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

抽象的。 背景：预防自杀是VHA的首要任务。而VHA的回应是实施了新的 筛查要求，REACH VET机器学习计划，以识别高危人群，以及新的 临床实践指南，这些方法不会为自杀风险最高的退伍军人提供“指示” 策略，例如专门针对自杀企图的心理治疗。减少退伍军人自杀未遂 需要解决潜在的跨诊断心理过程。情绪失调，或困难 管理情绪，在精神健康诊断中发生，并与更高的自杀风险有关。 培养情绪调节技能是有效预防自杀的关键因素。辩证行为 治疗(DBT)是一种行之有效的、多成分的、循证的自杀预防心理疗法 针对情绪失调，这在VHA并不普遍，因为实施它的复杂性。一个 资源高效、团体交付的自杀预防心理治疗，DBT技能小组(DBT-SG)已经 与VHA和非VHA样本中自杀意念和情绪失调的减少有关，并且是 在一项非VHA研究中，与全面DBT一样有效地减少了自杀企图和意念 自杀风险很高。我们提出了一项混合型1型试验来1)评估DBT-SG在 对自杀风险高的退伍军人进行跨诊断样本，以及2)确定个人和组织障碍 以及在VHA设施中采用DBT-SG的促进者。意义/影响：研究DBT-SG的临床 其有效性和影响其实施的因素与OMHSP的国家预防战略保持一致 退伍军人自杀、HSR&D和立法优先事项以评估高危退伍军人的创新干预 人群，以及鼓励DBT跨诊断研究的新VHA临床实践指南 针对高危退伍军人的方法。创新：这项研究填补了VHA和国家研究空白：这是第一次 多点试验以测试DBT-SG在VHA的有效性，同时收集可推广的 关于实施障碍和促进者的知识。临床有效性和障碍的结果和 OMHSP心理治疗和自杀预防办公室将使用辅导员来通知正在进行的自杀 预防举措。具体目标：(1)与常规治疗相比，测试DBT-SG的有效性 (Tau)在4个VAMC的多点随机试验中减少自杀企图和想法；(2)进行三部分， 混合方法形成性评估以确定DBT-SG成功的潜在促进者和障碍 在VHA设施中采用。方法：我们将在4个VAMC中随机选择N=254名退伍军人 自杀未遂和情绪失调对DBT-SG、TAU或TAU单独评价DBT-SG的有效性。 我们假设，相对于TAU，DBT-SG将与(H1a，主要结果)减少自杀有关 自杀未遂在18个月的随访中，(H_2b)增加了自杀未遂的存活时间，(H_2c)减少 自杀念头。探索性分析将评估情绪失调和应对技能的变化。在……里面 此外，在试验前、试验中和试验后，我们将进行混合方法的形成性评价，以 保健服务研究实施综合促进行动框架，以确定 DBT-SG实施障碍和促进者。在每个关键时刻，我们都将征求60个关键临床和医疗机构的意见 来自VHA国家和地方领导层、VHA临床医生和退伍军人的行政利益相关者 自杀的风险很高。实施/下一步：关于预防或拖延的有效性试验数据 自杀企图将决定DBT-SG是否适合更广泛的VHA实施。如果 DBT-SG是有效的，三部分形成性评价数据将被用于开发国家VA DBT-SG 与OMHSP的心理治疗办公室作为业务合作伙伴的实施战略。在每个项目年， 我们将向退伍军人、VHA临床医生以及VHA地方和国家领导层传播研究结果。

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.