you all can have a better understanding of what it is that we did for these particular systematic reviews.  The scope is pretty important and we’ll talk about some of the subtleties.  And then we’re going to go over the results from the different subsections of each of the reports.  There are quite a few limitations and there’s going to be quite a bit of discussion about future research, largely involving our discussants today, so we’ll have a pretty lengthy conversation about that at the end.  Okay.  

So just to get started on the reports.  A little bit of background.  I’m assuming that folks are attending today because they’re interested in in the topic and it’s a topic a lot of people care greatly about and for good reason.  You can see some of the general stats up there on our background slide.  Suicide is something that greatly impacts members of the military and Veterans.  I feel like it’s probably every week or so I pick up the New York Times and find yet another article about suicide in Veteran and military population.  It’s something that our country cares greatly about.  The VA cares greatly about and so we wanted to get as much information as possible put together in these reports to try to assist research and policies in these areas.

There are a lot of different stats out there available.  The rates of suicide in members of the military and Veteran population.  The background slide contains some information from some of that research, but I know that those rates do vary depending on what locations you’re looking at.

One important thing to note is that it’s very likely that Veterans returning from the Iraq and Afghanistan conflicts referred to as the the OEF and OIF Veterans may be particularly at risk and Dr. Haney is going to talk a little bit more about that in this state of the research for those Veterans.

Okay.  So I’m going to turn it over—actually—let’s see—I’m not going to turn it over to Dr. Haney.  Had to figure out where my slides—I’m going to wait and not go over the key questions for the reports right yet.  We’re going to do that as we get to each section so we can keep track a little bit better.  But the key questions for both reports are listed there and the first report focusing on risk factor assessment tools and the second one on intervention.

So first we did want to talk a little bit about the scope of the reports, because we think it’s pretty important for you to understand how these reports were scoped, the rationale for conducting these reports and the way that we did so that you can understand the limitations of our search and of the literature that we’re going to be talking about today.

Very importantly there are previous systematic reviews.  One by Hawton et al in 1999, Gaynes and colleagues in 2004 and Mann and colleagues in 2005.  These systematic reviews all looked at very similar key questions but none of them are focused on Veteran and military populations.  They were all pretty broad in their scopes.  There’s also very recent similar work that was conducted at the same time as our review and that was an NICE report in 2012 and that is available online.  There are clinical practice guidelines related to self-harm.  So a little bit more broadly scoped than these reports which were focused on suicide prevention specifically, but it’s worth taking a look at that report and we’re going to highlight a lot of their findings today.

This report was requested by the VA and DoD evidence based practice working group on suicide prevention.  This is a group of folks, Dr. Bradley and Dr. Brenner are going to talk a bit more about those clinical practice guidelines working group.  They’re a part of that workgroup.  Dr. Bradley is the chair in fact.  They’re going to give us a little more information at the end of the presentation on the work that that group is conducting now, but that is the group that commissioned our report.  They’re a primary stakeholder.

In terms of the scope of these reports, we searched previous reviews and recent literature.  We basically started in 2005 for the recent literature because as you can see those previous systematic reviews were pretty comprehensive and they searched all the way up until 2005.  At least the more recent ones Mann at all.  The NICE 2012 review searched all the way up through 2011 as we did.  So our end search date was November 18, 2011.  That’s just happen to be when we did our final search for this report.  And so the literature should be up to date through 2011.

A couple of other things to note, the outcomes that we included in this report it was specifically suicidal self-directed violence.  And that we have a quote there describing what that is because some people aren’t familiar with that terminology.  A lot of people refer to our outcomes as death by suicide and as suicide attempts or suicidal behaviors.  We’re going to try to use the term suicidal self-directed violence.  That’s the language that has been adopted by the VA.  Dr. Brenner has a great article talking about that language and the adoption side of VA.  Take a look at that if you’re interested more in the language so you can also respond to questions about that towards the end of the presentation.

Moderator:  I’m sorry for interrupting doctor—O’Neil—

Maya O'Neil:  Yes.

Moderator:  Can you please speak up a little towards the end of your sentences.  It seems to be trailing off.

Maya O'Neil:  Yes.

Moderator:  Thank you.

Maya O'Neil:  I’ll scooch closer to my phone as well.  I’m trying to see both computer screens and stay close to my phone which somehow has a very short cord these days.  I don’t know how that happens.

Okay.  So a couple of additional things to note about the scope of the report, the risk factor and assessment tool report included reviews on civilian populations and included primary literature just on Veterans and members of the military.

And so that information that Dr. Haney is going to talk about all the information from the primary literature is very specific to Veterans and members of the military, because that was the most important information for the clinical guidelines workgroup.

The interventions report, although we would have loved to have lots of literature to go through that was related to Veterans and members of the military, there was quite—there was a paucity of primary studies on those populations so what we focused on instead was a broader scope of interventions that related to civilian populations and we’ll talk about that in a bit.

Okay.  Just some methods information about systematic reviews.  We did a very comprehensive search.  Yu can see all the different sites that we searched.  Our search dates.  We did have some specific inclusion/exclusion criteria to try to make the population as similar as possible to our population of Veterans and members of the military.  So you can see there’s some country exclusion criteria there.   One of the reasons we did this was the other similar reports had a much broader focus.  So we wanted to have our report be as focused as possible on Veterans and members of the military.  We reviewed quite a few titles and abstracts and narrowed it down to relatively few that met our inclusion criteria.  I’m not going to go a lot into systematic review methodology, but an important thing to know is all these studies were dual blinded quality assessed for all the primary studies in the systematic reviews.  Feel free to ask questions at the end of the—to talk a bit more about the methods involved in conducting such a systematic review.

Now I think I’m going to actually turn it over to Dr. Haney.

Elizabeth Haney:  I’m going to talk through the Risk Factor portion of our report.  These are the key questions for the risk factor assessment section.  Key question one was what assessment tools are effective for assessing risk of engaging in suicidal self-directed violence in Veteran and military populations.

Key question two is in addition to the risk factors included by current assessment tools, what other risk factors could predict suicidal self-directed violence in Veterans and military populations.

And you’ll note that both of these key questions really focus on the Veteran and military populations as Dr. O’Neill said we focused our primary literature review on the literature addressing the specific populations that we were interested in.

First we conducted our review of existing systematic reviews on risk factors in civilian populations.  When we looked at the systematic reviews by Mann and Gaynes and also the NICE report from 2011.  We noticed that Mann and Gaynes did not systematically address individual risk factors.  The NICE report methodology differed from our report in several ways that are important to note here.  First only prospective studies evaluating risk of repetition of self-harm were included. That is more broad than the outcomes that we were looking at.  Second NICE included a country scope that was broader than what we used and also, lastly, they included studies that were minimally adjusted for known risk factors and I will explain a little bit more about that as we talk about the methods for assessing risk factor article.

In our review of existing systematic reviews for risk factors for civilian populations and we noted the following risk factors for non-fatal self harm and those include prior self harm and depression systems, schizophrenia and related symptoms.  Alcohol misuse, other psychiatric history, unemployment and registered sick, female gender.  I’ll note that for those there was mixed and poor quality evidence.  Unmarried status which for this particular systematic review was not predictive in the analysis and younger age.

Risk factors for suicide then include suicide intent or intent to die.  Male gender.  Psychiatric history.  Older age.  Violent methods of self-harm, physical health problems.  There’s mixed evidence here.  And alcohol abuse, mixed evidence.

One thing I’ll say about these reports.  The summary on this slide really reflects the conclusions from the systematic review that we were evaluating.  So we did not go to the primary articles in the case for instance, female gender as a risk factor for non-fatal self harm when it’s mixed quality evidence.  That is the conclusion from the systematic review.

So then we moved to the systematic review of primary risk factors and I would like to expand a little bit on our specific methods for this portion of the report.  

In general new risk factors for any outcome may act through or as a result of existing risk factors.  So the thing you’re talking about a suicide, it is hard to identify a new risk factor without taking into account those that we already know.

So therefore, controlling for known risk factors is essential for identification of new risk factors.  So we were going through the primary literature we included only studies that adjust for one of the followings and we chose these four a priori and did our literature review with these in mind.  So suicidal ideations, history of suicide attempts, substance use disorder, and history of any mental health diagnosis.  We excluded studies that reported only rates in a specific population again because the rates could vary based on things that are dramatically different and may not have accounted for risk factors that are listed on this slide above.

Studies of genetic testing to predict suicide and that was felt that it was out of the scope of this report.  Also excluded studies of post mortem tissue, mainly the biochemical studies and pathologic studies associated with suicide.  Mostly because those things seemed not appropriate for prediction.  It’s going to be possible to do a pathologic study and use it for prospective prediction of suicide and then we excluded randomized control trials that failed to account for treatment allocation which is sort of a specific methodological problem with those trials, but has to do with adjustment or confounding.

So the results of this systematic review of primary literature on risk factors on Veteran and military population.  We identified twenty six studies.  Twenty two with an unclear or low risk of bias.  I’ll just expand on that for a minute.  We rated all the studies for quality and they either had low risk of bias, unclear risk of bias or high risk of bias so out of the twenty six, four had a high risk of bias and therefore we didn’t look at them further.  The twenty two that were included had either unclear or low.  Most if not all had unclear bias.  Just a little bit of a sense of the quality of the literature overall.

Generally longitudinal studies are thought to be more valid than a cross sectional study for prediction.  And then the outcomes included suicide and suicide attempts.  Within suicide attempts there are self reported attempts and objective attempts.  Self report attempts might be reported on a questionnaire, objective attempts are things where they showed up at the emergency room or had a clinical outcome as a result of the attempt.  So the table here on this slide shows the different types of studies for, by study design and also by outcome.  For suicide attempts, we had two longitudinal studies that use self-report.  We had five cross sectional studies that use self report and we had two retrospective studies that use objective suicide attempt criteria.

For suicide we had eleven longitudinal studies, and two retrospective studies.  So the results of our systematic review were Veteran and military populations, the risk factors for suicide are grouped here according to category.  Demographic factors include male, gender, younger age, white race, education and smoking.  Psychiatric factors include the number of conditions, PTSD for which there’s mixed evidence, depression, anxiety bipolar, schizophrenia, alcohol, substance abuse and inpatient hospitalization.  Among military factors, only traumatic brain injury was identified and other factors include diabetes, cardiovascular disease, lower mental health functioning overall as an SF-12, severe pain and activity limitations.

In terms of the risk factors for suicide attempts, demographic factors include marital status for which there was mixed results; psychiatric factors include the presence of psychiatric conditions, PTSD, depression, bipolar disorder, prior suicide attempt, social phobia, alcohol abuse, substance abuse which was mixed and negative life events.

Military factors include multiple types of specific trauma and in the particular study which this refers to has multiple very specific types of trauma outlined and I didn’t fit them all on the slide, but it’s available in the report.

The one other comment about these and this is true of all literature reviews of risk factors is that we are reliant on the primary literature as to how they described or defined their risk factor.  So some of these, especially the psychiatric, they may overlap and we may ask ourselves what this presence of psychiatric conditions mean and to define that we have to go back to the primary literature to figure out how they describe it.

I’m going to turn it back to Dr. O’Neil now to talk about assessment tools.

Maya O'Neil:  Okay so as part of the risk report we also looked at the existing risk assessment tools and we found three systematic reviews that all reported insufficient evidence or existing tools for predicting suicidal self-directed violence.  Because of that we want to broaden our scope as much as possible as we expanded it to two very broadly scoped systematic reviews that were recommended by our peer reviewers and technical expert panels. For those of you who were interested there the Brown and Goldston reviews. Brown is focused on adult population and Goldston focused on child and adolescent populations and even in those very broadly scoped non-systematic reviews, the authors highlight the scale for suicidal ideation and the Beck Hopelessness scale as two measures that have shown associations with death by suicide.

However, the authors also note that there is overall insufficient evidence to very strongly recommend any of these specific measures.  The more information, more research is needed on all the suicide risk assessment tools.  Though the authors do recommend the two that show most promise.

We also looked at five primary studies.  We only found five primary studies that researched assessment tools in Veteran and military populations.  We were quite surprised that there weren’t more studies in this area and so we’re going to be talking to the discussants about why that might be at the end of the presentation.  But I wanted to highlight the findings from each one of these studies—the five of them.  The addiction severity indexes researched and this is part of very a pretty lengthy clinical interview that used to be used in the VA but is now no longer used in VA settings so even though in this one study there are aspects of the longer clinical interviews that’s associated with suicidal self-directed violence. Because it’s no longer used in VA settings and because it’s quite a lengthy clinical interview, it’s probably not going to be at the forefront of future research.

There’s also a study on the personality assessment inventory and that was specifically in a population of Veterans with TBI.  Some things to note about the PAI is that it’s pretty lengthy, it’s complex to interpret and score and you’re generally supposed to be a psychologist and a psychometrician to be able to interpret and score it.  So it’s not really conducive to primary care settings and that was one of the main interest of our clinical practice guide lines group stakeholders.  However, the research is important, the PAI is used pretty frequently in Veteran population and so it’s something that definitely should be considered for future research.  There was one study on the interpersonal psychological service which is not at all well researched so we did not recommend it for research. Two studies where on two brief screening tools and both of them could be potentially useful in primary care settings.  The Beck Depression Inventory two and the affective stakes questionnaire.  One thing to note from the two studies.  The Beck Depression inventory was not significantly associated with suicidal self-directed violence.  There is a caveat about using that in future research; however, all the research on those two measures and also on the Scale for Suicidal Ideation and Beck Hopelessness scale even though they’ll come down as the most promising measures for use as a brief screening tools in a primary care settings and they are definitely in need of additional research and overall all of our previous systematic reviews and our conclusions as well is that there is very limited evidence particularly for Veteran and military populations.  One other assessment tool that we wanted to point out is anytime that there’s something that is used in Veteran and military populations, something that’s been adapted by the VA like the PHQ-9 is something that definitely warrants further research.  So we’ve just got a question about that that popped up.  We did not find any studies that specifically looked at the PHQ-9, or even the items on the PHQ-9 that specifically focused on suicidal self directed violence, but that is something that is warranted in terms of future research because it’s so widely adopted in the VA settings.

I do see a comment but audio is intermittent, so please comment if that’s a problem if it’s an ongoing problem and see if Molly will help out.  Molly—

Molly:  Dr. O’Neil, it’s not an issue on your end at all.  The audio being streamed through your computer; so if you want clearer, then you need to call into the toll number or you can view the live captions.  Thank you.

Maya O'Neil:  Okay.  Great.  Thanks, Molly.  Okay.  So that is our summary of the risk and assessment report and at this point we’re going to go over to the interventions report.  So, please feel free to jot down any questions that you might have about the risk and assessment report and we’re happy to address those at the end, but we’re going to move onto the interventions report at this point.

You can see the key questions for the interventions report.  There’s a lot of typing up there.  We got pretty specific with our key questions but the important things you ought to know is that we’re looking at the interventions as well as the follow-up services.  We wanted to find information on Veteran and military populations and didn’t and so the information that we’re going to be talking about is focused on civilian populations because there was so little information on Veteran and military population.  One other thing to highlight is the difference between an intervention and a referral of follow-up service.  It’s a little more complicated than we thought initially—we thought it would be easier to separate the studies into two different piles.  But a lot of the studies have intervention components and referral and follow-up service components.  So the way that we separated it out is the two types of studies is anything that was an intervention or had any intervention components, we classified as an intervention study.  So anything that was designed to treat a symptom.  If the studies focused solely on access to services, follow-ups from treatments, those types of things and have no intervention or therapy component, then they classified the study as a referral and follow-up study.  We’ll be talking about both of them to see there’s quite a range.

Okay so first of all, we’re going to talk about the pharmacotherapy results that we found highlighted in the previous systematic reviews.  So overall, the research discussed that there were very few studies with relatively small sample sizes, short term follow-up assessment periods and methodological quality concerns.  So all of the funding from the previous reports were stated with the caveat that the previous studies were few and far between and the quality, etc.

The previous reports let’s see—also on the antidepressant trial do not show a benefit for suicide reductions but that rates of suicide may have been too low to detect and effect.  So this is a problem that came up quite a bit particularly in the interventions report.  The power to detect an effect you need to have a certain base rate of the outcome of interest.  And fortunately, but it was a pretty low base rate for suicidal self-destructive violence.  And it’s a very important out come to research and unfortunately it doesn’t happen more frequently than it does; however, that makes it really difficult to research and so that was a problem with a lot of the studies and it was highlighted in the previous reviews and you’ll see that come up quite a bit in our discussion here.

There were some of the other reviews weren’t limited to looking at RCT’s—randomized controlled trials, and so they had highlighted observational studies showing a correlation between increase in prescription rates and decreased in suicide rates.

However, that evidence is considered lower strength than the evidence contained from randomized controlled trials or metaanalysis.

There were some positive findings from trials of antipsychotic medications and again the reports are based on small samples of patients and very few studies.  Finally the previous systematic reviews reported mixed results related to mood stabilizing medications.  So the Gaynes et all report that they found no reduction in suicide rates based on the one trial of lithium.  However the Mann et al report and the NICE report both describe some non-significant reduction in suicide rates for patients receiving lithium.  That’s a little bit messy, probably in need of further research.

So then we also reviewed pharmacotherapy in primary studies.  These are all from non-Veteran and military populations and these primary studies were all conducted in 2005 or later.  So our findings—we have nine trials that looked at antidepressant medications and those trials provided insufficient evidence to make a strong conclusion about the effectiveness of antidepressants and that was again largely because of the really low base rates of the outcomes of interest so the overall small sample sizes and lower quality studies and some of these studies just happen to report almost as a harm instead of an outcome of interest so they happen to report suicidal self-directed violence as a potential harm but they were really looking at the effectiveness of anti-depressive medications in the reduction of depressing not necessarily suicide or suicide attempts and so it’s something to take with a grain of salt when you’re looking at the overall results.  We also found three trials investigating anti-psychotic medications.  And again they provided insufficient evidence for the effectiveness of the antipsychotic medications.  We found one more recent trial of lithium versus valproate and one trial of lithium versus citalopram.  And those trials also provided insufficient evidence.

Those—we also found one trial of omega-3 supplements which provided insufficient evidence.  So overall you can see unfortunately there really aren’t a large amount of good quality trials that are adequately powered, assuring that they have a large enough sample size to detect an effect any interventions.  So it’s very hard to say anything definitive about pharmacotherapy, unfortunately.

Okay so now we’re going to talk about the psychotherapy findings from the intervention report.  And these are the psychotherapy findings that were listed in the previous systematic reviews.  All of the previously published reviews on this topic report an overall insufficient to low strength of evidence to the effectiveness of any of the psychotherapeutic interventions that they investoigated.  Here’s a summary of their findings.  Their reports all highlighted mixed results related to cognitive therapies.  One thing I want to highlight with cognitive therapies is there’s a lot of subtle differences between the different cognitive therapy interventions that were investigated and that might have had something to do with the mixed results that were found.  However, we weren’t able to break down and combine different types of cognitive therapies and neither were the previous reports because so many of them are so different.  They’re different populations and there are subtle differences in the types of therapies that are being researched.  It’s very hard to combine and do any sort of quantitative Meta analysis combining those results which might eventually lead to more adequately powered analyses in the future if more studies are done.  What you need to be comparable studies so that they can be combined.  At this point overall mixed results related to cognitive therapies.  All the reports cited positive results for patients with borderline personality disorder with Dialectical Behavior Therapy.  However, again because of the issue of slight differences in the version of DPT that were being investigated or different populations, for example, sometimes it was an all female—a young female population that was being investigated or in very different countries, it’s very difficult to combine the findings.  But it is notable that all the results were positive for dialectical behavior therapy.  There are some positive findings reported for interpersonal psychotherapy and null findings reported for outpatient day hospitalization and there were positive findings for problem solving therapy, some positive results for patents with borderline personality disorder.  For psychoanalytically oriented partial day hospitalization.  And also for transference focused psychotherapy.  So as you can see there is quite a variety of psychotherapies that have been investigated in these previous reports.

Again, because of the heterogeneity of the studies and the populations, it’s really hard to combine those results so that even though there might be positive findings here and there it’s hard to say definitively you know this intervention we know works because it’s likely very specific to that study so we need additional studies to really confirm some of these other findings.

Those are the findings from the previous systematic reviews.  We also looked at the primary studies conducted since 2005.  We found moderate strength of evidence for problem solving treatment in addition to usual care when compared to usual care alone and it’s that had recent repeated suicide attempts.  They were being really specific here.  I’ve been talking about studies that are adequately powered. So this was a study that had a pretty large—it was conducted outside of the Untied States in a non-Veteran military population.  It was a population that had been hospitalized and the moderate strength evidence in favor of problem solving treatment is only related to populations with recent repeated suicide attempts so it’s very specific; however this was the strongest evidence we found of all the information out there.  There was no benefit of the intervention compared to usual care for the overall group of patients.  This was a subgroup analysis.  However, the findings were pretty strong and that’s why it’s a moderate strength rating and it’s probably the best available evidence out there.  We’re going to be talking about the best available evidence and it’s important to—it’s really important in areas like this with an outcome that has a great impact, that we really care about; however, there’s insignificant to low strength evidence in most cases where we still have to set policy; we still have to, as clinicians we still have to treat patients and we still have to do research so we need to know what the best available evidence is.

I’m going to try to highlight that throughout and this is one of those examples.  So for this specific population, problem solving therapy is your best bet and probably the way to go.  We did find other trials that provided insufficient and null strength evidence.  Mostly those were related to limitations in quality and the issue of insufficient statistical power, as we talked about.  I do want to highlight other promising results.  Probably your next best bets are dialectical behavior therapy and cognitive behavior therapy targeting suicidal behavior.  Those—for dialectical behavior therapy we had a question come  in and asking that has a low strength of evidence rating.  Why are you recommending that?  And that really relates to the issue of heterogeneity of studies.  Although the studies can’t be combined and put together because the populations are so different, if we see an overall pattern there are positive results popping up over and over again for dialectical behavior therapy that’s probably going to be the next best bet for the studies that we want to implement as clinicians or research or make policy about.  So those are the other pretty good bets for people who are researchers, clinicians, policymakers, etc.  Something we need to investigate.  Okay.

A little bit of information about referral and follow-up services from the existing systematic reviews.   Previous reviews have highlighted postcard interventions are showing promise, but though those results are mixed and have a low strength of evidence the postcard interventions.  These interventions that involve mainly follow-up postcards to patients at set time intervals particularly after they have been psychiatrically hospitalized.  What we found in our primary studies was three studies of postcard interventions that also showed mixed results.  We found two studies on youth nominated support team interventions and one study on a community treatment and one trial of a depression care management program and all of our studies yielded non-significant results and overall these studies provide low strength of evidence.  So not a lot of information to rush forward with in terms of referral and follow-up services.

One caveat I want to insert in here particularly for those of you who are trying to take the findings in these reports and go to the next step which is implementation is you never want to take findings that are low strength or insufficient strength evidence as—throw up your hands and say there’s nothing we can do.  It’s absolutely not the case.  If there’s some type of intervention that you think as a clinician, as a researcher you know that you think there’s good reason to go forward with that intervention and have a referral and follow-up services here.  If we think that it’s pretty important for patients who have been psychiatrically hospitalized let’s say to receive follow-up services to try to encourage them to come to additional mental health appointments following psychiatric hospitalization it’s probably common sense and we want to do it.

You certainly don’t want to take these reports and there isn’t evidence for it but let’s not do it.  We always want to make sure that as clinicians, researchers and policy makers we are going forth with good, sound common sense good clinical care for patients.

All right.  So just an overview of results.  Let me turn it back over to Betsy so that she can talk about the overview of the risk factors so she can give you a reminder so that you can be thinking about questions for our discussants that we’re going to go to in a minute here.

Betsy:  So for risk factors we found that suicide was predicted by demographics, by some military factors, psychiatric factors and others.  And suicide attempts were predicted by psychiatric factors and trauma experiences.  For assessment tools although there was overall limited evidence like we talked about the scale for suicidal ideations—the Beck Hopelessness scale,  Affective States Questionnaire, the Depression Inventory II and Patient Health Questionaire-9 are probably in need of investigation with Veteran and military populations.  Primarily because of their utility in VA settings and in primary care settings.  In terms of interventions, best available evidence is for problem solving therapy and promising interventions are Dialectical Behavior therapy and cognitive behavior therapy targeting suicidal self-directed violence.  It doesn’t mean that you should rule out other types of interventions, but this is the best available evidence at this point.

We’ve talked quite a bit about the limitations and future research priorities as we go and I’ll leave up the slide for just a few seconds here.  But we’re going to be addressing these questions with our discussants.  So the need for evaluating new risk factors is only once known risk factors are already accounted for.  It will be established that here’s a known risk factor can explain additional variants and I’m talking in statistical terms and we want to be already accounting for those known risk factors and seeing what other information we need to get from our Veteran and members of the military and of course we need studies specific to Veteran and military populations.  In terms of assessment tools, reclassification analysis is the gold standard.  We obviously need more of that type of study.  And then we need to examine brief and easy to administer assessment tools in Veteran and military populations.  

The overall recommendations that we made for interventions and referral and follow-up services is that instead of small scale trials of multiple new and slightly different interventions that are conducted in different populations etc.  Probably what we need are fewer but methodologically sound and very large scales trials of the most promising interventions.  This is really hard to do.  It probably involves doing multi-site interventions, etc.  So we’re going to talk to the discussants about this in a minute and see if they have any ideas about the best type of studies that we need to be doing to really move us forward in terms of finding the best and most effective interventions and referral and follow-up services.

Yes, we had a question come up about reclassification analysis.  And I’m going to turn that over to Dr. Haney for a second so that she can discuss that.

Elizabeth Haney:  So to try to explain it briefly reclassification analysis is a type of study that tries to identify how much of a particular risk assessment tool changes the clinical impression of an individual’s risk.  So say for instance you have a person who you believe to be of moderate risk on the basis of existing depression.  And you don’t know for certain whether they are at imminent risk of suicide in which you might do something like hospitalize or actually they have enough safety or protective mechanisms around them that you can allow them to go home and continue on their treatment program.  What you’re looking for in that situation is the risk assessment tool that could move you from moderate to either high or low and safely predict the outcomes in that situation.  So there are statistical methods to look at the change in your risk category across, over time and the ability of the risk assessment tool to help you predict above and beyond the known risk factors.  I hope that helps.

Moderator: We also have a question about the interventions specifically asking about how CBT for suicidal behavior was identified as a promising intervention when the overall the cognitive  therapy has mixed results and other modalities like IPT has positive results and weren’t included in the list of promising interventions.  That’s a really, really good question and this is really where this is a bit more of an art than a science.  What we found with the cognitive interventions was some overall patterns that the cognitive interventions that were less focused on suicide and more focused on just treating depression were potentially dragging down the results and although we weren’t able to combine the cognitive therapy studies that were more focused on studies there seems to be a bit of a pattern that the CBTs focused on suicidal behavior is that we found pretty consistent positive results for those studies.  And so that was across previous reports and current primary studies that we looked at.

So that’s why we’re recommending it as something for further research.  Any of the interventions that have positive findings, especially given such low base rates are probably, weren’t further interventions, so there shouldn’t be a lot of bias in picking which ones of those.  We really just tried to pick those that had the most research behind them and most consistent.  Like I was saying with—it’s sort of similar with dialectical behavior therapy.  There are quite a few studies with DBT and though it’s really difficult to combine those—we can’t do that in a quantitative manner, overall it does seem like that is a promising intervention and we need some larger scale trials for getting effective DBT.

Let me just take a look at where we are with time here.  So I want to make sure we have enough time to ask some questions of our discussants so let’s see—perhaps, Dr. Bradley if I could turn it over to you.  If you could tell us a bit about creating clinical practice guidelines.  I know you have more experience with this, particularly than I do.  And if you could give us a little bit of information just in general about that process but also specifically the guidelines related to the suicide.  Is Dr. Bradley—

Moderator:  He is here—just give me one more second.  Dr. Bradley—who called in—please go ahead and under your audio section—telephone is clicked.  Can you just press unmute on your line?

John Bradley:  Yes.  There we go.

Moderator:  Perfect.

Moderator:  Yes, that’s excellent.

John Bradley:  Sorry for the technical—

Moderator:  I turn it over to you.

John Bradley:  Great.  I’d be happy to comment on the clinical practice guideline development process, but first I’d like to thank you group for all of the exquisite work that you have done in compiling all of this information and making sense out of the morass really of data that’s out there and different studies and bring it into a cohesive whole.  So that has been terribly effective for us in the clinical practice guideline development.

And first to clarify my role as one of the co-chairs and also acknowledge the contributions and the leadership of Dr. Jan Kapem and Ira Katz and Brett Snider from the DOD.  We were all co chairs for the CPG workgroup and working under with the exquisite support of Odem Suskin who’s been shepherding us through the process.

The clinical practice guideline working group has been in existence since 2011.  It has had a mandate from both the DOD and the VA to really give the field some guidance in terms of the evaluation and management of patients with self-directed violence and those at risk of suicide and like you mentioned sort of the holy grail that we’re all seeking in the field as well as to share with primary care clinicians and other front line practitioners is this Holy Grail of predictive value and having a degree of confidence that when you’re doing your assessment for a patient that you’re assessing things that matter and that your assessment leads to differing interventions because the state of the art right now such that it is is that patients at elevated risk no matter what the sort of screening criteria that we use across different clinical practices by and large get very similar treatment interventions.  They get treatment as usual if there’s an underlying psychiatric condition and they may or may not get some suicide specific psychotherapy.  So we’re hopping to bring and find a degree of resolution to this and figure out at what stages for what patients are all these different treatment approaches valuable and we’re trying to bring the field from this sort of correlation and association of risk factors to one where risk factors and warning signs can have a predictive value in terms of the treatment that’s afforded the patients and recognizing that there’s a high false positive of predictive—high false positive predictions for all of these associated factors you want to really distill out what the most effective and timely and important treatment should be rather than giving everybody the full complement of all potential suicide interventions.

And really develop this into a best practice process.  And so all of that being said, you know we’re at the stage right now in the clinical practice guideline working group of really combing though all of the studies and evidence tables that you all have so neatly prepared for us to see what are the specific recommendations that we can make that are most finely rooted in the evidence and then which are the more general recommendations that ought to be considered that are evidence informed or expert consensus.

We’re right at the cusp right now of drafting our draft recommendations in preparation for the DOD VA suicide prevention conference next week to get some feedback from the field and from our wider expert panel to provide something that’s useful to the field and as you stated so well that there are very specific strong recommendations that be made and less robust general recommendations that can be made and so the challenge right now is to really put the weight behind the various recommendations at the various levels that we have.  For example around the problem solving treatments, one of the questions is should a patient who presents with suicidal ideation alone without history of behavior be offered problem solving therapy and you know while there may be a valid reason to recommend that does the evidence really support it for ideation alone or just for the previous attempters and does that treatment then minimize the risk of future behaviors and future death by suicide.  These are the larger questions that we’re wrestling with to see how we inform practice.

I hope that answers your question.  I’d be happy to take any further questions or follow-up.

Moderator:  That’s great.  Thank you so much for providing that overview.  I know Dr. Brenner is also a part of the Clinical Practice Guidelines work group.

John Bradley:  Yes.

Moderator:  Working on writing these clinical practice guidelines, so feel free to jump in there with information, but I want to put up—if I can get my slides to work.

I want to throw out questions particularly to Dr. Brenner and Valenstein who are leaders in this area in the VA and basically some questions and similar questions from the audience that about how we’re going to take this body of limited research and implement changes in policy and research and practice.  Where do we go from here?  What’s the best kind of research that we should be doing?  What does VA leadership need to do?  What research is ongoing, etc?  So either one of you can go ahead and take that—

Moderator:  Can I interject real quick—this is molly.  I just want to remind our panelist that only one person can speak at a time otherwise all audio is blocked out, so maybe if we can go in turn.  I don’t mind if we go alphabetically or by expertise, but please note if two people are speaking at once or your line is unmated it does interfere with the audio.

Moderator:  Let’s turn it over to Dr. Brenner first.  We’ll go alphabetically.  SO Lisa, if you’re willing to talk a little bit about what kind of research you think is a good next step?  Where do we go from here as researchers and clinicians?

Lisa Brenner:  Yes, I think and I definitely want Marcia to jump in   Can you hear me okay?  I’d like to say first.

Moderator:  Yes.

Lisa Brenner:  Great.  You know I think that what has been put together is really wonderful because it gives us many, many great starting points and so I think in terms of my clinical practice, certainly going with where the evidence is now and trying to use evidence informed treatment to then help us get to a place where we can have evidence based treatment.  So certainly I think you’ve mentioned specifically a number of potential effective tools like the Beck Hopelessness scale, like CBT for suicide—interventions like CBT for suicide prevention and problem solving therapy that are promising and should really help guide us in terms of our clinical practice.  I’m not sure I have tons more to say about research.  What we’re trying to do the challenging thing of studying something while we’re proving clinical care.  Anything that we can do, I know there’s some evolving interest in the VA of doing a new kind of research or a new model of research that looks at research in clinical settings called point of care clinical trials which is a very exciting possibility in which we can use skills that our therapists have currently and look at interventions in the context of current clinical care settings.  That would be an exciting way to economically potentially look at things are they are happening on the ground. Dr. Valenstein I’m going to turn it over to you to see what you think?

Marcia Valenstein:  Thanks.  Can people hear me?

Moderator: Yes.

Marcia Valenstein:  So I’d like to emphasize the last thing that Lisa said.  One of the clouds from this evidence based review was that we have too many small trials in different populations that are underpowered and that we have tables and tables of research studies and very few conclusions we can draw from them and the way beyond this I think clearly is to think about what Lisa just said  The VA is in a position because of the it’s a large distributor of the health system to work as evidence informed intervention and then see which actually produces the best results.  And I think most of the clinicians on the call will probably know there’s been a variety of interventions implemented over the last many years and one thing that the VA could do, the research community and the clinical community work together is to roll out different interventions and different places and actually do comparison studies.  I think that’s the only way we move beyond very small trials on different populations with slightly different [inaudible] and no answers with [inaudible].

I’m done, so other people can talk.

Moderator:  Thank you so much to all of you.  I think I’m also wondering if Dr. Valenstein if you can respond to the last question that’s up there about what research is ongoing in VA military settings.  I know that Dr. Brenner also has information about this, so let me turn it over to you so that Dr. Brenner.

Marcia Valenstein:  I actually think Dr. Brenner will be more able to address this.  Her group and people in our group are several studies that are several studies that are ongoing so we thought [inaudible].

Lisa Brenner:  Thanks.  I think there are a number of exciting things happening right now around research and looking at interventions also looking at assessment and I’m guessing with the time we have left, we’re not going to have time to get into specifics of any of them, but what I would suggest people do is look at websites. The VISN 19 MIRECC website and it has a nice listing of our trials right now.  We have several trials looking at things like blister packaging medication to facilitate means restriction and we had a cognitive based therapy trial for people with TBI around suicide prevention and also I know that the military research suicide consortium they have a very nice website and many of our studies are online looking at not only interventions or old interventions with new applications.  Caring letters via texting which there is evidence for contact via caring letters post intervention.  I know they’re also working on a virtual hope kit.  So lots of exciting—I think strategies, some of which are old and being relooked at in novel ways and some of which are just brand new.

So very hopeful about that.  Check out both of those websites and I know myself and Dr. Peter Gutierez and Dr. Thomas Joiner are happy to talk some about any specifics of those trials.

Moderator:  Great.  Thank you.  One final question probably for Drs. Brenner and Valenstein again we’ve gotten some questions here about funding for such studies.  People wondering about given the desire for larger better powered mutli-site studies, is this feasible given the current funding limits?  Questions like how you get funding when there’s a weak evidence base for some of these interventions?  Maybe the two of you could speak a little bit for current VA funding streams and/or what you would like to see from VA funding sources in order to be able to conduct some of these large scale trials.  Dr. Brenner, you want to take a stab at that first?

Lisa Brenner:  Sure.  Well, I think as has been mentioned all the time that suicide can be really challenging to study because of the low base rate of behavior.  And so certainly we need good researchers collaborating across the country to address these problems.  One thing has nothing to do with funding but we’d love to see more and more VA researchers connecting about how to put together grants so that we can look at this in a comprehensive way.  My bias would be in the current context of care.  That would be wonderful I think and really maximize the ability to utilize existing resources.  Because this is such a large issue like Dr. O’Neill indicated, there is funding available perhaps in this area where other funding is not currently available.  So certainly would encourage people to explore Department of Defense funding and we’ve been very lucky and successful in getting Department of Defense funding for projects that would be equally applicable to Veterans. and also I know there’s continuing interest just from feedback I received and not speaking on behalf of the VA in any way shape or form but I know this is an area of interest and import and that many leadership is very tuned into that in terms of funding mechanisms so I know that’s not specific but I think you know some of this is also about putting together good grants that are doable and feasible and having the right people who know about this kind of research if this is interesting to you and your interest have been in other areas, how can you partner or collaborate with people who may have more expenses with suicide and suicide prevention.

Moderator:  Dr. Valenstein?

Marcia Valenstein:  I’m just waiting because I didn’t want to lock out the whole audio.  So I totally agree with Lisa.  I think there are a variety of funding options as Lisa said.  The DOD has been very interested in this and there’s been quite a bit of interest in this type of work within the military component and the guard.  And in addition the VA has several different opportunities.  One would be the Cooperative Studies Program where you could potentially enlist a member of VA sites as—you get the large numbers that you need.  There is planning and a committee out at this point and trying to look at Lithium and get more definitive answer about whether or not lithium is a medication that reduces suicide risk and to be adequately powered they’re going to need multiple VA sites and is a current group to study.

There’s also the VA R&D and funding stream QUERI also has a special interest in suicides.  And working with QUERI, the patient care community might be the way to go.  I’m now done.

Moderator:  Thank you so much.  I think that’s probably all we’re going to have time for because we’re right up against our time limit, but I want to thank the discussants for really taking the time to respond to the pretty complex and difficult questions and also contributing so greatly to the report and for the whole clinical practice guidelines work group for being so engaged and really trying to use the report to their benefit as their dealing with really complicated and difficult task of clinical practice guidelines without a whole ton of evidence and so that makes it a lot harder I think as Dr. Bradley was talking about.  Thank you all so much for joining us today and I—there are quite a few questions that have come in and I’ll be addressing those and I’m going to turn it over to Molly so she can do the last part of this.

Molly:  Thank you very much, Dr. O’Neil.  I too would very much like to thank Drs. Bradley, Brenner and Valenstein for joining us today.  Your expertise on these calls is invaluable to the field and of course to our coauthors of the two—two authors of the reports and I have disseminated to all of you under the chat screen where you can find the reports and where you can find a copy of the slides.  You can also always e-mail cyberseminar@va.gov for any additional questions but please note that this session has been recorded.  I will send all remaining questions to Dr. O’Neil and Dr. Haney and they can respond in writing and I will get those posted as soon as I receive responses.  We are getting many thank yous from everyone, so you guys did an excellent job and I really appreciate it and I also want to thank our attendees for joining us and you will receive a follow-up e-mail in the next day or two which will have a direct link to the recording and will have access to all the PDF files and as I mentioned previously, if you’re looking for the ESP reports, just go to the HSR&D website and you can click on ESP reports and you will get there.  And at this time I do want to ask all of our attendees as you exit the session there is a survey that will pop up on your screen—it will take just a moment to load and it’s five very short questions and it does provide excellent feedback and it tells us what you want to hear out of our next cyber seminars, so please do check that out, and fill it out.  So with that I want to thank everyone once again and this does formally conclude today’s HSR&D Cyber seminar.  Have a nice day.

**[End of Recording]**