Evaluating the Use of Peer Specialists to Support Suicide Prevention

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Preventing suicide is a top priority for the Veterans Health Administration (VHA). Despite ardent and sustained efforts over the last decade, the suicide rate for VHA patients remains significantly higher than civilians and non- VHA using Veterans. Suicide prevention efforts for high risk VHA patients focus on clinical (e.g., mental health) and service use (e.g., case management) factors. What has yet to be tested is an approach that targets factors in community living, which are better conceptualized as rehabilitative in nature. For it is not only mental and physical illnesses that heighten suicide risk in VHA patients, but also struggles with their sense of self-worth, meaning, and social connections in the community. To help patients with high risk of suicide, this application proposes to adapt and test a promising approach called PREVAIL, which uses ‘Peer Specialists’ (i.e., Veterans with psychiatric disabilities who have been trained to help others with similar conditions). Peer Specialists do not devalue clinical care but engage in rehabilitative tasks of building a life of self-respect and connectedness in one’s local community by offering empathy, hope, and advice based personal experience of mental health recovery. PREVAIL is promising, but still has not demonstrated clinical effectiveness and requires adaptation to address the unique characteristics of Veterans and the VA health care system. This project proposes to use Intervention Mapping, a multi-method, systematic approach using diverse stakeholders, to adapt and pilot PREVAIL. The VHA is the single, largest employer of Peer Specialists and research shows that they can enhance standard clinical care in mental health, physical health, and rehabilitative outcomes. However, Peer Specialists have only just begun to be deployed in suicide prevention efforts. The primary aims of this study are to: 1) Use Intervention Mapping to identify which components of PREVAIL require adaptation to reduce suicidal ideation in high risk VHA patients and to identify implementation strategies useful for the VHA system; and 2) Pilot test the feasibility and acceptability of the adapted PREVAIL, rehabilitative measures, and suicide-related outcomes for use in a rigorous prospective study. With guidance from a steering committee comprised of researchers, VHA leadership, and patients, needs assessment interviews with diverse VHA staff, Peer Specialists, and patients will be conducted to inform the adaptation. Based on results from the needs assessment and the literature on suicide prevention, psychiatric rehabilitation, and peer-based approaches, the steering committee will help adapt PREVAIL. Twelve high suicide risk Veterans with unipolar or bipolar depression will participate in a 3-month “pre- pilot” and provide feedback on how the adapted PREVAIL may be revised. After making any necessary modifications to the intervention, a second group of 12 high suicide risk Veterans with unipolar or bipolar depression will be recruited to participate in a formal pilot test to further evaluate the feasibility and acceptability of recruitment, retention, and assessment procedures. Patients will be from the West Haven and Newington Connecticut medical centers. The Peer Specialists will be from VA Connecticut’s Errera Community Care Center, one of VHA’s leading centers of innovation in psychosocial rehabilitation and one of the largest employers of Peer Specialists. All participants will receive standard VHA care from the Connecticut campuses while participating in this study. Participants will be assessed at baseline, post-intervention, and 3-month follow-up in their level of functional impairment and community integration; sense of hope, quality of life, meaning, and purpose; and self-views and social support. Chart reviews will also be completed at 3-month follow-up to assess for changes in health care visits involving suicidal behaviors. If acceptability (> 50% enrollment of eligible participants) and feasibility (> 70% of enrollees complete follow-up assessment) are demonstrated, this study will result in a novel rehabilitation-oriented suicide prevention intervention to test in a fully-powered randomized controlled efficacy trial.