A Hybrid Effectiveness-Implementation Multisite Trial of a Dialectical Behavior Therapy Skills Group for Veterans at High-Risk for Suicide Attempt

点击翻译按钮获取中文摘要

Abstract. Background: Suicide prevention is VHA’s highest priority. While VHA has responded by implementing new screening requirements, the REACH VET machine-learning program to identify those at high risk, and new clinical practice guidelines, these approaches do not provide Veterans at highest suicide risk with “indicated” strategies, such as psychotherapy that specifically targets suicide attempts. Reducing Veteran suicide attempts requires addressing underlying transdiagnostic psychological processes. Emotion dysregulation, or difficulty managing emotions, occurs across mental health diagnoses and is associated with higher suicide risk. Developing emotion regulation skills is a key element of effective suicide prevention. Dialectical behavior therapy (DBT) is a well-established, multi-component, evidence-based suicide prevention psychotherapy targeting emotion dysregulation that is not widely available at VHA given the complexities of implementing it. A resource-efficient, group-delivered suicide prevention psychotherapy, DBT Skills Group (DBT-SG), has been associated with reduced suicidal ideation and emotion dysregulation in VHA and non-VHA samples and was as effective as full-scale DBT in reducing suicide attempt and ideation in a non-VHA study of individuals with high suicide risk. We propose a hybrid type 1 trial to 1) evaluate the effectiveness of DBT-SG in a transdiagnostic sample of Veterans at high risk for suicide, and 2) identify individual and organizational barriers and facilitators for DBT-SG adoption in VHA facilities. Significance/ Impact: Studying DBT-SG’s clinical effectiveness and factors affecting its implementation align with the OMHSP’s National Strategy for Preventing Veteran Suicide, HSR&D, and legislative priorities to evaluate innovative interventions in high risk Veteran populations, and new VHA Clinical Practice Guidelines that encourage transdiagnostic research on DBT approaches for high-risk Veterans. Innovation: This study fills VHA and national research gaps: it is the first multisite trial to test the effectiveness of DBT-SG at VHA while simultaneously gathering generalizable knowledge about implementation barriers and facilitators. Outcomes on clinical effectiveness and barriers and facilitators will be used by OMHSP Psychotherapy and Suicide Prevention offices to inform ongoing suicide prevention initiatives. Specific Aims: (1) Test the effectiveness of DBT-SG compared to treatment-as-usual (TAU) to reduce suicide attempt and ideation in a multisite randomized trial at 4 VAMC’s; (2) Conduct a 3-part, mixed-methods formative evaluation to identify potential facilitators and barriers to DBT-SG’s successful adoption in VHA facilities. Methodology: We will randomize N=254 Veterans across 4 VAMC’s with recent suicide attempt and emotion dysregulation to DBT-SG + TAU or TAU alone to evaluate DBT-SG effectiveness. We hypothesize that DBT-SG, relative to TAU, will be associated with (H1a, primary outcome) reduced suicide attempt during 18-month follow-up, (H2b) increased survival time for suicide attempt, and (H2c) reduced suicidal ideation. Exploratory analyses will assess change in emotion dysregulation and coping skills. In addition, before, during and after the trial, we will conduct a mixed-method formative evaluation, guided by the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, to identify DBT-SG implementation barriers and facilitators. At each juncture, we will seek input from 60 key clinical and administrative stakeholders drawn from VHA national and local leadership, VHA clinicians, and Veterans at high risk for suicide. Implementation/Next Steps: Effectiveness trial data about the prevention or delay of suicide attempts will determine the appropriateness of DBT-SG for more widespread VHA implementation. If DBT-SG is effective, the 3-part formative evaluation data will be used to develop a national VA DBT-SG implementation strategy with OMHSP’s Psychotherapy Office as the operations partner. In each project year, we will disseminate study findings to Veterans, VHA clinicians, and VHA local and national leadership.