Reducing Suicide Risk in Older Veterans with Mental Health Disorders using Problem Solving Therapy

拟议的随机对照试验将检验一种简单的行为疗法对减少 自杀意念和越来越多的理由生活在有自杀风险的老年退伍军人中。两个共同的问题 在老年人中，功能性残疾和执行功能障碍会增加自杀风险，并将被检查为 治疗结果的主持人和调解人。拟议的研究将检验问题解决疗法 (PST)使用传授技能的协议来解决有效问题的情感和实际障碍 解决问题。协作性安全计划的VA日常护理实践将是控制条件，这里指的是 到加强日常护理(EUC)。为了参与者的安全，参加PST的退伍军人也将获得EUC。这个 研究设计是随机分配到处理，PST+EUC，或对照条件，EUC。两者都有 治疗和对照是在六个疗程中提供的循证干预措施。这项研究将进行 在VA Palo Alto(主要站点)和VA Syracuse/VA Canandaigua(次要站点)。 自杀意念和生存理由的纵向评估将在11个时间点进行： 基线，在每周六次治疗后，治疗后(7周)，在1，3，6 一个月的随访。招募目标是在五年内招募150名退伍军人，75名参与者 随机分配到每个治疗组。退伍军人必须年满60岁或以上，报告有自杀意念，并满足 抑郁症、焦虑症和/或创伤后应激障碍的诊断标准为 符合条件的。如果退伍军人有精神病症状，他们将被排除在外，并被转介到其他服务， 双相情感障碍，严重的强迫症，或指示边缘人格障碍的升高症状； 酒精/物质使用障碍；严重或不稳定的医疗条件；最近的头部损伤(过去一年) 或头部损伤病史，昏迷24小时或以上；晚期疾病；阳性 显示可能的痴呆症的认知屏幕；或如果他们不能参与研究或 后续会议。招聘将通过退伍军人管理局、退伍军人中心和 社区确保在每个地点总共招募75名退伍军人的可行性。为了满足此次招聘 目标是，主要和次要地点将每个月招收2至3名退伍军人。 录音带治疗过程的保真度评级将由独立评分者在20%的过程中进行。 混合效应模型将被用来估计治疗效果与对照结果 自杀念头和活着的理由。模特将因人口统计、医疗和精神疾病而有所不同 合并症和精神药物的使用。对于主要目标，模型将确定PST加EUC是否 与EUC相比，仅在自杀意念和生存原因方面有更大的治疗效果。 次级目标将决定基线功能障碍和执行功能障碍是否适度治疗 结果，以及这两个变量从基线到治疗后的变化是否显著 与自杀意念和生存原因的改变有关(中介)。第三目标将使用 评估退伍军人对治疗和控制满意度的定性方法包括 治疗对他们有帮助的问题，以及为未来退伍军人改进治疗的建议。海流 VA/DoD自杀临床实践指南(CPG)没有列出专门针对老年人的治疗方案 退伍军人，尽管大多数VHA患者年龄在55岁或以上。因此，基于证据的结果来自 拟议的工作有可能成为中央人民政府关于将PST与安全规划结合使用的建议 和/或单独与年长的退伍军人一起进行安全规划。可以通过以下方式支持治疗的传播 在基于问题解决的干预措施方面扩展现有的退伍军人培训基础设施。

The proposed randomized control trial will examine the efficacy of a brief behavioral treatment for reducing suicidal ideation and for increasing reasons for living in older Veterans at risk for suicide. Two common issues in older adults, functional disability and executive dysfunction, increase suicide risk and will be examined as moderators and mediators of treatment outcomes. The proposed study will examine Problem Solving Therapy (PST) using a protocol that teaches skills to address emotional and practical barriers to effective problem solving. The VA usual care practice of collaborative safety planning will be the control condition, herein referred to as enhanced usual care (EUC). For participant safety, Veterans enrolled in PST will also receive EUC. The study design is random assignment to the treatment, PST plus EUC, or the control condition, EUC only. Both the treatment and the control are evidence-based interventions delivered in six sessions. The study will occur at VA Palo Alto (primary site) and VA Syracuse/VA Canandaigua (secondary site). Longitudinal assessment of suicidal ideation and reasons for living will occur at eleven timepoints: baseline, after each of the six weekly treatment sessions, posttreatment (7 weeks), at 1-, 3-, and 6- month follow-up. The recruitment goal is 150 Veterans over a five-year period with 75 participants randomized to each treatment. Veterans must be 60 years or older, report suicide ideation, and meet diagnostic criteria for a depressive disorder, anxiety disorder, and/or posttraumatic stress disorder to be eligible. Veterans will be excluded and referred for other services if they have psychotic symptoms, bipolar disorder, severe OCD, or elevated symptoms indicative of borderline personality disorder; an alcohol/substance use disorder; severe or unstable medical conditions; recent head injury (past year) or history of a head injury with loss of consciousness for 24 or more hours; terminal illness; positive cognitive screen indicative of possible dementia; or if they are unable to participate in the study or follow-up sessions. Recruitment will occur through multiple strategies at VA, Vet centers, and in the community to ensure the feasibility of recruiting a total of 75 Veterans at each site. To meet this recruitment goal, the primary and secondary site will each enroll 2 to 3 Veterans per month. Fidelity ratings of audiotaped treatment sessions will be made by independent raters on 20% of sessions. Mixed effects modeling will be used to estimate the effect of treatment versus the control for the outcomes of suicidal ideation and reasons for living. Models will covary for demographics, medical and psychiatric comorbidity, and psychotropic use. For the primary aim, models will determine whether PST plus EUC is associated with a larger treatment effect compared with EUC only for suicidal ideation and reasons for living. Secondary aims will determine if baseline functional disability and executive dysfunction moderate treatment outcomes, and whether a change in these two variables from baseline to posttreatment are significantly associated with (mediate) change in suicidal ideation and reasons for living. The tertiary aims will use qualitative methods to assess Veteran satisfaction with the treatment and control including the types of problems with which treatment helped them, and suggestions for improving it for future Veterans. The current VA/DoD Clinical Practice Guidelines (CPGs) for suicide do not list treatment options specifically for older Veterans despite the majority of VHA patients being 55 years or older. Thus, evidence-based outcomes from the proposed work have potential to inform the CPG recommendations for using PST with Safety Planning and/or Safety Planning alone with older Veterans. Dissemination of the treatment could be supported by expanding existing VA training infrastructure in problem solving based interventions.