High Risk Suicidal Behavior in Veterans
Condition: Suicide
MeSH terms: Suicide
Study type: Interventional

Summary: 
      Suicide is a pressing problem in the US military, with evidence of increased risk for suicide
      particularly among soldiers serving in Iraq and Afghanistan. To date, there are very few
      studies that empirically evaluate treatment efficacy to prevent suicide. One treatment that
      has been shown empirically to decrease suicidal behavior is Dialectical Behavioral Therapy
      (DBT), although these studies have been limited to patients with borderline personality
      disorder (BPD). The current proposal aims to examine the efficacy of DBT in reducing suicidal
      behavior more broadly in a diagnostically heterogeneous group of veterans with high risk
      suicidal behavior. One of the difficulties in doing research in suicide prevention is that
      serious suicidal behavior is a relatively rare event, and alone is not a satisfactory target
      for treatment studies. It is extremely important, therefore, to identify intermediate
      symptoms that are closely associated with high risk suicidal behaviors, as targets for
      treatment. One critical area our proposal addresses is validating new treatment models for
      suicide in veterans; DBT has been empirically validated to reduce suicidal behavior in
      individuals with BPD, but has not been tested more broadly to target suicidal behaviors. The
      second critical area which our proposal addresses is exploring new suicide risk assessment
      measures. While the investigators do not specifically propose to develop new screening tools,
      the investigators do propose to identify potentially important domains that specifically
      differentiate ill high risk suicide veterans from low risk. This information will be useful
      in future efforts to modify the DBT approach to be more effective for the broader diagnostic
      group of high risk suicidal veterans.
    

Detailed description: 
      This project proposes two related studies. The first project is a randomized clinical trial
      of 120 veterans identified with high-risk suicidal behavior comparing the efficacy of DBT vs.
      treatment as usual (TAU) on suicidal behavior as a primary outcome measure. A second aim of
      the present project is to examine group differences between 200 300 veterans at high risk for
      suicide and 200 veterans at low risk in a variety of symptom domains. The goal of this will
      be to identify symptoms associated with suicidal behavior that can be used as secondary and
      exploratory outcome measures for DBT. The investigators will assess symptom domains including
      mood and substance use that have been associated with suicidal behavior by previous research
      and validate those in our veteran population by comparing symptoms in low vs. high risk
      veterans recently discharged from the James J Peters VAMC (JJPVA) psychiatric inpatient unit.
      In addition, the investigators will explore indices of interpersonal function and measure
      features that have some evidence of offering protection from suicide, which could be viewed
      as resilience factors. A particular emphasis of the present project is to characterize the
      nature of the interpersonal dysfunction in high risk individuals, as there exists very good
      evidence that social isolation, or a lack of a sense of "belonging" puts people at
      particularly high risk for suicide, in particular in a military sample. The investigators
      intend to assess the impact of DBT vs. TAU on these symptom domains in addition to their
      impact on suicidal behavior.

      The subject population for both projects will be veterans identified on a "high risk" suicide
      list at the James J. Peters VAMC; veterans are so identified by the suicide coordinator
      because of a recent inpatient hospitalization involving high-risk suicidal behavior. Priority
      will be given to OEF/OIF veterans. In order to identify symptoms associated with high risk
      suicidal behavior, the investigators will examine symptoms domains in our high risk subjects
      and contrast them with a comparison group of veterans recently discharged from the
      psychiatric inpatient service or treated in the outpatient mental health department at the
      James J Peters VA Medical Center with no history of high-risk suicidal behaviors (low risk
      veterans). Groups will be matched with respect to age and gender. For this project, the
      investigators will include veterans with a variety of diagnoses, including post-traumatic
      stress disorder (PTSD), substance abuse, affective disorders, personality disorders, and
      anxiety disorders. The investigators will exclude subjects with current psychosis or
      cognitive impairment as these symptoms would prevent appropriate engagement in DBT. Patients
      from the high-risk suicide list will be eligible to participate in a six month DBT treatment
      study and will be randomized to full DBT vs. TAU. Both groups will have psychopharmacological
      management by their outpatient psychiatrist and be able to participate in standard ancillary
      outpatient clinical offerings (e.g. AA, sleep group). Both treatment groups will be assessed
      at baseline, at the 6 month treatment completion mark, as well as follow-up time points
      including one year and eighteen months after enrollment.
    

Intervention name(s): Dialectical Behavior Therapy; Treatment As Usual
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Dialectical Behavior Therapy is an empirically validated treatment approach emphasizing the role of emotion regulation in the treatment of suicidal and self-destructive behaviors in BPD; TAU for these subjects involves close tracking by the Suicide Prevention Coordinator and treatment by their individual team of clinicians. Additionally, a support group with psychoeducation about suicide prevention will be offered as part of TAU
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment