Development and Testing of a Veteran-Centered Lethal Means Safety Suicide Prevention Intervention

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Background: Seventeen Veterans die by suicide on a daily basis, and Veterans often seek care in Emergency Departments (EDs) prior to a suicide attempt. Lethal means safety (LMS) interventions, which aim to reduce access to common methods of suicide such as firearms or toxic medications, are considered important components of suicide prevention programs and are recommended for Veterans with elevated suicide risk. Significance/Impact: The Veterans Health Administration (VHA) considers suicide prevention a clinical and research priority. In 2019, VHA began screening all Veterans seeking ED care for elevated suicide risk. The VA’s National Strategy for Preventing Veteran Suicide highlights “efforts to reduce access to lethal means of suicide among Veterans with identified suicide risk.” However, no LMS intervention has been developed to accompany this initiative and prior LMS interventions have not been developed for US Veterans or VHA settings. The proposed work will address this critical gap in VHA suicide prevention efforts by developing and testing a Veteran-centered, ED-based LMS intervention for multiple methods of suicide. Innovation: Several evidence gaps must be addressed in developing such an intervention. No prior LMS intervention has been shown to be efficacious in promoting medication and firearm safety, and prior interventions have not accounted for the various, person-specific mechanisms by which individuals change behaviors. The proposed intervention will incorporate multiple evidence-informed elements specifically chosen to target different but complimentary behavioral mechanisms highlighted within the Health Belief Model (e.g., self-efficacy) as critical to behavior change. Elements include those that equip staff with evidence-based communication strategies, and provide Veterans with practical, patient-centered support to facilitate LMS behaviors. To ensure that this intervention meets the needs of at-risk ED patients and is sustainable long-term if shown to be efficacious, we will engage Veteran and clinical stakeholders to develop the intervention. Engaging stakeholders in intervention development, an emerging VHA priority, is critical for ensuring feasibility, acceptability, and credibility. As one Veteran remarked during a focus group, “I appreciate you all askin’ us what we’re thinkin’, rather than just sayin’, ya know, here’s what it is and here’s what it’s gonna be.” Specific Aims and Methodology: Aim 1: Identify contextual factors that may inform development of the intervention. I will conduct semi- structured qualitative interviews with up to 30 at-risk Veterans who recently received VHA ED care to identify intrapersonal, interpersonal, and institutional factors that should be considered during intervention refinement and adaptation in Aim 2. Aim 2: Leverage the expertise of a diverse sample of stakeholders to refine intervention elements, adapt them for use among Veterans and within VHA EDs, and develop a final intervention protocol and related materials. Building on prior studies and knowledge gained from Aim 1, I will employ a stakeholder-engaged process to refine, adapt, and finalize the LMS intervention protocol and materials. I will use two evidence-based methods to engage stakeholders and build consensus (Nominal Group Technique, online modified-Delphi process). Aim 3: Pilot the ED-based LMS intervention among 40 Veterans to assess feasibility and acceptability. I will assess feasibility of recruitment, staff fidelity to the intervention, and Veteran engagement, including after ED discharge, and acceptability of the intervention among participants, intervention staff, and ED staff. Next Steps/Implementation: Results from this pilot study will support an IIR application to test the efficacy of this intervention in promoting LMS behaviors among at-risk Veterans. If found to be efficacious, consistent with VHA’s public health approach to suicide prevention and my long-term career goals, my future work will aim to adapt and disseminate the intervention across various VHA (e.g., primary care) and community settings.