Rapid Referral to Suicide Specific Intervention in Psychiatric Emergency Care

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This revised proposal responds to HSR&D's Targeted Solicitation for Health Services Research on Suicide Prevention. Same-day psychiatric emergency clinics are increasingly implemented and are a best practice in increasing access to mental health care and in suicide prevention. Our preliminary data indicate a high frequency of suicidal ideation and recent suicidal behavior among Veterans accessing same-day mental health evaluation, and yet fewer than half of Veterans with these risk factors engage in outpatient mental health appointments that are set following their initial acute evaluation. To reduce risk of suicide during the transition from acute to outpatient care, it is unclear if models that “bridge” the transition should emphasize telephone outreach, as delivered by Suicide Prevention Coordination teams, or suicide-specific psychotherapy, such as Collaborative Assessment and Management of Suicidality (CAMS). CAMS is a brief transdiagnostic evidence-based psychotherapy that is recognized by the Joint Commission and Zero Suicide Framework as indicated for Veterans experiencing active suicidal ideation and/or recent suicidal behavior. This single-site 4- year randomized clinical trial addresses pragmatic questions regarding the relative impact of rapid referral to CAMS versus compared to outreach delivered by Suicide Prevention Coordinators for Veterans who are accessing same day mental health evaluation and who are gauged to be at elevated risk for suicide. In a Hybrid Type 1 research design, we propose to recruit Veterans from the same-day clinic setting who report recent or current active suicidal ideation and/or suicide attempt within the past 3 months. Veterans will be randomized to timely initiation of CAMS or to telephone outreach from Suicide Prevention Coordinators. The primary outcome (Aim 1) is the 12-month rate of suicide-related behavior or psychiatric hospitalization. Aim 2 contrasts indicators of operational efficiency between randomized conditions, including Veterans' rate of missed appointments at referred ongoing mental health care and urgent care re-presentation. We will also evaluate secondary outcomes (e.g., suicidal ideation severity). Aim 3 will examine the mediating impact of outpatient mental health treatment engagement on primary outcomes. Aim 4 evaluates fidelity to CAMS and its association with outcomes. Fidelity and in-person outcomes are measured by use of information technology, called eScreening, that is integrated with the electronic medical record and is used coordinate rapid referral and measurement-based care. This project builds on our preliminary data which indicate that research recruitment and rapid referral to CAMS therapy in same-day setting is highly feasible, acceptable and potentially impactful. This project is innovative in its focus on transitional care interventions in the same day clinic setting and its integration of health information technology to facilitate rapid referral, extensible to the dissemination of other evidence-based treatments. This research directly responds to the National Prioritized Research Agenda for Suicide Prevention, which emphasizes a need for care models that deliver “suicide-specific intervention as soon as risk is identified” and addresses important gaps on the impact of timely suicide prevention strategies identified the White House report. The study also responds to the HSR&D Mental and Behavioral Health, Access, and Care Coordination Priority Areas. We expect that these data will inform best practices in suicide prevention in same day mental health services where many at-risk Veterans are seen.