A Novel Peer-Delivered Recovery-Focused Suicide Prevention Intervention for Veterans with Serious Mental Illness

背景：自杀是一个主要的公共卫生问题，特别是在患有严重精神疾病的退伍军人中 (SMI，即精神障碍或双相情感障碍)。这些退伍军人的自杀率是最高的 美国人和退伍军人的思想和行为。然而，SMI诊断通常被排除在外。 以自杀为重点的临床试验的标准，以及患有SMI的人经常脱离护理，有 认知障碍，社会支持有限。这些因素可能会影响该项目的可行性和 当前自杀预防干预措施的有用性，如自杀安全规划--VHA标准 关心。这项建议通过提供恢复策略(支持)的同行来完善和试点自杀预防- 首个针对患有SMI的退伍军人量身定做的自杀预防干预措施，以提高他们对生活和 社会。 意义/创新：预防自杀是VA/DoD和RR&D的临床首要任务。 创新有几个原因：1)SMI诊断经常被排除在自杀预防之外 这项研究和这项建议寻求为退伍军人量身定做一种新的以自杀为重点的干预措施 SMI；2)这项建议是少数几项包括患有SMI的退伍军人以加强安全规划的研究之一， 这是至关重要的，因为这是VHA现有的自杀预防护理标准；3)这项建议整合了 预防自杀的康复模式和最佳做法；4)由同行专家提供支持， 《2019年退伍军人事务部/美国国防部危险患者评估和管理临床实践指南》 为自杀强调了未来研究的优先事项，以探索“后急性护理方法”，如安全 规划，并且这种方法可以由同行交付；5)这是第一次将 以自杀为中心的干预中的认知学习策略，以适应SMI中的认知障碍。 方法：这项拟议的为期5年的研究旨在完善和试点同伴提供的干预措施，以改善 功能和社会康复以减少自杀风险；该提案包括两个阶段。阶段1(1.5 年)采用以用户为中心的设计方法，在科学和消费者的帮助下改进支持(n=8) 咨询委员会利益攸关方以及培训我们的PSS以在公开审判中忠于试点案件(n=15)和 定性访谈。支持是由同行提供的为期4周的干预措施，旨在加强安全规划 通过为每个退伍军人在自杀危机后的康复提供个性化的功能和社会目标 同时包括认知学习策略，以提高干预材料的回忆和突显。跟随 第1阶段、第2阶段(3.5年)的改编包括一项试点(n=50)随机对照试验(RCT) 与包含标准要素的增强型标准护理(ESC)条件相比较的支持 在VHA实施自杀预防，包括：1)自杀风险评估，2)退伍军人事务部安全规划 干预，3)及时转诊至退伍军人管理局精神卫生门诊，以及4)自杀预防协调员 后续联系方式。这两个阶段的资深参与者将在基线、中期和 治疗、治疗后和治疗后3个月(并在治疗后进行定性访谈；同伴 提供干预的专家也将在治疗后接受定性访谈)。初级阶段 要评估的结果是个人康复的改善和自杀意念严重程度的降低。 次要结果涉及个人和社会职能的各个领域的变化。 下一步：这项CDA-2是在VHA内制定研究计划的第一步，重点是 通过为患有以下疾病的退伍军人量身定做以自杀为重点的康复干预措施来加强自杀相关护理 SMI。在可行性和初步影响确认之前，Chalker博士将提交RR&D功绩 探索多站点、动力充足的RCT支持与ESC的对比。我们会强调考试 (2)支持变革机制。

Background: Suicide is a major public health concern, particularly among Veterans with serious mental illness (SMI, i.e., psychotic disorders or bipolar disorders). These Veterans have among the highest rates of suicidal ideation and behavior among U.S. and Veteran populations. Yet, an SMI diagnosis is often an exclusion criterion for suicide-focused clinical trials, and people with SMI are frequently disengaged from care, have cognitive impairments, and have limited social supports. These factors may likely impact the feasibility and usefulness of current suicide prevention interventions such as suicide safety planning – a VHA standard of care. This proposal refines and pilots SUicide Prevention by Peers Offering Recovery Tactics (SUPPORT) – the first suicide prevention intervention tailored to Veterans with SMI to improve participation in their lives and society. Significance/Innovation: Suicide prevention is a top clinical priority for VA/DoD and RR&D. This research is innovative for several reasons: 1) SMI diagnoses have frequently been excluded from suicide prevention research and this proposal seeks to tailor a novel suicide-focused intervention specifically to Veterans with SMI; 2) this proposal is one of few studies that includes Veterans with SMI to enhance safety planning, which is crucial given that it is an existing suicide prevention standard of care in VHA; 3) this proposal integrates the recovery model and best practices into suicide prevention; 4) SUPPORT is delivered by Peer Specialists, which the 2019 VA/DoD Clinical Practice Guidelines for the Assessment and Management of Patients at Risk for Suicide highlighted a priority for future research to explore “post-acute care approaches,” such as safety planning, and that such approaches could be peer-delivered; 5) this is the first intervention to integrate cognitive learning strategies in a suicide-focused intervention to accommodate cognitive impairments in SMI. Methodology: The proposed 5-year study aims to refine and pilot a peer-delivered intervention to improve functional and social recovery to decrease suicide risk; the proposal consists of two phases. Phase 1 (1.5 years) employs a user-centered design approach to refine SUPPORT aided by scientific and consumer (n=8) advisory board stakeholders as well as training our PSs to fidelity on pilot cases in an open trial (n=15) and qualitative interviews. SUPPORT is a 4-week peer-delivered intervention intended to augment safety planning by addressing functional and social goals personalized to each Veteran’s recovery following a suicidal crisis while including cognitive learning strategies to enhance recall and salience of intervention material. Following adaptations from Phase 1, Phase 2 (3.5 years) includes a pilot (n=50) randomized controlled trial (RCT) of SUPPORT compared to an enhanced standard care (ESC) condition that contains the elements of standard practice suicide prevention delivered at VHA, which include: 1) suicide risk assessment, 2) VA Safety Planning Intervention, 3) timely referral to VA mental health outpatient care, and 4) Suicide Prevention Coordinator follow-up contacts. Veteran participants in both phases will be quantitatively assessed at baseline, mid- treatment, post-treatment, and 3-months post-treatment (and qualitatively interviewed at post-treatment; Peer Specialists delivering the intervention will also be qualitatively interviewed post-treatment). The primary outcomes to be evaluated is improvement in personal recovery and reduction in suicidal ideation severity. Secondary outcomes concern changes in various domains of personal and social functioning. Next Steps: This CDA-2 is the first step toward developing a program of research within VHA focused on enhancing suicide related care by tailoring recovery-informed suicide-focused interventions to Veterans with SMI. Pending confirmation of feasibly and preliminary impact, Dr. Chalker would submit for an RR&D Merit to explore a multi-site, adequately powered RCT of SUPPORT versus ESC. We would emphasize 1) examination of moderators or groups of interest (such as women Veterans) and 2) SUPPORT mechanisms of change.