Motivational Interviewing to Address Suicidal Ideation: A Randomized Controlled Trial with Suicidal Veterans

退伍军人健康管理局(VHA)早就知道，最近发生自杀危机的退伍军人 因为那些在急性精神病院住院的人自杀的风险增加。作为回应，VHA开发了一种 自杀预防战略和加强对高危退伍军人的日常护理(EUC)，增加护理协调， 安全计划，并可使用24小时危机热线。还出现了一系列创新的自杀事件 整个VHA的预防试验。然而，在降低自杀风险方面显示出希望的唯一干预措施 在退伍军人中的尝试是安全规划，这已经在VHA实施。尽管做出了这些努力， 这类危机后的自杀率已经趋于平稳，而且这种风险并没有明显降低。 人口，需要开发和测试补充这些已经存在的额外战略 已实施的方法。 研究表明，减少自杀行为的治疗可能需要专注于生活的动机 和死亡的动机，以获得最佳的效果。PI开发了一个修订版的《励志》 访谈解决自杀意念(MI-SI-R)以帮助退伍军人解决生活方式的矛盾心理 增加生活的动力，这是通过一到两次面对面的会议和电话助推器来提供的 会议。在一项针对精神病住院退伍军人的初步随机对照试验(RCT)中，MI-SI-R plus 与EUC相比，EUC的自杀企图减少了50%，自杀想法的可能性降低了41% 只有EUC一个人。此外，专案后分析表明，MI-SI-R对自杀企图有更强的影响 有自杀未遂史的人有自杀倾向的风险，但没有自杀史的人对自杀意念的影响更大 自杀未遂历史，这需要复制。还需要更多的研究来深化我们的 通过检测MI-SI-R患者的疗效了解MI-SI-R及其假想的机制模型 不同的精神障碍及其可能的动机机制。 我们提出了一种RCT，将MI-SI-R+EUC(MI-SI-R+EUC)与单独使用EUC进行比较，样本为470个高 来自三个VHA医学中心的最近有自杀危机的退伍军人的风险，定义为自杀的高危 在Beck自杀意念量表中，一个月内有自杀意念或有自杀意念。一半(n=235)将是 随机到MI-SI-R+EUC(面对面、通过视频连接或电话进行三次会议)，其余 参与者(n=235)将单独获得EUC。所有参与者将被要求完成电话跟踪 在随机化后3、6、9和12个月进行评估。这将使我们能够确定MI-SI的疗效- R+EUC在以下情况下降低自杀企图风险(目标1)和减少总体自杀意念(目标2) 与单独使用EUC相比。我们还将探讨MI-SI-R+EUC在以下方面具有不同影响的可能性 有不同自杀未遂史和不同精神障碍的患者并调查推定的 激励机制(探索性目标3)。 这项研究具有重要意义，因为自杀预防是VHA的优先事项，目标人群是已知的 采取具有很高实施潜力的短暂干预措施，风险非常高。它的创新之处在于 它测试了一种针对生活动机的修订干预措施，使其在以下干预措施中具有创新性 在全面的试验中进行了测试，探索可能影响其有效性的潜在条件，并检查 假想的激励机制。

Veterans Health Administration (VHA) has long known that Veterans who have recently had a suicidal crisis such as those in acute psychiatric hospitalization are at increased risk for suicide. In response, VHA developed a suicide prevention strategy and enhanced usual care (EUC) for high-risk Veterans by adding care coordination, safety plans, and access to a 24-hour crisis hotline. There has also been a broad array of innovative suicide prevention trials across VHA. However, the only intervention that has shown promise in reducing risk for suicide attempts in Veterans is Safety Planning, that has already been implemented across VHA. Despite these efforts, suicide rates following such crises have plateaued and there has been no observable reduction in risk in this population, requiring the development and testing of additional strategies that complement these already implemented approaches. Research suggests that treatments to reduce suicidal behavior may need to focus on both the motivation to live and the motivation to die to obtain optimal effects. The PI developed a revised version of Motivational Interviewing to Address Suicidal Ideation (MI-SI-R) to help Veterans resolve ambivalence about living by increasing the motivation to live, that is delivered as one-to-two in-person sessions with a telephone booster session. In a preliminary randomized controlled trial (RCT) in psychiatrically hospitalized Veterans, MI-SI-R plus EUC was associated with 50% fewer suicide attempts and 41% lower likelihood of suicidal ideation compared to EUC alone. Furthermore, post-hoc analyses suggested that MI-SI-R had a stronger impact on suicide attempt risk among those with an attempt history, but a stronger impact on suicidal ideation among those without a suicide attempt history, which requires replication. Additional research is also needed to deepen our understanding of MI-SI-R and its hypothesized mechanistic model by examining its efficacy among patients with different psychiatric disorders and its putative motivational mechanisms. We are proposing an RCT comparing MI-SI-R plus EUC (MI-SI-R+EUC) to EUC alone in a sample of 470 high- risk Veterans with recent suicidal crises from three VHA Medical Centers, with “high-risk” defined as a suicide attempt within a month or suicidal ideation > 5 on the Beck Scale for Suicidal Ideation. Half (n = 235) will be randomized to MI-SI-R+EUC (three sessions in-person, via Video Connect, or telephone) and the remaining participants (n = 235) will receive EUC alone. All participants will be asked to complete telephone follow-up assessments at 3, 6, 9, and 12-months after randomization. This will allow us to determine the efficacy of MI-SI- R+EUC in reducing risk for suicide attempts (Aim 1) and reducing overall suicidal ideation (Aim 2) when compared to EUC alone. We will also explore the possibility that MI-SI-R+EUC has a differential impact among patients with different suicide attempt histories and different psychiatric disorders and investigate putative motivational mechanisms (Exploratory Aim 3). This study is significant because suicide prevention is a VHA priority and targets a population that is known to be at very high-risk with a brief intervention that has high potential for implementation. It is innovative because it tests a revised intervention that targets the motivation to live making it novel among interventions that have been tested in full-scale trials, explores potential conditions that may impact its efficacy, and examines hypothesized motivational mechanisms.