Caring Letters for Suicide Prevention: Implementation Strategies in Military and VA Healthcare Systems David D. Luxton, PhD, MS (University of Washington, Seattle) Rona Margaret Relova, MD (VA Palo Alto) Fred MacRae, LCSW (VA Palo Alto) 2017 US Department of Defense and VA Annual Suicide Prevention Conference Denver, Co August 1-3, 2017 1 Acknowledgments We are grateful for all involved in the Caring Letters for Military Suicide Prevention including our site PIs, research staff, and the inpatient unit staff at MAMC, TAMC, LRMC, NMCSD, VAPAHCS, and WNYVAHCS, as well as staff at The National Center for Telehealth & Technology, Military
Operational Research Programs, and the Geneva Foundation. This project is partially supported by the Department of the Army through the federal grant award, W81XWH-11-2-0123. The Military Operational Medicine Research Programs, 504 Scott Street, Fort Detrick MD 21702-5012 is the awarding and administering acquisition office. The content of this information does not necessarily reflect the position or the policy of the Government, and no official endorsement should be inferred. 2 Agenda Background Suicide risk after treatment discharge Overview of Caring Contacts Intervention Evidence-base (and limitations) Methods and Procedures Current Randomized Controlled Trial Safety Protocol Best Practice Recommendations
Lessons learned from a Randomized Controlled Trial Benefits and Cost Integration with current practices in DoD and VA Healthcare Systems 3 Caring Letters for Suicide Prevention: Implementation Strategies in Military and VA Healthcare System Background and Overview David D. Luxton, PhD., M.S. Is affiliated with: Department of Psychiatry & Behavioral Sciences University of Washington, Seattle 4 Suicide risk very high after discharge
from psychiatric hospitalization: Civilian population: Up to 100 x greater risk for suicide than general population (Geddes et al, 1997; Goldcare et al., 1993) *Highest risk within one week of discharge U.S. Service Members: Risk 5 x greater than the general AD U.S. military population (2001-2011) (Luxton, Trofimovich & Clark, 2013) *8.2 times higher in the first 30 days compared to at one year Veterans (in VHA care): 12 weeks post-hospitalization approximately 5 x the base rate of the active treatment population and 54 x that of the general U.S. population (1999 2004) (Valenstein, et al. 2009) * Emergency departments (EDs) also see high number of suicide attempters. Data underscores the need for interventions during and after inpatient stays. 5
Reasons for high posthospitalization suicide rates High risk population to begin with Suicidality not effectively treated while in care Brief inpatient stays Limited staff levels (weekends), especially at emergency departments Lack of suicide specific treatments Not found to be high-risk at time of discharge Lack of care transition/discontinuity of care Return to same environment (i.e., stressful conditions) Social isolation/lack of support Luxton, June & Comtois (2012) 6 Caring Contacts Intervention
Caring letters is a suicide prevention intervention that entails the sending of brief messages that espouse caring concern to patients following discharge from treatment. Original caring letters study (Motto,1976; Motto & Bostrom, 2001) Example Motto letter: Dear ____: It has been some time since you were here at the hospital, and we hope things are going well for you. If you wish to drop us a note we would be glad to hear from you. Simple, non-demanding, expressions of care that... With multiple contacts, may contribute to a sense of belongingness (via a caring connection) Reminders of treatment availability may provide route to seek help May help patients to feel better about treatment and therefore motivate them to adhere to treatment 7
Motto (1976); Motto & Bostrom (2001) Letters were sent monthly, decreasing to quarterly, for five years. Patients in the contact group had a lower suicide rate in all five years of the study Survival analyses revealed a significantly lower rate in the contact group (p=.04) for first two years Rates differences gradually diminished by year 14 8 WHO SUPRE-MISS study (Fleischmann et al., 2008)
Randomized Controlled Study in 5 countries Compared group of previous suicide attempters who received psychoeducation + series of personalized follow-up contact (either by telephone or in person) vs. noncontact control group Individuals who received the personalized follow-up intervention were less likely to later die by suicide than those in the control group 9 Other Caring Contacts Studies Outcomes: Self-directed violence or suicide ideation reduction (Luxton, June, & Comtois, 2013)
Postcards (Beautrais et al., 2010; Carter et al., 2005; Carter et al., 2007) Postal letters (Motto, 1976; Motto & Bostrom, 2001) SMS Texting (Chen, Mishara & Liu,2010; Comtois, et al) Email (Luxton et al., 2012) Mixed modality (in-person, phone, etc.) (Fleischmann et al., 2008) 10 Evidence Reviews Luxton, June & Comtois (2013) systematic qualitative review in CRISIS: 3 of 11 studies reviewed showed a statistically significant reduction in repeat suicide attempts 2 studies proved to prevent deaths by suicide (Mottos caring letters (1976) and the WHO study reported by
Fleischmann et al. (2008) 4 studies, showed mixed or non-conclusive results but did show trends toward a preventative effect. 2 studies did not show preventative effects for the follow-up interventions (Beautrais et al., 2010; Cedereke et al., 2002) Luxton, D. D., June, J. D. & Comtois, K. A. (2013). Can Post-Discharge Follow-up Contacts Prevent Suicide and Suicide Behavior?: A Review of the Evidence. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 34, 32-41. doi: 10.1027/0227-5910/a000158 11 Evidence Reviews (Cont.) Milner, Carter, Pirkis, Robinson, & Spittal (2015), meta-analytic review in British Journal of Psychiatry: 14 eligible studies overall, 12 were used in meta-analyses. For any subsequent episode of self-harm or suicide attempt, there was a non-significant reduction in the overall pooled odds ratio of 0.87 (95% CI 0.74-1.04, p=0.119) for intervention compared to control.
The number of repetitions per person was significantly reduced in intervention versus control (IRR 0.66, 95% CI 0.540.80, p<0.001). There was no significant reduction in the odds of suicide in intervention compared to control (OR 0.58, 95% CI 0.24-1.38). Milner, A. J., et al (2015). Letters, green cards, telephone calls and postcards: systematic and meta-analytic review of brief contact interventions for reducing self-harm, suicide attempts and suicide. British Journal of Psychiatry, 206(3), 184-190. 12 Data Limitations Large samples needed for suicide (mortality) outcomes Need assessment of possible benefits in welldesigned trials in clinical populations Need to consider contact modality, frequency, etc. Has not been full replication of Motto study... 13
Caring Letters for Military Suicide Prevention: A Randomized Controlled Trial (Luxton, PI) Military Operational Medicine Research Program (MOMRP) funded six site randomized controlled trial MAMC (Washington State) LRMC (Germany) TAMC (Hawaii) NMCSD (San Diego) Palo Alto VAHCS (California) Western NY VAHCS (New York) 14 Caring Letters for Suicide Prevention: Implementation Strategies in Military and VA Healthcare System
Methods and Procedures Rona Margaret Relova, MD (VA Palo Alto, Investigator) 15 VA Palo Alto SitePersonnel Rona Margaret Relova, MD Fred MacRae, LCSW Matilda Stelzer, MD Gopin Saini, MBBS Tina Lee, MD Melody R. Cardona Valerija Nikolic, RN Kristine Lalic David D. Luxton, PhD (Principal Investigator) 16 Specific Aims
1. Evaluate caring letters as an intervention for suicide prevention in the Military and VA health care systems. 2. Provide recommendations regarding the best practices for conducting caring contacts research trials. 3. Provide guidelines in navigating the regulatory and compliance processes in DoD and VA systems. 17 Statistical Methods & Analyses Hypothesis #1 Frequency of suicide will be significantly lower in the intervention group compared to the usual care group. Hypothesis #2 Frequency of medically admitted self-inflicted injuries will be lower in intervention group compared to the
usual care group. Hypothesis #3 The time to suicidal behavior will be longer among patients in intervention group compared to usual group. (Luxton et al., 2014) 18 Study Design A prospective randomized controlled trial (RCT) that tests the effectiveness of the caring contacts intervention to prevent suicidal behavior among U.S. service members and veterans at 6 sites: 1. Madigan Army Medical Center (MAMC) 2. Tripler Army Medical Center (TAMC) 3. Landstuhl Regional Medical Center (LRMC) 4. Navy Medical Center San Diego (NMCSD) 5. VA Palo Alto 6. VA Western New York
19 Study Design (2) Eligible participants are randomized into two groups: (1) caring letters (CL) group (2) no-contact usual care (UC) group CL group receives 13 scheduled emails over 2 years after discharge from inpatient psychiatry units. Follow-up contacts for both CL and UC groups are conducted two years after hospital discharge. 20 Study Design and Procedure Follow-up and NDI/S Assessments Review
Hospital Discharge Usual Care (no email contacts) Referral Referral and and Consent Consent Interview Interview Measures Measures Randomize Randomize
d d Caring E-mails (13 over two years) Time in study: 0 Months 24 Months 21 Caring Letters (Emails) Schedule 22 Participant Demographics
* Palo Alto VA site only 6% Participation 23% 57% 14% Approached and enrolled Did not have emails Refused to consent Other reasons 23
Participant Demographics (2) NoOther; High School Graduate degree; 0.58% Diploma; 2.05% 4.68% College degree; 26.32% High School Diploma; 66.37% Education Level No High School Diploma High School Diploma
College degree Graduate degree Other 24 Participant Demographics (3) 3.51% 22.51% 28.65% 7.60% 37.72% Marital Married Status
Caucasians African Americans Asians Amer Indian Native Hawaiian Others 26 Participant Demographics (5) Age Distribution 50 46 45 Number of Participants
40 35 28 30 25 29 24 20 15 10 10 5 0
2 <30 years 30 -40 years 40 -50 years 50-60 years 60 -70 years >70 years Age Groups 27 Measures and Outcomes Data
Data is collected during three time periods: (1) Initial interview: -Positive Assets Search Semi-Structured Interview Tool (PASSIT) -Interpersonal Needs Questionnaire (INQ) -Acquired Capability for Suicide Scale (ACSS) -Soldiers Perceptions of Unit Cohesion Scale 28 Measures and Outcomes Data (2) (2) Two-year intervention period: -Email replies -Undelivered emails -Content of replies (indicated crisis, expressed gratitude) 29
Measures and Outcomes Data (3) (3) Two years after index hospitalization: -Suicides and all cause mortality rates will be collected. -Sources: data will be obtained from CDC National Death Index Plus (NDI-Plus), Social Security Administration Death Master File -Surveys will be conducted to obtain information re: mental health service utilization. -Electronic health records will be reviewed to assess the accuracy of self-reported data. 30 Email and Data Management All Centralized email system for each site is established: [email protected] E-mails are monitored for any potential
crisis state; all emails are archived. Data collected on paper are entered into secure local database. Copy of local database is sent to lead site for inclusion into a master database using encryption. Local site maintains essential logs: subject recruitment, email tracking, etc. 31 Letter Example Dear _________, We are just checking in with you again to let you know we are thinking about you. Hope youre doing something that is relaxing and enjoyable. Its good to take a break and treat yourself to something. We hope everything is going well. If you feel like dropping us a line, we would be happy to hear from you. Best wishes, Gopin Saini & Matilda Stelzer Please note that the following resources are always available to you: Veterans Crisis Line: 1-800-273-8255 Press 1 as soon as you hear the
recording asking if you are a veteran to be connected to a VA counselor immediately. Online chat is also available at www.veteranscrisisline.net DoD/VA Suicide Outreach: www.suicideoutreach.org 32 Safety Protocol Safety plan is established for instances when a threat for self-harm or harm to others is received in an email reply or follow-up contact (Phone Call or Mailed in Surveys) There is immediate notification to the treatment team or the Suicide Prevention Coordinator (VA sites) when a participant indicates crisis state. Contact time - Usually no more than one day from contact of SPC to the contact of Participant and reconnection to care.
33 Safety Protocol (2) Timely reconnection to care of the patient is ensured. Resources will be included in caring emails sent to patients to reinforce availability of support. Frequency of caring letters is decreased over time to reduce the sense of loss that may be experienced by the recipient. Preliminary Report: Participants* (n=29) were reconnected through this study in a timely manner: mean time of 90 minutes. *Participants indicated distress through email or final survey (completed by phone or mailed-in). 34 Patient Responses Thank you for these follow-up emails, they have been nice to receive. I must admit that
I was surprised at first and came to enjoy seeing them in my email. There were times that you seemed my only friends, then I woke up and went to church and found them again. Thank you for reaching out to me. It is easy just to try and stay away from everyone but you give me a channel to reach through. I have a couple more appointments set at the VA to get some help. Thanks for the note. Things haven't been going too good. Not only have I been
still suffering from depression, anxiety, and varying degrees of EtOH abuse and my 16yr battle with my eating disorder, but, to make matters worse I fell about a month or so ago and ended up badly spraining my ankle as well as a jones Total: 57 patients fracture Lost, thats where I responded am. Indicated crisis: 29 Indicated appreciation: 42 35 Insights Gained from Progress
Report (2) Greatest strengths of this study: simplicity, portability, low-cost Able to reach military service members and veterans who choose not to continue care, who do not have easy access to care and who move frequently Inexpensive to implement Provides adjunctive support system or additional safety net Can potentially reduce future costs associated with psychiatric re-hospitalizations, reduce costly service utilizations Currently study has more than 1300 participants enrolled, suggesting patient engagement to the intervention 36
Caring Letters for Suicide Prevention: Practicality & Feasibility of a Caring Contact Program Recommendations Fred MacRae, LCSW VA Palo Alto 37 Existing VA Contact Programs Caring Letters is one type of contact program Our project is research, intended to inform programs Caring Letters Program is not meant to replace or compete with the already established Mail Program for Veterans Flagged
for High Risk of Suicide. Differences between the programs include 38 Mail Program / Caring Letters Program Mail Program Caring Letters Program Purpose Caring Contact Caring Contact Modality
Postal Mail Email Target Population High Risk Veterans Veterans discharged from Inpatient Psych Unit Frequency Recommended 1x/Month for 2 years 13 emails in 2 years (timed and scheduled
intervals) initiated from the discharge date Staffing SPC Team Research Staff Volunteers Peer Counselors Etc. 39 Mail Program/ Caring Letters Program Mail Program Caring Letters Program
Personalized email or Letter Some Yes Initial Team Contact Varies Clinician and/or SPC Clinical Assessment Yes Baseline Assessment by Caring Letters team. Final Survey
No Yes Standard Treatment/ Treatment Team Yes No (Outside of the standard of treatment) Patient Health Questionnaire, Rudd Suicide Ideation Scale, Interpersonal Needs Questionnaire,
Acquired Capability for Suicide, mental and medical treatment history (past 2 years). 40 Beginnings and Endings 30-Minutes Initial Assessment Provides information for personalization of emails. Builds relationship with individual who will there after represent the caring letter team. 30- Minutes Final Assessment
Formal assessment tools administered by caring person apart from treatment team has provided valuable clinical information apart from treatment team including revelation of acute distress. Immediate intervention by CrisisLine/SPC and or treatment team. 185 Completed the Final Assessment: 12 individuals had highly concerning scores indicating significant suicide risk. SPC and Treatment Team notified outreach to veteran initiated *at VAPA out reach to veteran was within 1 day.
41 Implementation considerations Type of contact modality Email, Postal (letter/postcard), texting, in person Frequency of contact Recommendation is one during first week, and then monthly for a six months (longer better). Personalized contact vs. generic (personalized assumed better) Target high risk vs. all patients/clients (this is cost/benefit consideration) 42 Best Practice Considerations
Need process for addressing emergencies/crises (safety plan) see Luxton, Thomas, et al (2014) Consider duty-to-warn, etc. Consider impact of sending final contact Titrate contacts Let patient know final contact is arriving Consider institutional policy regarding contact Site specific safety rules and procedures Consider legal/regulatory requirements when using technology (data security, etc.)
Consent Disclaimers/reminders 43 Per Subject Costs 1 staff hr required for initial assessment and relationship building. 1 staff hr required for final follow-up/assessment. Approximately 5 minutes/ month for personalization and sending. (Set templates in place) Additional expected 5 minutes /month for record keeping and data base update. Reading emails: average 1 minute per entrant per/ month on average as very few would be responding monthly Referral to SPC/Treatment Team: Appox. 10
minutes per distress email Approximately less than 2 minutes per month on average Approximately 1 hr SPC time per distress contact 44 Potential Benefits of the Program 1. Creates a sense of caring connection to team outside of treatment environment. 2. Each friendly email gently invites spontaneous and casual response without obligation to reply. 3. Inability for veteran to establish on going email exchange outside of scheduled times, prevents staff splitting. 4. The ease of response, is likely to result in veterans reporting times of emotional stress/crisis which allows for treatment team outreach and re-engagement at vulnerable times.
5. Non clinical staff could administrate program providing handoff to clinical staff at any signs of distress. 45 Benefits (cont.) Greatest strengths of this intervention: simplicity, portability, low-cost Able to reach military service members and veterans who choose not to continue care, who do not have easy access to care as well as for those who move frequently. Can augment other interventions and treatments for suicide 46 Implementation Recommendations
Must read. Reger, M. A., Luxton, D. D., Tucker, R., Comtois, K. A., Katz, I. R., Keen, A. D., et al. (2017). Implementation Methods for the Caring Contacts Suicide Prevention Intervention. Professional Psychology: Research and Practice. http://dx.doi.org/10.1037/pro0000134 47 Thankyou! Questions? Contact: [email protected] 48 References
Luxton, D. D., June, J. D. & Comtois, K. A. (2013). Can PostDischarge Follow-up Contacts Prevent Suicide and Suicide Behavior?: A Review of the Evidence. Crisis: The Journal of Crisis Intervention and Suicide Prevention. 34, 32-41. Luxton, D. D., Kinn, J. T., June, J. D., Pierre, L. W., Reger, M. A., Gahm, G. A., (2012). The Caring Letter Project: A Military Suicide Prevention Pilot Program. Crisis: The Journal of Crisis Intervention and Suicide Prevention. 33, 311-316. Luxton D. D., Trofimovich, L., & Clark, L. L. (2013). Suicide Risk among U.S. Service Members Following Psychiatric Hospitalization, 2001-2011. Psychiatric Services. Luxton, D. D., Thomas, E. K., Chipps, J., Relova, R. M., Brown, D., McLay, Ret al. (2014). Caring Letters for Suicide Prevention: Implementation of a Multi-Site Randomized Clinical Trial in the U.S. Military and Veteran Affairs Healthcare Systems. Contemporary Clinical Trials, 37, 252-260. Milner, Carter, Pirkis, Robinson, & Spittal (in press), Letters, Green Cards, Telephone calls, and Postcards: A systematic and metaanalytic review of brief contact interventions for reducing selfharm, suicide attempts, and suicide, British Journal of Psychiatry.49 References
Motto JA: Suicide prevention for highrisk persons who refuse treatment. Suicide and Life-Threatening Behavior 6:223230, 1976 Motto JA, & Bostrom AG. (2001). A randomized controlled trial of postcrisis suicide prevention. Psychiatric Services, 52, 828-833. Reger, M. A., Luxton, D. D., Tucker, R., Comtois, K. A., Katz, I. R., Keen, A. D., et al. (2017). Implementation Methods for the Caring Contacts Suicide Prevention Intervention. Professional Psychology: Research and Practice. http://dx.doi.org/10.1037/pro0000134 Valenstein M, Kim HM, Ganoczy D, et al: Higher-risk periods for suicide among VA patients receiving depression treatment: prioritizing suicide prevention efforts. Journal of Affective Disorders 112:5058, 2009 Vaiva, G., Walter, M., Al Arab, A. S., Courtet, P., Bellivier, F., Demarty, A. L., Libersa, C. (2011). ALGOS: The development of a randomized controlled trial testing a case management algorithm designed to reduce suicide risk among suicide attempters. BMC Psychiatry, 1, 17. 50
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