Evaluating Treatments for Suicidal Veterans With PTSD

Study Overview
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Brief Summary
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Posttraumatic Stress Disorder (PTSD) is a significant driver of suicide risk among Veterans, but there is a critical knowledge gap about how to treat PTSD among people at elevated risk for suicide. Although evidence-based treatments for PTSD reduce suicide risk, Veterans at high risk for suicidal behavior rarely receive these potentially life-saving treatments. Prior research suggests that a treatment that combines Dialectical Behavior Therapy (DBT) with the DBT Prolonged Exposure protocol (DBT PE) for PTSD improves both PTSD and suicide-related outcomes. This study will evaluate whether DBT + DBT PE improves these outcomes more than Prolonged Exposure plus suicide risk management, the gold standard VA care for this population. The proposed study will also examine factors that make it easier and harder to implement these treatments in VA settings. The results will help to inform treatment guidelines for this high-priority Veteran population.

Detailed Description
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Background: Posttraumatic stress disorder (PTSD) is a significant risk factor for suicide among Veterans. Evidence-based psychotherapies (EBPs) for PTSD reduce suicide risk, but Veterans at elevated acute risk for suicide, such as those who have engaged in self-directed violence (SDV), rarely receive these treatments. This is largely due to the historical exclusion of high-risk individuals from PTSD treatment trials, which has resulted in a lack of evidence-based guidance about indicated treatments for this population. Without such guidance, clinicians are often reluctant to use EBPs for PTSD with suicidal individuals. A treatment that combines Dialectical Behavior Therapy (DBT), a suicide-focused EBP, with the DBT Prolonged Exposure (DBT PE) protocol for PTSD has been developed for this high-risk population and shows promise in reducing both SDV and PTSD while being feasible, acceptable, and safe to deliver. However, a large-scale randomized controlled trial (RCT) is needed. This study will compare the effectiveness of DBT + DBT PE to the current VHA gold standard of care for this population, Prolonged Exposure therapy augmented with suicide risk management (PE + SRM), while also examining the potential for implementation of both interventions in VHA. Significance: There is a critical gap in knowledge about how to treat PTSD among individuals at high risk for suicidal behavior. As a result, VA/DoD Clinical Practice Guidelines do not specify indicated treatment strategies for this population. Experts have recommended two approaches to facilitate the safe and effective use of EBPs for PTSD with individuals at elevated acute suicide risk, including combining these treatments with suicide-focused EBPs or augmenting them with suicide risk management strategies. This project will help to fill this critical gap by rigorously evaluating these two approaches among Veterans with SDV. The results will provide important information to inform guidelines about indicated treatments for this high-risk population. Innovativeness: This will be the first large-scale RCT to evaluate treatments for PTSD among Veterans who have engaged in SDV, an HSR&D high priority group. The DBT + DBT PE intervention is the first treatment designed to address both SDV and PTSD, and results will indicate if this novel treatment improves outcomes compared to the current VHA gold standard of care. To facilitate more rapid implementation of these findings into clinical practice, implementation barriers and facilitators for both treatments will also be evaluated. Specific Aims: This study will randomize 200 Veterans with PTSD, recent and repeated SDV, current suicidal ideation, and emotion dysregulation to DBT + DBT PE (intervention) or PE + SRM (control). Aim 1 will test the hypothesis that DBT + DBT PE will be superior to PE + SRM in improving clinical outcomes and engagement in trauma-focused treatment. Exploratory analyses will examine Veteran characteristics that may predict better engagement and outcomes in DBT + DBT PE versus PE + SRM. Aim 2 will examine barriers and facilitators to implementation of both treatments. Methods: This is a multi-site hybrid type 1 effectiveness-implementation trial. Veterans will be treated in outpatient settings at three VA sites and assessed at 5 points over 18 months. A mixed-methods approach will be used to evaluate barriers and facilitators to implementation, including conducting interviews with 45 key stakeholders (Veterans, providers, and leadership). Primary Outcomes/Endpoints: Primary outcomes will be reductions in SDV episodes at 18-month follow-up and reductions in PTSD severity at post-treatment. Implementation/Next Steps: This project will provide much-needed information about how to safely and effectively treat PTSD among Veterans at elevated acute risk for suicide. If one or both treatments are found effective, Aim 2 will provide vital information about how to maximize future implementation success. Future implementation activities would be coordinated with the investigators' national operational partners.

Official Title
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A Hybrid Effectiveness-Implementation Trial of Treatments for Veterans With PTSD at Elevated Acute Risk for Suicide

Conditions
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Self-directed Violence, Post-traumatic Stress Disorder (PTSD)

Intervention / Treatment
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* Behavioral: Dialectical Behavior Therapy
* Behavioral: Dialectical Behavior Therapy Prolonged Exposure protocol
* Behavioral: Prolonged Exposure therapy
* Behavioral: Suicide risk management


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: PTSD Recent and repeated self-directed violence Current suicidal ideation Emotion dysregulation Veteran eligible for VHA mental health care at participating site (Seattle, Minneapolis, and Durham VAs) Age 18+ Willing to participate in all study activities Exclusion Criteria: Unable to maintain safety independently Currently engaged in and/or recent (past year) history of receiving a sufficient dose of DBT or PE Plan to move away or be unavailable for >4 weeks in the next 18 months Unable to sufficiently comprehend study procedures due to lack of English proficiency or moderate to severe cognitive impairment

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: 2-arm randomized clinical trial
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: DBT + DBT PE<br>This condition combines one year of standard Dialectical Behavior Therapy (DBT) with the DBT Prolonged Exposure (DBT PE) protocol for PTSD. | Behavioral: Dialectical Behavior Therapy<br>* Standard Dialectical Behavior Therapy (DBT), including DBT individual therapy (1 hour/week), DBT group skills training (2 hours/week), between-session coaching (as needed during business hours), and therapist consultation team (1-1.5 hours/week).<br>* Other names: DBT;Behavioral: Dialectical Behavior Therapy Prolonged Exposure protocol<br>* DBT PE is designed to be integrated into DBT to formally treat PTSD once patients meet standardized readiness criteria. The core procedures are in vivo and imaginal exposure with processing that are delivered in individual therapy sessions (1.5 hours/week).<br>* Other names: DBT PE;|
| Active Comparator: PE + SRM<br>This condition provides up to 18 sessions of Prolonged Exposure therapy (PE) for PTSD augmented with suicide risk management (SRM). | Behavioral: Prolonged Exposure therapy<br>* Standard PE is delivered in individual therapy sessions (1.5 hours/week) and uses the core procedures of in vivo and imaginal exposure with processing.<br>* Other names: PE;Behavioral: Suicide risk management<br>* Standard VA suicide risk management procedures, including comprehensive suicide risk assessment and safety planning.<br>* Other names: SRM;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Self-Injurious Thoughts and Behaviors Interview - Revised Short Form (SITBI-R-SF) | Number of self-directed violence episodes | Baseline to 18 months | 
| Clinician-Administered PTSD Scale for DSM-5 Revised (CAPS-5-R) | Total Severity Score (range = 0 - 200, higher is worse) | Baseline to 18 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Beck Scale for Suicide Ideation (BSSI) | Total Score (range = 0 - 38, higher is worse) | Baseline to 18 months | 
| Brief Symptom Inventory (BSI) | Global Severity Index (range = 0 to 4, higher is worse) | Baseline to 18 months | 
| Difficulties in Emotion Regulation Scale-16 (DERS-16) | Total Score (range = 16 - 80, higher is worse) | Baseline to 18 months | 
| World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) | General Disability Score (range = 12 - 60, higher is worse) | Baseline to 18 months | 
| Self-Injurious Thoughts and Behaviors Interview Revised Short Form (SITBI-R-SF) | Non-suicidal self-injury frequency and remission; Suicide attempt frequency and remission | Baseline to 18 months | 
| Clinician-Administered PTSD Scale for DSM-5 Revised (CAPS-5-R) | PTSD diagnostic status | Baseline to 18 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Stress Disorders, Post-Traumatic, Suicide, Self-Injurious Behavior